Høringssvar og høringsnotat, fra indenrigs- og sundhedsministeren

1
Alkohol & Samfund, Høffdingsvej 36, stuen, 2500 Valby
www.alkohologsamfund.dk
6.3.2023
Høringssvar til udkast til forslag til lov om ændring af lov om tobaksvarer
m.v., lov om elektroniske cigaretter m.v., lov om forbud mod salg af tobak
og alkohol til personer under 18 år og lov om røgfri miljøer. (Implemente-
ring af dele af delegeret direktiv vedrørende opvarmede tobaksvarer samt
andre præciseringer og tekniske justeringer)
Afsender: Alkohol & Samfund
Ida Fabricius Bruun, Direktør, ifb@alkohologsamfund.dk, tlf. 29807766
Generelle bemærkninger
Alkohol & Samfund takker Indenrigs- og Sundhedsministeriet for at give mulighed for at give be-
mærkninger til lovforslaget om lov om tobaksvarer m.v., lov om elektroniske cigaretter m.v., lov om
forbud mod salg af tobak og alkohol til personer under 18 år og lov om røgfri miljøer.
Alkohol & Samfund ser et stort behov for at sikre håndhævelse for salg af alkohol både fysisk i bu-
tikker og hos onlineforhandlere. Grundlæggende ser vi et behov for styrket forebyggelse af børn og
unges alkoholforbrug i form af strukturelle tiltag, herunder alderskontrol for salg af alkohol. Derfor
imødekommer vi lovforslaget. Alkohol & Samfund har særligt interesseret sig for det afsnit der om-
handler præcisering af kravene til alderskontrol og Sundhedsstyrelsens skilte.
Dog vil Alkohol & Samfund anvende anledning til at gøre opmærksom på, at vi kan konstatere på
baggrund af vores mystery shopping undersøgelser, at håndhævelsen af loven for salg af alkohol
er utilstrækkelig. Samtidig ser vi danske unge, der drikker meget, tidligt og på en uhensigtsmæssig
måde. Derfor er der behov for en yderligere skærpning for at sikre loven bliver håndhævet for salg
af alkohol både online og i fysiske butikker.
Til sidst vil Alkohol & Samfund understrege, at én samlet 18-årsgrænse for al salg af alkoholhol-
dige drikkevarer med en alkoholvolumenprocent på 1,2 eller derover, vil være et effektivt tiltag for
at gøre det nemmere for detailhandlen at håndhæve aldersgrænserne for salg af alkohol, samt et
vigtigt tiltag for at udskyde danske børn og unges alkoholdebut
Tekstnære bemærkninger
Kapitel 2.2.3 Præcisering af krav til alderskontrol og Sundhedsstyrelsens skilte
Effektiv alderskontrol ved fysiske salgssteder
”Det foreslås, at på fysiske salgssteder vil alderskontrollen skulle ske ved at efterspørge gyldig bil-
ledlegitimation, hvis sælgeren er i tvivl om, hvorvidt kunden opfylder aldersgrænserne.” (s. 16)
Alkohol & Samfunds mystery shopping undersøgelser viser at børn og unge helt ned til 13 år kan
købe alkohol i kiosker, supermarkeder og på tankstationer. Ved test af 16-årsgrænsen kunne de
Offentligt
L 123 - Bilag 1
Sundhedsudvalget 2022-23 (2. samling)
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Alkohol & Samfund, Høffdingsvej 36, stuen, 2500 Valby
www.alkohologsamfund.dk
unge købe alkohol i 79% af tilfældene i 2020, mens de unge, der testede 18-årsgrænsen kunne
købe alkohol i 65% af tilfældene.1
Derfor mener vi, at lovgivningen ikke er skærpet nok, hvis der øn-
skes effektiv håndhævelse. I det svenske Systembolaget er det lovpligtigt, at alle kunder under 25
år viser billedelegimitation2
. I Danmark bør fysiske salgssteder pålægges altid at spørge kunder,
der er eller ser ud til at være under 25 år om gyldig legitimation ved salg af produkter, der har en
aldersbegrænsning, herunder alkoholholdige varer.
Effektivt alderskontrolsystem
”Ved markedsføring af produkterne online foreslås det, at der skal etableres og drives et generelt al-
derskontrolsystem. Alderskontrolsystemet skal sikre, at kunden ikke kan gennemføre køb af produk-
terne uden først utvetydigt at tilkendegive, at kunden opfylder aldersgrænserne.” (s. 16)
Alkohol & Samfund gør opmærksom på, at der allerede findes effektive metoder til at verificere al-
der ved onlinesalg af alkohol fx ved brug af MitID. I Alkohol & Samfunds mystery shopping under-
søgelse3
af salg af alkohol fra onlineforhandlere, var Rema1000 den eneste forhandler med et al-
derskontrolsystem, der effektivt forhindrede mindreårige i at købe alkohol online. Rema1000 an-
vendte MitID (dengang NemID), der kontrollerede køberens alder og afviste gennemførelse af kø-
bet. Derfor opfordrer vi til, at onlineforhandlere af alkohol pålægges at anvende MitID ved køb af
alkohol, for effektivt at forhindre onlinesalg af alkohol til mindreårige.
Derfor finder Alkohol & Samfund det særligt problematisk, at følgende bemærkninger til §2, stk. 3
og §3, til nr. 3 (s. 44-45), da det ikke sikrer, at aldersverificeringen foregår effektivt:
”Ved utvetydig tilkendegivelse skal forstås, at kunden direkte skal forholde sig til og foretage en aktiv
handling for at verificere sin alder. Det er således som udgangspunkt ikke tilstrækkeligt, hvis kunden
alene skal acceptere de generelle handelsbetingelser, som indeholder et krav om at kunden skal
være fyldt 18 år. Det betyder f.eks. at accept af generelle handelsbetingelser og bekræftelse af, at
kunden er fyldt 18 år skal meddeles separat”
”Alderskontrolsystemet skal sikre, at kunden ikke kan gennemføre køb af produkterne uden først
utvetydigt at tilkendegive, at kunden opfylder aldersgrænsen.
Der er ikke krav til den konkrete metode, hvorpå kunden tilkendegiver sin alder (pop up, afkrydsning
eller andet). Alderskontrolsystemet kan f.eks. bestå af en fast procedure for, at kunden ved køb af
produktet vil blive præsenteret for et spørgsmål om, hvorvidt kunden er over 16 år. Denne tilgang
bygger på den aktuelle praksis på området samt forslaget til et alderskontrolsystem, når elektroniske
cigaretter og genopfyldningsbeholdere med nikotin markedsføres til danske forbrugere ved hjælp af
fjernsalg på tværs af grænser, jf. bemærkningerne til § 15, stk. 2, i lov om elektroniske cigaretter,
1
Alkohol & Samfund (2021). Solgt ulovligt. https://alkohologsamfund.dk/files/media/docu-
ment/Solgt%20ulovligt.pdf
2
https://www.omsystembolaget.se/salja-med-ansvar/ansvarsfull-forsaljning/skydda-unga-fran-alkohol/dar-
for-ber-vi-om-legg/
3
Alkohol & Samfund (2021). Solgt ulovligt. https://alkohologsamfund.dk/files/media/docu-
ment/Solgt%20ulovligt.pdf
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Alkohol & Samfund, Høffdingsvej 36, stuen, 2500 Valby
www.alkohologsamfund.dk
jf. Folketingstidende 2015-16, tillæg A, L 144 som fremsat, side 44. Ved utvetydig tilkendegivelse
skal forstås, at kunden direkte skal forholde sig til og foretage en aktiv handling for at verificere sin
alder. Det er således som udgangspunkt ikke tilstrækkeligt, hvis kunden alene skal acceptere de ge-
nerelle handelsbetingelser, som indeholder et krav om, at kunden skal være fyldt 16 år. Det betyder
f.eks. at accept af generelle handelsbetingelser og bekræftelse af, at kunden er fyldt 16 år skal med-
deles separat.
En deaktiveret ordre på baggrund af betalingskortet, f.eks. ved brug af korttyper, der kun kan udste-
des til personer under 18 år, er ikke tilstrækkeligt i sig selv til at opfylde kravene om utvetydig tilken-
degivelse. Det er heller ikke tilstrækkeligt i sig selv, hvis købet ophæves eller ordren ikke bliver leve-
ret, idet kunden i disse tilfælde ikke har afgivet en tilkendegivelse. (s. 47-48)
Med overstående krav til ”utvetydig tilkendegivelse af alder” er det meget nemt at omgå alders-
grænserne. Det har Alkohol & Samfund netop bevist ved tidligere undersøgelser af online salg af
alkohol.
Opmærksomhed på tredjeparters salg af alkohol fx leveringsbud
Bemærkninger til lovforslagets enkelte bestemmelser til §3, til nr. 4: ”Det påhviler den person eller
virksomhed m.v. der erhvervsmæssigt markedsfører produkterne på hjemmesider, profiler, apps m.v.
at sikre, at der ikke sælges alkoholholdige drikkevarer med en alkoholvolumenprocent på 1,2 eller
derover til børn og unge under 16 år i strid med reglerne i § 2, stk. 1, og den foreslåede § 2 a, stk. 4, i
lov om forbud mod salg af tobak og alkohol til personer under 18 år.” (s. 48)
Alkohol & Samfund gør opmærksom på, at dette er væsentligt, da det kan være uklart ved køb gen-
nem tredjepart fx brug af udbringningsservices (Fx Wolt.dk eller Snackreload.dk). Det skal være ty-
deligt at udbringningsvirksomheden også skal verificere alder – gerne elektronisk, da køb foregår
”online” via app eller hjemmeside. Det opfordres til at Sikkerhedsstyrelsen fører tilsyn med disse
typer af virksomheder.
Sikre at Sikkerhedsstyrelsens kan føre effektiv kontrol af håndhævelsen for salg af alkohol
Bemærkninger til lovforslagets enkelte bestemmelser til §3, til nr. 10: ”Det fremgår af § 2 b, stk. 1, i
lov om forbud mod salg af tobak og alkohol til personer under 18 år, at Sikkerhedsstyrelsen fører
kontrol med, at kravene i §§ 1-2 a og regler udstedt i medfør af § 2 a, stk. 6, overholdes. Af lovens §
2 b, stk. 2, fremgår det, at Sikkerhedsstyrelsens repræsentanter til enhver tid uden forevisning af legi-
timation har adgang til forhandleres butikslokaler med henblik på at kontrollere overholdelsen af §§
1-2 a og regler udstedt i medfør af § 2 a, stk. 6. Af lovens § 2 b, stk. 3, fremgår det, at Sikkerhedssty-
relsens repræsentanter mod behørig legitimation og uden retskendelse kræve kan at få meddelt alle
oplysninger fra detailforhandlere og købere af alkohol, tobaksvarer, tobakssurrogater og urtebase-
rede rygeprodukter, der er nødvendige for kontrollen efter stk. 1.” (s. 55)
”Efter § 15 a, stk. 1, i kapitel 6, i samme lov kan indenrigs- og sundhedsministeren bemyndige Sikker-
hedsstyrelsen til at føre kontrol med, at kravet i § 15, stk. 1, overholdes. Det følger af bestemmelsens
stk. 2, at indenrigs- og sundhedsministeren kan fastsætte regler om adgangen til at påklage afgørel-
ser, der er truffet i henhold til bemyndigelsen efter stk. 1, herunder at afgørelserne ikke skal kunne
påklages. Af samme bestemmelses stk. 3 følger, at ministeren endvidere kan fastsætte regler om
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Alkohol & Samfund, Høffdingsvej 36, stuen, 2500 Valby
www.alkohologsamfund.dk
udøvelsen af de beføjelser, som Sikkerhedsstyrelsen bliver bemyndiget til at udøve efter stk. 1.” (s.
17)
Sikkerhedsstyrelsens kontrol med overholdelsen af aldersgrænser burde være ent væsentlig faktor
for at begrænse ulovligt salg af alkohol til mindreårige. Men Sikkerhedsstyrelsens kontroller har
vist sig ikke at være en effektiv metode til at sikre fysiske salgssteders håndhævelse af loven.
Alkohol & Samfund har aktivt testet om fysiske salgssteder håndhæver loven om salg af alkohol
ved mystery shopping. Mystery shopping er en metode, hvor 13-15-årige tester køb af alkohol for
16-årsgrænsen og 16-17-årige tester køb af alkohol for 18-årsgrænsen.
Sikkerhedsstyrelsen har ikke hjemmel til at foretage mystery shopping. Ud af de 550 alderskontrol-
ler Sikkerhedsstyrelsen foretog i 2020, observerede styrelsen kun to tilfælde af ulovligt salg af alko-
hol til mindreårige4
. I 2020 fandt Alkohol & Samfund i en stikprøve til sammenligning brud i 82 ud
af 110 tilfælde5
.
Hvis man reelt ønsker at sikre, at salgssteder ikke sælger alkohol ulovligt til børn og unge, så bør
Sikkerhedsstyrelsen sikres hjemmel til at udføre mystery shopping for at skabe en effektiv kontrol,
der sikrer håndhævelse af loven mere effektivt.
Mystery shopping har en dokumenteret effekt i andre europæiske lande til øget håndhævelse af
loven for salg af alkohol. Derfor vurderer Alkohol & Samfund, at mystery shopping kan være et nyt-
tigt initiativ til øge håndhævelsen af loven og reducere ulovligt salg af alkohol til mindreårige i Dan-
mark. I Norge har mystery shopping medvirket til, at ulovligt salg af alkohol er faldet fra 40 % i 2007
til 18,5 % i 20196
. Salget af alkohol til unge under aldersgrænserne er altså mere end halveret i lø-
bet af de 12 år, som Juvente har gennemført mystery shoppingen. Ligeledes i Schweiz har vedva-
rende mystery shopping ændret ID-kulturen. Aldersgrænserne for salg af alkohol ligner de danske
med 16 år for salg af øl og vin, samt 18 år for salg af spiritus. Da de første mystery shoppere for-
søgte at købe alkohol i 2000, blev de kun spurgt om ID i 3,5 % af købsforsøgene7
. I 2019 blev
mystery shoppere bedt om at vise billede-ID i 80 % af købsforsøgene8
. I Schweiz er mystery shop-
ping indskrevet i loven og opgaven ligger hos den Schweiziske Føderale Toldadministration.
Mystery shoppingen bliver varetaget af både private institutioner og myndighederne efter en proce-
dure, der svarer til den Alkohol & Samfund anvender.
4
Tal indhentet fra Sikkerhedsstyrelsen i november 2020
5
Alkohol & Samfund (2021). Solgt ulovligt. https://alkohologsamfund.dk/files/media/docu-
ment/Solgt%20ulovligt.pdf
6 Skjenkekontrollen, 2019. Kontrollrapport 2019. Oslo: Juvente; 2019. s. 1-20. Hentet fra https://om.skjen-
kekontrollen.no/wp-content/uploads/2020/03/Kontrollrapport-2019-ferdig.pdf
7 Europa Kommissionen, 2012. Eyes on Ages A research on alcohol age limit policies in European Member
States. Legislation, enforcement and research. Holland: Dutch Institute for Alcohol Policy. s. 51. Hentet fra
https://ec.europa.eu/health/sites/health/files/alcohol/docs/eyes_on_ages_report_en.pdf
8 Swiss Customs Administration, 2020. “Test purchases”. Hentet d. 9.12.2020 fra https://www.ezv.ad-
min.ch/ezv/en/home/topics/alcohol/praevention_jugendschutz/praeventionsinstrumente/testkae-ufe.html
British American Tobacco Denmark A/S (House of Prince)| Bernstorffsgade 50 – 1577 Copenhagen V – Denmark - CVR 13801134 | A member of the British American Tobacco Group
Indenrigs- og Sundhedsministeriet
Sagsnr.: 2213653
Dok. nr.: 2523532
sum@sum.dk
cfma@sum.dk
København den 06.03.2023
British American Tobacco Denmark A/S
Bernstorffsgade 50
1577 Copenhagen V
Denmark
Tel + 45 39 55 63 00
CVR 13801134
www.bat.com
British American Tobacco Denmark A/S takker for muligheden for at afgive høringssvar på høringen
vedrørende;
Udkast til forslag til lov om ændring af lov om tobaksvarer (Implementering af dele af
delegeret direktiv vedrørende opvarmede tobaksvarer m.m.)
Med venlig hilsen
Anders Preben Burlund
Government Affairs Manager
British American Tobacco Denmark A/S
2
BRITISH AMERICAN TOBACCO DENMARK A/S & NICOVENTURES TRADING
LIMITEDS SVAR TIL SUNDHEDSMINISTERIET
KOMMENTARER ANG. NATIONAL IMPLEMENTERING AF DELEGERET DIREKTIV
OM OPVARMEDE TOBAKSVARER OG ANDEN REGULERING AF NIKOTIN- OG
RØGFRI TOBAKSVARER
I
LOVFORSLAGET OM ÆNDRING AF LOVEN OM TOBAKSVARER M.V., LOVEN
OM ELEKTRONISKE CIGARETTER M.V., LOVEN OM RØGFRI MILJØER OG
DIVERSE ANDRE LOVE.
6 MARTS 2023
3
`
1. INTRODUKTION ............................................................................................................3
2. SAMMENFATNING........................................................................................................5
3. DET DELEGEREDE DIREKTIV OVERSKRIDER PÅ ULOVLIG VIS DE
DELEGEREDE BEFØJELSER......................................................................................6
4. DEFINITION OG KLASSIFICERING AF THP .............................................................14
5. SUNDHEDSMÆSSIGE KONSEKVENSER VED IMPLEMENTERING AF
DET DELEGEREDE DIREKTIV...................................................................................17
6. ALDERSKONTROL VED KØB....................................................................................18
7. KONKLUSION..............................................................................................................18
1. INTRODUKTION
1.1 Dette anbringende fra British American Tobacco Denmark A/S (driver også virksomhed under
navnet House of Prince A/S) ("BAT Denmark") og Nicoventures Trading Limited
("Nicoventures") (dette "Svar") reagerer på en høring om udkastet til lovforslaget om
ændring af loven om tobaksvarer m.v., loven om elektroniske cigaretter m.v., loven om forbud
mod salg af tobak og alkohol til personer under 18 år og loven om røgfri miljøer (under ét,
"Lovforslag").
1.2 Dette dokument reagerer især på den foreslåede implementering af det delegerede direktiv
2022/2100/EU af 29. juni 2022 ("Delegeret direktiv")1 vedrørende opvarmede tobaksvarer
("THP'er") i dansk lovgivning samt visse forslag vedrørende alderskontrol for køb af
tobaksvarer og nikotinprodukter.
1.3 BAT Denmark og Nicoventures er medlemmer af koncernen British American Tobacco
("BAT"). Nicoventures er involveret i udviklingen og kommercialiseringen af BAT's udvalg af
alternative tobaksvarer og nikotinprodukter. BAT's hovedfokus var historisk set traditionelle
tobaksvarer, men koncernen fokuserer i stigende grad på udvikling og kommercialisering af
ikke-brændbare alternativer til konventionelle cigaretter til voksne rygere, der ellers ville
fortsætte med at ryge. Dette omfatter udvikling og salg af THP'er både globalt og inden for
EU, herunder i Danmark. BAT Denmark er ansvarlig for distribution af BAT's THP'er i
Danmark.
1.4 BAT Denmark og Nicoventures omtales samlet som "BAT" nedenfor.
1.5 Det delegerede direktiv
1.6 Det delegerede direktiv ændrer og supplerer direktiv 2014/40/EU af 3. april 2014
("Tobaksvaredirektivet" eller "TPD") og blev offentliggjort af Europa-Kommissionen
("Kommissionen") i EU-Tidende d. 3. november 2022. Det delegerede direktiv ændrer artikel
7, stk. 12 i tobaksvaredirektivet således:
"Andre tobaksvarer end cigaretter og rulletobak samt opvarmede tobaksvarer er undtaget fra
forbuddene i stk. 1 og 7. Europa-Kommissionen kan vedtage delegerede retsakter i
overensstemmelse med artikel 27 med formål at kunne trække denne undtagelse tilbage for
en bestemt produktkategori, hvis der sker en væsentlig ændring i forholdene som fastsat i en
rapport fra Kommissionen.
1
Europa-Parlamentets og Rådets direktiv (EU) af 29. juni 2022 om ændring af Europa-Parlamentets og
Rådets direktiv 2014/40/EU om ophævelse af visse undtagelser for opvarmede tobaksvarer, C(2022)
4367 findes her: https://eur-lex.europa.eu/legal-content/DA/TXT/PDF/?uri=CELEX:32022L2100&from=EN
4
I første afsnit forstås ved "opvarmet tobaksvare" en ny kategori af tobaksvarer, der opvarmes
for at frembringe en emission indeholdende nikotin og andre kemikalier, som derefter
inhaleres af brugeren/brugerne, og som afhængigt af deres karakteristika er røgfrie
tobaksvarer eller røgtobak."
1.7 Som følge heraf gør det delegerede direktiv følgende gældende:
1.7.1 Opretter en ny produktkategori, der ikke var forudset i tobaksvaredirektivet og derfor
ikke blev defineret herunder, dvs. et "opvarmet tobaksprodukt"; og
1.7.2 Fjerner samtidig for denne nye produktkategori undtagelsen fra forbuddet mod at
markedsføre tobaksvarer med en kendetegnende aroma (artikel 7, stk. 1 i
tobaksvaredirektivet) eller tobaksvarer, der indeholder aromastoffer i deres
bestanddele (artikel 7, stk. 7 i tobaksvaredirektivet).
1.8 Det delegerede direktiv ændrer også artikel 11, stk. 1 i tobaksvaredirektivet, og fjerner
dermed muligheden for, at medlemsstaterne undtager THP'er til rygning fra forpligtelsen til at
bære informationsmeddelelsen og kombinerede sundhedsadvarsler (artikel 9, stk. 2 og 10 i
tobaksvaredirektivet). Med andre ord fordrer det delegerede direktiv, at medlemsstaterne
stiller disse krav for THP'er til rygning.
1.9 Det delegerede direktiv blev vedtaget på grundlag af delegerede beføjelser, som er tildelt
Kommissionen i artikel 7, stk. 12, og artikel 11, stk. 6 i tobaksvaredirektivet for at fjerne
ovennævnte undtagelser for etablerede kategorier af tobaksvarer, når der indtræffer en
"væsentlig ændring i forholdene". Eksistensen af denne "væsentlige ændring i forholdene"
beror på, at Kommissionen kan påvise, at visse økonomiske fakta/betingelser er til stede,
herunder at markedsandelen for THP'er er over 2,5 % af det samlede salg af tobaksvarer i
EU. I rapporten, der blev vedtaget den 15. juni 2022 ("Kommissionens rapport"), hævder
Kommissionen, at den har fastslået, at disse økonomiske fakta/betingelser er til stede.2
1.10 Den 16. november 2022 indgav Nicoventures og andre BAT-enheder en ansøgning om
ophævelse af det delegerede direktiv ved EU-Domstolen ("EU-Domstolen").3 Den 13.
december 2022 anfægtede Nicoventures og andre BAT-forretningsenheder også indirekte
det delegerede direktiv over for High Court of Ireland og indgav en anmodning om at få sagen
indbragt ved EU-Domstolen.4 Begge disse sager er igangværende.
1.11 Lovforslaget
1.12 Lovforslaget foreslår implementering af det delegerede direktiv ved:
1.12.1 Indsættelse af en ny definition af THP'er i § 2, stk. 31 i loven om tobaksvarer m.v.
1.12.2 Ændring af §§ 14, 15 og 16 i loven om tobaksvarer m.v. for at inkludere THP'er i de
eksisterende forbud mod markedsføring af tobaksvarer med en kendetegnende
aroma eller tobaksvarer, der indeholder aromastoffer i deres bestanddele.
1.13 Som forklaret nærmere i dette svar mener vi, at det delegerede direktiv er ugyldigt i henhold
til EU-lovgivningen og derfor ikke bør implementeres i den danske lovgivning – og bestemt
ikke så længe de ovennævnte igangværende retssager vedr. det delegerede direktiv endnu
ikke er afgjort ved domstolene. Vi mener også, at de forslag, der implementerer det
delegerede direktiv, med større sandsynlighed vil skade folkesundheden end at gavne den.
2
Rapporten fra Kommissionen, der fastslår en væsentlig ændring af forholdene for opvarmede tobaksvarer
i overensstemmelse med direktiv 2014/40/EU, COM(2022) 279 af 15. juni 2022, findes her:
https://ec.europa.eu/transparency/documents-register/detail?ref=COM(2022)279&lang=en=en
3
Sag T-706/22, offentliggjort i EU-Tidende den 16. januar 2023, se her: https://eur-lex.europa.eu/legal-
content/EN/TXT/?uri=CELEX%3A62022TN0706&qid=1673874316710
4
Fortegnelse nr. 2022/1085 JR
5
1.14 Lovforslaget indeholder også tydeliggørelse af kravene til alderskontrol ved salg af
tobaksvarer og nikotinprodukter både på fysiske salgssteder og online. Som forklaret
nedenfor støtter vi disse tiltag fuldt ud.
2. SAMMENFATNING
2.1 BAT er imod den foreslåede implementering af det delegerede direktiv af følgende grunde:
2.1.1 Kommissionen har ulovligt overskredet omfanget af de delegerede beføjelser, som
den er blevet tillagt. I særdeleshed:
(A) Ved at regulere en ny kategori af tobaksvarer, dvs. THP'er, som aldrig er
blevet taget i betragtning af EU-lovgiveren, behandler det delegerede
direktiv et "væsentligt element" i betydningen jf. artikel 290, stk. 1, i traktaten
om Unionens funktionsmåde ("TEUF"), som ikke kunne været blevet
delegeret til Kommissionen. Bekymringen blev rejst af fire medlemslande,
da Kommissionen første gang kom med et udkast til det delegerede
direktiv,5 og det indrømmes i al væsentlighed i Kommissionens
Begrundelse, der ledsager det delegerede direktiv.6
(B) Det delegerede direktiv introducerer en ny "særlig produktkategori" i
henhold til tobaksvaredirektivet, dvs. THP'er, det overskrider
Kommissionens delegerede beføjelser og krænker de generelle EU-
lovprincipper om retssikkerhed og legitime forventninger. Kommissionen
har kun beføjelse til at ændre reglerne for en eksisterende produktkategori.
Den kan ikke oprette en ny produktkategori.
(C) Den nye "særlige produktkategori", der introduceres af det delegerede
direktiv, er ikke i overensstemmelse med systemet for tobaksvaredirektivet.
Det er ikke muligt, at THP'er på samme tid er en "ny kategori af tobaksvarer"
og en "særlig produktkategori" og omfatter både "røgfri tobaksvarer" og
"røgtobak", da disse er gensidigt udelukkende.
(D) Kommissionens tilgang til vurdering af tilstedeværelsen af en "væsentlig
ændring i forholdene" er behæftet med fejl og overskrider den tekniske
opgave, der er delegeret til den, især fordi den vurderer markedsandele på
"antal cigaretter" i modsætning til tobaksvægten, til trods for at en enkelt
opvarmet tobakspind kun indeholder ca. halvt så meget tobak som en
cigaret.
2.1.2 Det delegerede direktiv er derfor ugyldigt i henhold til EU-lovgivningen og bør ikke
overføres til den danske lovgivning,da enhver lov der implementerer det Delegerede
directiv ind i gældende dansk lov, vil være ugyldig. Især ikke givet de forhold, hvor
det delegerede direktiv er genstand for igangværende retssager.
2.2 Såfremt Sundhedsministeriet – uanset ovenstående – mener, at det bør fortsætte med at
overføre det delegerede direktiv til dansk lovgivning, mener vi – uden at det berører
ovenstående punkter – at Sundhedsministeriet bør anvende et passende sprog til at definere
THP'er og anerkender forskellen mellem røgfri tobaksvarer og røgtobak, og at de skærpede
mærkningskrav i artikel 9, stk. 2 og artikel 10 i tobaksvaredirektivet alene gælder for THP'er
"i det omfang, de er røgtobak".
5
18. møde i gruppen af eksperter i tobakspolitik den 9. februar 2022 kan ses her
https://ec.europa.eu/transparency/expert-groups-
register/screen/meetings/consult?lang=en&meetingId=38075&fromExpertGroups=true
6
Stk. 2 i Begrundelsen, der ledsager Europa-Parlamentets og Rådets direktiv (EU) .../... om ændring af
Europa-Parlamentets og Rådets direktiv 2014/40/EU om ophævelse af visse undtagelser for opvarmede
tobaksvarer, C(2022) 4367 endelig udgave af 29. juni 2022, findes her:
https://data.consilium.europa.eu/doc/document/ST-10815-2022-INIT/en/pdf
6
2.3 Implementering af det delegerede direktiv i lovforslag vil sandsynligvis have en negativ
indvirkning på folkesundheden. I særdeleshed:
2.3.1 De førende sundhedsmyndigheder har anerkendt den reducerede risikoprofil for
THP'er sammenlignet med brændbare tobaksvarer.
2.3.2 De foreslåede aromabegrænsninger vil påvirke voksne rygere negativt og vil
sandsynligvis medføre utilsigtede konsekvenser, da en reduktion af
forbrugerudvalget af ikke-brændbare produkter kan føre til, at voksne genoptager
rygning eller opsøger det uregulerede ulovlige marked, hvis deres foretrukne
smagsstoffer ikke længere er til rådighed.
2.3.3 Ved at anvende regler på THP'er, der er møntet på brændbare tobaksvarer,
formidles det vildledende budskab, at de risici, der er forbundet med THP'er, er de
samme som dem, der er forbundet med indtagelse af brændbare tobaksvarer. Det
har den virkning, at brugen af mere farlige brændbare tobaksvarer bibeholdes, og
det undergraver deres potentiale til at reducere skader som følge af tobaksrygning.
2.3.4 I sidste ende vil en ubalanceret lovgivning forhindre THP'er i at opnå deres
potentiale for at reducere tobaksskader.
2.4 På baggrund af ovenstående, og hvis Sundhedsministeriet vælger at overføre det delegerede
direktiv til dansk lovgivning, bør det vente med at gøre det til den senest mulige dato (dvs. 23.
juli 2023).
2.5 BAT støtter de foreslåede præciseringer af kravene til alderskontrol ved salg af tobaksvarer
og nikotinprodukter ved køb.
3. DET DELEGEREDE DIREKTIV OVERSKRIDER PÅ ULOVLIG VIS DE DELEGEREDE
BEFØJELSER
3.1 Lovvalg
3.2 Artikel 290, stk. 1 i TEUF indeholder følgende (understregning tilføjet):
"Kommissionen kan i en lovgivningsmæssig retsakt få delegeret beføjelse til at vedtage
almengyldige ikke-lovgivningsmæssige retsakter, der supplerer eller ændrer visse ikke-
væsentlige bestemmelser i den lovgivningsmæssige retsakt.
De lovgivningsmæssige retsakter afgrænser udtrykkeligt delegationens formål, indhold,
omfang og varighed. De væsentlige bestemmelser på et område er forbeholdt den
lovgivningsmæssige retsakt og kan derfor ikke være omfattet af delegation."
3.3 I henhold til EU-Domstolens retspraksis er et element "væsentligt" i betydningen af den anden
sætning i artikel 290, stk. 1 i TEUF, såfremt det fordrer politiske valg der falder inden for EU-
lovgivningens ansvarsområder, fordi det kræver, at de pågældende modstridende interesser
skal afvejes ud fra en række vurderinger. Der skal endvidere tages hensyn til det pågældende
felts karakteristika og særlige egenskaber.
3.4 EU-domstolens retspraksis fastslår endvidere, at de delegerede beføjelser skal være præcist
afgrænset i den lov, der tildeler de delegerede beføjelser, og at afgrænsningerne ikke kan
overlades til Kommissionens eget skøn. Dette princip er formuleret således i Kommissionens
egne retningslinjer om delegerede love: "Lovgiveren skal udtrykkeligt og præcist beskrive de
beføjelser, den har til hensigt at delegere til Kommissionen" og "upræcise formuleringer [...]
er ikke mulige.7" Derfor skal Kommissionens beføjelser fastslås og fortolkes præcist, ikke
upræcist, og fortolkes på omfattende vis.
7 Delegerede love – Vejledning til Kommissionens tjenester, 24. juni 2011, SEC(2011) 588, stk. 52 findes
her: https://ec.europa.eu/transparency/documents-register/detail?ref=SEC(2011)855&lang=en
7
3.5 Ved at regulere ny kategori af tobaksvarer regulerer Kommissionen et "væsentligt
element" og træffer ulovlige politiske valg
3.6 Som det fremgår af selve det delegerede direktiv, er THP'er "nye kategorier af tobaksvarer" i
henhold til artikel 2, stk. 14 i tobaksvaredirektivet, hvilket betyder, at de er markedsført efter
den 19. maj 2014. THP'er kan derfor ikke betragtes som en af de eksisterende
"produktkategorier" i henhold til artikel 7, stk. 12 og artikel 11, stk. 6 i tobaksvaredirektivet.
3.7 EU-lovgiveren kunne ikke på lovlig vis have delegeret beføjelser til Kommissionen til at
regulere en ny kategori af tobaksvarer. Lovgiveren ville i den forbindelse have delegeret
beføjelserne til at regulere et nyt produkt, som EU-lovgiveren aldrig havde taget i betragtning,
og som havde en helt anden risikoprofil end de etablerede tobaksvarekategorier (se
yderligere i afsnit [4.16-4.20] nedenfor). Ifølge enhver analyse omfatter dette politiske valg
hinsides de "ikke-væsentlige elementer", der kan behandles via delegeret lovgivning.
3.8 Fire medlemsstater gjorde tobaksekspertgruppen opmærksom på dette, da Kommissionen
udgav første udkast til det delegerede direktiv.8 I henhold til disse medlemsstater gælder der
følgende for det delegerede direktiv:
3.8.1 "har en dybdegående indvirkning på området med opvarmede tobaksvarer" og
introducerer en "kompleks og omfattende reform"; og
3.8.2 "overskrider den delegerede beføjelse i henhold til direktiv 2014/40/EU og omfatter
væsentlige elementer, der er forbeholdt de europæiske lovgivere".
3.9 Kommissionen har aldrig reageret på denne bekymring – hverken i tobaksekspertgruppen
eller i Begrundelsen, der ledsager det delegerede direktiv.
3.10 Som nævnt ovenfor fordrer den etablerede retspraksis, at der ved vurderingen af, om et
element er "væsentligt", skal tages hensyn til det "pågældende felts karakteristika og særlige
egenskaber". I den forbindelse skal det bemærkes, at artikel 168, stk. 5, i TEUF udtrykkeligt
udelukker "nogen form for harmonisering" med hensyn til "beskyttelse af folkesundheden i
forbindelse med tobak", hvilket tydeligt påpeger nye kategorier af tobaksvarers "væsentlige"
karakter. Denne begrænsning af EU's beføjelser kræver, at delegerede beføjelser på dette
område ikke kan fortolkes i bredt omfang. Selvom vi har forståelse for, at artikel 114 i TEUF
er det retsgrundlag, der anvendes for tobaksvaredirektivet, ville det være højst
bemærkelsesværdigt, hvis Kommissionen i kraft af en delegeret lov kunne påvirke en
medlemsstats evne til at godkende salg af visse tobaksvarer med nedsatte risikoprofiler (i
forhold til cigaretter) som et instrument i en folkesundhedspolitik. Hvis dette var muligt, ville
en sådan traktats sikkerhedsforanstaltning i henhold til medlemsstaternes kompetence være
værdiløs.
3.11 Konklusionen om, at indførelsen af nye regler for nye produkter ikke kan ske ved delegeret
handling, fremgår ligeledes af ordlyden af artikel 7, stk. 12, og artikel 11, stk. 6 i
tobaksvaredirektivet, der fastslår, at de delegerede beføjelser kan benyttes til "en bestemt
produktkategori".
3.12 Begrebet "bestemt produktkategori", som anvendes i artikel 7 i tobaksvaredirektivet, svarer til
de veletablerede "kategorier", der er anført i artikel 2, stk. 14, litra a), i tobaksvaredirektivet.
Denne bestemmelse definerer "ny kategori af tobaksvarer" som ethvert tobaksprodukt:
3.12.1 bortset fra "cigaretter, rulletobak, pibetobak, vandpibetobak, cigarer, cigarilloer,
tyggetobak, tobak der indtages nasalt eller tobak der indtages oralt", som
3.12.2 også er "nyt", dvs. det er første gang markedsført efter 19. maj 2014.
3.13 I medfør af tobaksvaredirektivets klare ordlyd skal begrebet "bestemt produktkategori" derfor
opfattes særskilt fra begrebet "ny kategori af tobaksvarer". Disse er gensidigt udelukkende
8
18. møde i gruppen af eksperter i tobakspolitik den 9. februar 2022
8
produktgrupper, da artikel 2, stk. 14 udtrykkeligt definerer "ny kategori af tobaksvarer" som
modsætningen til "særlige produktkategorier".
3.14 Dette bekræftes yderligere af artikel 28, stk. 2 i tobaksvaredirektivet, som opremser de
elementer, som Kommissionen skal være særlig opmærksom på i sin rapport om
anvendelsen af tobaksvaredirektivet. Artikel 28, stk. 2 skelner mellem markedsudviklinger
vedrørende nye kategorier af tobaksvarer (artikel 28, stk. 2, litra b)) og markedsudviklinger,
der udgør en væsentlig ændring i forholdene (artikel 28, stk. 2, litra c)). Dette understreger
igen tydeligt, at nye kategorier af tobaksvarer adskiller sig fra produktkategorierne i artikel 7,
stk. 12 og artikel 11, stk. 1 i tobaksvaredirektivet, og som er underlagt de delegerede
beføjelser.
3.15 Det bekræftes yderligere af prøven i artikel 28, stk. 2 i tobaksvaredirektivet på, om der er sket
en "væsentlig ændring i forholdene". Den første alternative betingelse for at tale om en
væsentlig ændring i forholdene er, at salgsmængderne for produktkategorien er steget med
mindst 10 % i mindst fem medlemslande. Men for nye kategorier af tobaksvarer som f.eks.
THP'er vil startniveauet pr. definition være nul, hvilket gør det matematisk umuligt at fastslå
en stigning på 10 %. Selv hvis man ignorerer denne matematiske virkelighed ved at tage
udgangspunkt i et tidspunkt kort efter lanceringen af den nye kategori af tobaksvarer på
markedet, vil enhver beregning, der tager udgangspunkt i et meget lavt grundtal, resultere i
enorme procentstigninger, selv om stigningen i absolutte tal er meget begrænset. Det gør
denne betingelse praktisk talt ubrugelig. Dette fremgår af Kommissionens rapport, der
angiveligt viser stigninger på over 999 % i salget af THP i visse medlemslande beregnet ud
fra meget lave grundværdier i 2018.9 Det er absurd, og det kan ikke have været hensigten
med EU-lovgivningen.
3.16 Denne fortolkning bekræftes også af tobaksvaredirektivets lovhistorik. I Begrundelsen til
Kommissionens forslag til tobaksvaredirektivet står der:
"Nye kategorier af tobaksvarer er produkter, der indeholder tobak, som ikke falder inden for
nogen af de etablerede produktkategorier (f.eks. cigaretter, rulletobak, pibetobak,
vandpibetobak, cigarer, cigarilloer, tyggetobak, tobak der indtages nasalt eller tobak der
indtages oralt), og som introduceres på markedet efter direktivets ikrafttræden. [...]10"
(understregning tilføjet)
3.17 Konklusionen er klar. Den delegerede beføjelse i artikel 7, stk. 12, og artikel 11, stk. 6,
påtænker, at Kommissionen kan fjerne visse undtagelser, hvis nogle af de etablerede
kategorier skulle nå et vist salgsniveau hos forbrugere, som udløser tærsklen for "væsentlig
ændring i forhold" som defineret i artikel 2, stk. 28 i tobaksvaredirektivet, f.eks. cigarilloer eller
cigarer. Som fordret af artikel 290, stk. 1 i TEUF blev den politiske beslutning om at fjerne
disse undtagelser i tilfælde af øget salg af disse etablerede kategorier i forhold til andre
tobaksvarer (dvs. det væsentlige element) taget af EU-lovgiveren ved optagelse af
tobaksvaredirektivet. Den delegerede beføjelse defineres også præcist af lovgiveren som
fordret af artikel 290, stk. 1 i TEUF. Denne delegerede beføjelse kan dog ikke anvendes til at
regulere nye produkter, som lovgiveren aldrig specifikt har taget i betragtning – som ikke er
en "særlig produktkategori" i henhold til artikel 7, stk. 12, og artikel 11, stk. 6 i
tobaksvaredirektivet – og som har en fundamentalt forskellig risikoprofil fra de etablerede
tobaksvarekategorier.
3.18 Begrundelsen, der ledsager det delegerede direktiv, indeholder meget lignende argumenter:
"Artikel 7, stk. 12, og artikel 11, stk. 6, i direktiv 2014/40/EU giver ikke Kommissionen
nogen skønsmargen, men giver Kommissionen den tekniske opgave at fastslå, om der er
9 Kommissionens rapport, tabel 1.
10
Punkt 3.6 i Begrundelse til forslag til Europa-Parlamentets og Rådets direktiv om tilnærmelse af
medlemsstaternes love, forordninger og administrative bestemmelser vedrørende fremstilling,
præsentation og salg af tobak og relaterede produkter, KOM(2012)788 endelig udgave af 19.12.2012
findes her: https://eur-lex.europa.eu/legal-content/EN/TXT/?uri=celex%3A32014L0040
9
sket en væsentlig ændring i forholdene for en bestemt produktkategori, [...]. Den politiske
beslutning om at forbyde markedsføring af tobaksvarer med kendetegnende aromaer med
henblik på at opnå et højt sundhedsbeskyttelsesniveau, især for unge, er allerede foretaget
i medfør af EU-lovgiveren i selve direktiv 2014/40/EU (se også punkt 19 og 26 i
direktivet)."11 (understregning tilføjet)
3.19 Det er korrekt, at artikel 7, stk. 12, og artikel 11, stk. 6 ikke tildeler Kommissionen nogen
skønsmargen, men udelukkende den tekniske opgave at fastslå, om der foreligger en
væsentlig ændring i forholdene hvad angår eksisterende produktkategorier. Det er endvidere
korrekt, at eventuelle relevante politiske beslutninger bør anses for at være foretaget af
lovgiveren, navnlig at der for visse kategorier af eksisterende tobaksvarer var mulighed for en
mindre restriktiv ordning.
3.20 Dette bekræftes af punkt 19 og 26, som Kommissionens begrundelse, der ledsager det
delegerede direktiv, henviser til, og som siger følgende:
"(19) I betragtning af dette direktivs fokus på unge mennesker, andre tobaksvarer end
cigaretter og rulletobak bør der gøres en undtagelse fra visse krav vedrørende
indholdsstoffer, så længe der ikke sker væsentlige ændringer i forholdene hvad angår
salgsvolumen eller forbrugsmønstre blandt unge mennesker."
"(26) For anden røgtobak end cigaretter og rulletobak, der hovedsageligt forbruges af ældre
forbrugere og mindre dele af befolkningen, bør det være muligt fortsat at gøre en undtagelse
fra visse mærkningskrav, så længe der ikke er væsentlige ændringer i forholdene hvad angår
salgsvolumen eller forbrugsmønstre blandt unge mennesker. [...] For så vidt angår
vandpibetobak, der ofte opfattes som mindre skadelig end traditionel røgtobak, bør den fulde
mærkningsordning gælde for at undgå vildledning af forbrugerne."
3.21 Begrundelsen, der ledsager det delegerede direktiv og punkt 19 og 26, bekræfter, at de
delegerede beføjelser vedrører lovgiverens politiske beslutning om at behandle visse kendte
produktkategorier mindre strengt end andre. Ifølge Kommissionen blev cigaretter og
rulletobak betragtet som attraktive for unge mennesker, og vandpibetobak blev anset for at
kræve særbehandling på grund af påståede, fejlagtige opfattelser af dens skadelige virkning.
De resterende kategorier blev betragtet som "hovedsageligt indtaget af ældre forbrugere og
små dele af befolkningen." I betragtning af listen over "særlige produktkategorier" i artikel 2,
stk. 14, litra a), og det faktum, at tobak, der indtages oralt, er forbudt i alle medlemsstaterne
med undtagelse af Sverige, er det klart, at lovgiveren havde følgende for øje: pibetobak,
cigarer, cigarilloer, tyggetobak og tobak, der indtages nasalt.
3.22 Lovgiveren indarbejdede derefter en sikkerhedsmekanisme, i fald der skulle ske en ændring
i efterspørgslen fra cigaretter og rulletobak til en af disse produktkategorier (dvs. pibetobak,
cigarer, cigarilloer, tyggetobak eller tobak, der indtages nasalt). En sådan delegeret beføjelse
er faktisk af en rent "teknisk" karakter, nemlig at fastslå, om der var sket en "væsentlig
ændring i forholdene" hvad angår en af disse kategorier. I så fald måtte Kommissionen fjerne
undtagelsen for den pågældende kategori.
3.23 Uanset hvordan sagen analyses, ligger det uden for den "tekniske opgave" med at anvende
prøven på væsentlig ændring i forhold, når der oprettes en ny produktkategori, som lovgiveren
aldrig har taget i betragtning, og kategorien derefter pålægges de strengeste regler på trods
af den nedsatte risikoprofil i forhold til cigaretter – og det er netop hvad det delegerede direktiv
gør. Det indebærer også en betragtelig skønsmargen, og at der træffes valg ift.
sundhedspolitikken. Ifølge Kommissionens egen indrømmelse overskrider det vedtagne
delegerede direktiv derfor de delegerede beføjelser.
11
Begrundelse, der ledsager det delegerede direktiv, afsnit 2.
10
3.24 Det delegerede direktiv indfører ulovligt en ny "bestemt produktkategori" og krænker
dermed også de generelle EU-lovprincipper om retssikkerhed og legitime
forventninger
3.25 Selv om det principelt var muligt for Kommissionen at regulere et nyt produkt med en
delegeret beføjelse (hvilket det ikke er), overskrider det delegerede direktiv i væsentlig grad
den beføjelse, der er delegeret til Kommissionen i medfør af artikel 7, stk. 12, og artikel 11,
stk. 6.
3.26 Det delegerede direktiv introducerer den nye kategori "opvarmede tobaksvarer" i
tobaksvaredirektivet. Artikel 7, stk. 12 og artikel 11, stk. 6 i tobaksvaredirektivet giver dog kun
Kommissionen mulighed for at fjerne en undtagelse for eksisterende, veletablerede
produktkategorier. De giver ikke Kommissionen mulighed for at oprette en ny "bestemt
produktkategori".
Denne fortolkning understøttes af Kommissionens rapport, der blev vedtaget den 20. maj 2021.12
3.27 I denne rapport giver Kommissionen udtryk for, at definitionerne i tobaksvaredirektivet13 bør
ændres og forbedres, og at tobaksvaredirektivet ikke giver "fleksibilitet til at definere nye
produktkategorier."14 Som forklaret i afsnit [3.8] herover, blev samme opfattelse gentaget af
flere medlemsstater under processen med at indføre det delegerede direktiv, herunder i de
fire medlemslandes fælles erklæring, hvori der stod: "ved at introducere en definition af
"opvarmede tobaksvarer" (...) overskrider Kommissionen ifølge os grænserne for de
delegeringskompetencer, den er tildelt".15
3.28 Desuden ville det være ulogisk, hvis Kommissionen nu kunne oprette nye produktkategorier,
som den retroaktivt kunne anvende historiske data på for at fastslå en "væsentlig ændring i
forholdene". Uanset hvad, hvis oprettelsen af en ny produktkategori skulle være mulig, ville
den retroaktive anvendelse af prøven i sig selv være et separat grundlag for ugyldigheden af
det delegerede direktiv, da dette ville være i strid med principperne om juridisk sikkerhed og
legitime forventninger. Der er intet i tobaksvaredirektivets tekst eller dets lovgivningsmæssige
historik, der antyder, at Kommissionen kan påberåbe sig artikel 7, stk. 12, og artikel 11, stk.
6 for at ændre reglerne for en ny kategori af tobaksvarer og underminere de
investeringsbeslutninger, der træffes i henhold til disse regler. Den retsusikkerhed, der
forårsages af det delegerede direktiv, blev sågar fremhævet af medlemsstaterne i deres
fælles erklæring som nævnt i afsnit [3.8] ovenfor.
3.29 Den retroaktive anvendelse af prøven ville også give Kommissionen mulighed for at tage
højde for de historiske data i forbindelse med tilpasning af definitionen af en ny
produktkategori med henblik på at opfylde kriterierne i prøven på en "væsentlig ændring i
forholdene". Sagt på en anden måde kan Kommissionen ved at definere en ny
produktkategori på bredere eller smallere vis – set i lyset af historiske data – indirekte
kontrollere, om der er sket en væsentlig ændring i forholdene. Faktisk synes Kommissionen
at have gjort netop dette i nærværende tilfælde ved at oprette en ny produktkategori, der
omfatter både produkter til rygning og røgfri produkter. Dette har gjort det muligt for
Kommissionen at skabe og regulere en ny produkttype, nemlig opvarmede tobaksvarer til
rygning, som, så vidt BAT ved, ikke findes på EU-markedet og bestemt ikke i mængder, der
12 Rapport fra Kommissionen til Europa-Parlamentet, Rådet, Det Europæiske Økonomiske og Sociale
Udvalg og Regionsudvalget om anvendelsen af direktiv 2014/40/EU om fremstilling, præsentation og salg
af tobak og relaterede produkter, COM(2021) 249 endelig udgave af 20.5.2021 ("Artikel 28-rapport")
findes her: https://eur-lex.europa.eu/legal-content/EN/TXT/PDF/?uri=CELEX:52021DC0249&from=EN
13
Artikel 28-rapport, fodnote 43.
14
Artikel 28-rapport, side 12. Se også bl.a. med hensyn til opvarmede tobaksvarer erklæringen om, at
tobaksvaredirektivet "ikke (...) giver fleksibilitet til at håndtere hurtige produktudviklinger". (side 12).
15
18. møde i gruppen af eksperter i tobakspolitik den 9. februar 2022
11
ville kunne betegnes som en "væsentlig ændring i forholdene". Dette kan ikke være en korrekt
anvendelse af artikel 7, stk. 12, og artikel 11, stk. 6.
3.30 Det delegerede direktiv indfører på ulovlig vis en ny "bestemt produktkategori", der
ikke er i overensstemmelse med systemet i tobaksvaredirektivet
3.31 Den nye kategori af opvarmede tobaksvarer, der introduceres i det delegerede direktiv, er
også uforenelig med tobaksvaredirektivets system af to årsager.
3.32 For det første harmonerer det ikke, at den nye kategori af opvarmede tobaksvarer både er en
ny kategori af tobaksvarer og en "bestemt produktkategori" på én og samme tid. Ifølge
betragtning 4 og artikel 1 i det delegerede direktiv er en "opvarmet tobaksvare" en "ny kategori
af tobaksvarer", som derfor ligger inden for rammerne af den generelle kategori "ny kategori
af tobaksvarer" i henhold til betydningen i artikel 2, stk. 14 i tobaksvaredirektivet. Men som
omtalt ovenfor i afsnit [3.12] er "bestemt produktkategori" og ny kategori af tobaksvarer to
grupper, der udelukker hinanden. Derfor kan et produkt aldrig indgå i begge grupper. Det
delegerede direktiv udvisker derfor de forskelle, som lovgiver har fastlagt mellem disse
begreber og produktgrupper, ved uretmæssigt at behandle en ny kategori af tobaksvarer som
en etableret produktkategori.
3.33 For det andet omfatter den nye kategori "opvarmede tobaksvarer", som defineret i det
delegerede direktiv, både tobaksvarer, der er "røgfri", og "røgtobak". I tobaksvaredirektivet
skelnes der dog klart mellem røgfri tobaksvarer og røgtobak,16 og der opstilles meget
anderledes og mere vægtige mærknings- og emballageregler for sidstnævnte,17 hvilket
afspejler deres grundlæggende forskelligartede karakter. Tobaksvaredirektivet indeholder
endvidere udtrykkeligt bestemmelser om, at nye kategorier af tobaksvarer er omfattet af den
ene eller den anden kategori, og i artikel 19, stk. 4, forklares det, at: "Hvilke af
bestemmelserne i dette direktiv, der finder anvendelse på nye kategorier af tobaksvarer,
afhænger af, om de pågældende produkter falder ind under definitionen af en røgfri
tobaksvare eller af røgtobak", og forskellen mellem dem er dermed baseret på eksistensen af
"forbrænding" eller den manglende eksistens deraf,18 dvs. afbrænding af tobak og den deraf
følgende frembringelse af røg.
3.34 Ifølge tobaksvaredirektivet er det derfor ikke juridisk muligt for en enkelt produktkategori at
omfatte både røgfri tobaksvarer og røgtobak i forbindelse med tobaksvaredirektivet.
3.35 Af ovennævnte årsager udgør det delegerede direktivs indførelse af den nye kategori THP'er
en væsentlig overtrædelse af tobaksvaredirektivet, hvilket, i medfør af artikel 290 i TEUF,
naturligvis ikke er en beføjelse, der kunne være blevet delegeret til Kommissionen.
3.36 Kommissionens tilgang til vurderingen af eksistensen af en "væsentlig ændring i
forholdene" går ud over omfanget af den opgave, som den er blevet tillagt
3.37 Som beskrevet ovenfor undersøges det i Kommissionens rapport, hvorvidt der er sket en
"væsentlig ændring i forholdene" i henhold til betydningen i artikel 2, stk. 28, i
tobaksvaredirektivet, og der konkluderes, at den første alternative betingelse og den
nødvendige betingelse begge var opfyldt.
3.38 Med hensyn til undersøgelsen af den nødvendige betingelse, dvs. at salgsvolumen af den
relevante produktkategori i detailleddet overstiger 2,5 % af det samlede salg af tobaksvarer
16 Se definitionerne fra artikel 2, stk. 9, i tobaksvaredirektivet, der definerer røgtobak og røgfri tobaksvarer i
afsnit [4.6-4.7] nedenfor.
17
De specifikke regler for røgtobak er fastlagt i artikel 9-11 i tobaksvaredirektivet, hvorimod de specifikke
regler for røgfri tobaksvarer er fastlagt i artikel 12 i tobaksvaredirektivet.
18
Se definitionerne af "røgfri tobaksvarer" og "røgtobak" fra artikel 2, stk. 5, og artikel 2, stk. 9, i
tobaksvaredirektivet i afsnit [4.6-4.7], som afhænger af, om der er tale om en "forbrændingsproces". Se
også definitionen af "urtebaseret rygeprodukt" i artikel 2, stk. 15, i tobaksvaredirektivet, hvor der ligeledes
henvises til, hvorvidt der foregår en "forbrændingsproces".
12
på EU-plan, søges det i Kommissionens rapport på upassende vis at vurdere dette på
grundlag af "cigaretter". I den forbindelse udføres der i Kommissionens rapport en række
komplekse datajusteringer og beregninger. Dette omfatter navnlig:
3.38.1 Der foretages justeringer af dataene for rulletobak, pibetobak og tyggetobak med
henblik på at konvertere dataene for disse produktkategorier til "cigaret"-
ækvivalenter for at kunne sammenligne dem med de andre produktkategorier.
(A) Rulletobak konverteres til "cigaretter" baseret på den antagelse, at 0,7 gram
af produktet er lig med én cigaret.19
(B) Pibe- og tyggetobak konverteres til "cigaretter" ved at tage markedsandel
af denne produktkategoris detailværdi og anvende denne på den samlede
markedsstørrelse i "cigaretter".20
3.38.2 Data fra tre forskellige kilder (herunder en med ikke-officielle kommercielle data)21
kombineres på forskellige måder, hvilket resulterer i, at salgsvolumen af opvarmede
tobaksvarer skulle udgøre 3,33 % af alle tobaksvarers samlede salgsvolumen i EU
i 2020.22
3.39 Ved at udvikle denne fejlbehæftede og komplekse metodologi og basere sine overvejelser
derpå går Kommissionen ud over omfanget af den opgave, som den er tillagt i henhold til
artikel 7, stk. 12, og artikel 11, stk. 6, i tobaksvaredirektivet, og som, som Kommissionen selv
forklarer i den begrundelse, der ledsager det delegerede direktiv, "[ikke giver] Kommissionen
noget skøn, men lader det være en teknisk opgave at fastslå, om der er sket en væsentlig
ændring i forholdene for en bestemt produktkategori".23 Det, som Kommissionen rent faktisk
har gjort, rækker langt ud over en teknisk beregning, der ikke indebærer skøn (som den burde
have været). Kommissionen har udviklet en kompleks metodologi, der indebærer forkerte
valg, der tilsyneladende fører til det ønskede resultat, nemlig en overskridelse af
grænseværdien på 2,5 %.
3.40 Grundlæggende set er Kommissionens tilgang til undersøgelsen af de forskellige
produktkategorier udelukkende baseret på "cigaretter" tydeligvis upassende, da dette er et
uanvendeligt grundlag for sammenligning af de forskellige produktkategorier. Eksempelvis er
det ganske enkelt ikke korrekt at sige, at en cigaret plus en cigar er lig med "to cigaretter"; en
cigar indeholder tydeligvis langt mere tobak end en cigaret. Ligeledes og helt grundlæggende
set indeholder en cigaret meget mere tobak end en THP, dvs. cirka dobbelt så meget.
3.41 Tobaksmængden eller -vægten er selvfølgelig det korrekte kriterium med hensyn til
markedsandelen, da hele formålet med aromaforbuddene i artikel 7, stk. 1, og artikel 7, stk.
7, i tobaksvaredirektivet og dermed det delegerede direktiv (som fjerner undtagelsen fra disse
forbud for THP'er) er at reducere tobaksforbruget.24 Som sådan svarer Kommissionens
beslutning om at anvende en beregning baseret på en "cigaret" uden at tage højde for
krystalklare forskelle mellem produkterne med hensyn til den tobaksmængde, som hvert
produkt indeholder, til at sammenligne to vidt forskellige ting.
3.42 En beregning baseret på tobaksmængden eller -vægten er derfor den korrekte metode. En
sådan metode ville også have undgået behovet for at bruge flere datasæt og komplekse
beregninger, der indebærer betydelige og problematiske justeringer. Nøjagtige vægtbaserede
19 Kommissionens rapport, tabel 3 asterisk og fodnote 3.
20 Kommissionens rapport, tabel 3 dobbelt asterisk og tabel 5 asterisk.
21
Dataene er hentet fra følgende tre kilder: (i) EU-CEG-data og Euromonitor-data om salg af opvarmede
tobaksvarer i EU (Kommissionens rapport, tabel 2), (ii) Euromonitor-data om samlet salg af tobaksvarer i
EU delt op efter produktkategorier (Kommissionens rapport, tabel 3) og (iii) Sporbarhedsproduktionstal for
cigaretter og rulletobak, både tidsjusterede og ikke-tidsjusterede tal (Kommissionens rapport, tabel 4).
22
Kommissionens rapport, afsnit 2.2.3.
23 Begrundelse, der ledsager det delegerede direktiv, afsnit 2.
24
Tobaksvaredirektivet, betragtning 16.
13
data om alle produktkategorier ville også have været let tilgængelige for Kommissionen i form
af EU-CEG-data.25 I Kommissionens rapport nævnes der imidlertid intet om den
vægtbaserede metode, og der angives ikke engang, at en opvarmet tobakspind kun
indeholder omtrent halvdelen af den tobak, der er i en cigaret. Da cigaretter udgør langt
størstedelen af tobaksmarkedet26, hvilket er et spørgsmål om simpel og ligetil matematik,
indebærer dette, at THP'ers markedsandel målt efter vægt vil være omtrent halvdelen af
markedsandelen målt efter "cigaret"-princippet, dvs. omkring 1,65 % i stedet for 3,33 %, og
dermed et godt stykke under grænseværdien på 2,5 %.
3.43 Ved ikke på behørig vis at undersøge og drage konklusioner ud fra de let tilgængelige data
på passende faglig vis (og i stedet for foretage uberettigede metodiske valg for at nå frem til
det resultat, den ønskede at opnå), er Kommissionen ulovligt gået ud over omfanget af den
tillagte opgave og har i bund og grund manipuleret betingelserne for sin brug af de delegerede
beføjelser.
3.44 Derudover har Kommissionen ikke givet offentligheden adgang til de underliggende data,
hverken da det delegerede direktiv blev offentliggjort, eller efterfølgende efter anmodning.
Dette har gjort det umuligt at foretage en rigtig undersøgelse af Kommissionens beregninger.
BATs juridiske repræsentanter har anmodet om adgang til disse data samt vægtdata fra EU-
CEG i henhold til forordning (EF) nr. 1049/2001. Imidlertid har Kommissionen afvist disse
anmodninger27 på baggrund af fuldstændigt usande påskud, herunder at Kommissionen ikke
"ejede" dataene, og at de derfor tilsyneladende ikke kunne udleveres, og at tilvejebringelse
af dataene af en eller anden grund ville omfatte "oprettelse af et nyt dokument", selv om
dataene allerede var blevet anvendt af Kommissionen selv i forbindelse med dens
beregninger.
3.45 Endelig bemærker vi, at Kommissionens rapport også indeholder en alternativ beregning
baseret på Euromonitor-data om det samlede salg af tobaksvarer i EU efter værdi, opdelt efter
produktkategorier, og den lander tilsyneladende på 3,51 %.28 Der skal under alle
omstændigheder ses bort fra denne beregning, da en sådan tilgang strider mod selve artikel
2, stk. 28, i tobaksvaredirektivet, hvori det fastlægges, at beregningen skal foretages på
baggrund af "salgsvolumen", ikke "salgsværdi". Derfor vil ethvert forsøg på at retfærdiggøre
det delegerede direktiv med henvisning til denne beregning være i strid med de tildelte
uddelegerede beføjelser.
3.46 Det delegerede direktiv er ugyldigt og bør ikke omsættes til dansk national ret
3.47 Som det tydeligt fremgår af ovenstående, udgør det delegerede direktiv en ulovlig udøvelse
af Kommissionens delegerede beføjelser. Det delegerede direktiv er derfor ugyldigt i henhold
til EU-retten, og eventuel lovgivning om omsætning af det delegerede direktiv til dansk
national ret vil også være ugyldig.
3.48 Som anført i afsnit [1.10] ovenfor anfægtes gyldigheden af det delegerede direktiv derudover
i øjeblikket både for EU-Domstolen og for de irske domstole. Selv om Sundhedsministeriet
mener, at det skal implementere det delegerede direktiv uanset ovenstående argumenter, bør
der under disse omstændigheder anvendes en forsigtig tilgang, og gennemførelse bør ikke
hastes igennem. Vi bemærker, at medlemsstaterne har indtil den 23. juli 2023 til at omsætte
det delegerede direktiv til national lovgivning. Vi opfordrer Sundhedsministeriet til at vente til
25 Blandt de oplysninger, der skal oplyses i EU-CEG-systemet, er den "[samlede] vægt af indholdet af tobak i
én produktenhed i mg" (en produktenhed er en pind eller 1 g for løs tobak) (se Kommissionens
gennemførelsesafgørelse (EU) 2015/2186, bilag, afsnit 3).
26 Kommissionens rapport, tabel 5.
27
BATs juridiske repræsentanter har indsendt en ansøgning om annullering af Kommissionens afgørelse
om afslag, som i øjeblikket er under behandling for Retten (ansøgning indgivet den 12. september 2022,
Herbert Smith Freehills v Kommissionen, T-570/22).
28
Kommissionens rapport, afsnit 2.2.4.
14
sidste øjeblik med at gennemføre direktivet, således at der muligvis først kan blive afsagt en
EU-dom om det delegerede direktivs gyldighed forud for omsætningen.
4. DEFINITION OG KLASSIFICERING AF THP
4.1 Som nævnt ovenfor mener vi ikke, at Sundhedsministeriet på nuværende tidspunkt bør
omsætte det delegerede direktiv til dansk ret. Hvis Sundhedsministeriet går videre med
omsætningen, mener vi dog, at det foreslåede sprog i lovforslaget er egnet til at definere
THP'er.
4.2 Det delegerede direktiv indsætter følgende i artikel 7, stk. 12, i tobaksvaredirektivet:
"I første afsnit forstås ved »opvarmet tobaksvare« en ny kategori af tobaksvarer, der
opvarmes for at frembringe en emission indeholdende nikotin og andre kemikalier, som
derefter inhaleres af brugeren/brugerne, og som afhængigt af deres karakteristika er røgfri
tobaksvarer eller røgtobak." (det understregede er blevet tilføjet).
4.3 Ifølge det delegerede direktiv findes der to typer THP'er: røgfri og røgtobak, og
klassificeringen af varen som røgfri eller røgtobak afhænger af varens egenskaber.
4.4 Lovforslaget gør på behørig vis noget ud af denne skelnen mellem røgfri tobaksvarer og
røgtobak, og det foreslås at indsætte følgende definition i tobaksvarelovens § 2, stk. 31:
"Opvarmet tobaksvare: En ny kategori af tobaksvarer, der opvarmes for at frembringe en
emission indeholdende nikotin og andre kemikalier, som derefter inhaleres af
brugeren/brugerne, og som afhængigt af deres karakteristika er røgfri tobaksvarer eller
røgtobak."
4.5 I lovforslaget anerkendes det endvidere, at det delegerede direktiv ved ændring af artikel 11,
stk. 1, i tobaksvaredirektivet, alene fjerner muligheden for, at THP'er kan undtages fra kravet
om påklæbning af den informationsmeddelelse, der er indeholdt i artikel 9, stk. 2, i
tobaksvaredirektivet og den kombinerede sundhedsadvarsel fra artikel 10 i
tobaksvaredirektivet: "for så vidt de er røgtobak".
4.6 I artikel 2, stk. 5, i tobaksvaredirektivet defineres røgfri tobaksvarer som "en tobaksvare, der
ikke forbruges via en forbrændingsproces, herunder tyggetobak, tobak, der indtages nasalt,
og tobak, der indtages oralt" (understregning tilføjet).
4.7 I artikel 2, stk. 9, i tobaksvaredirektivet defineres røgtobak som "tobaksvarer, som ikke er
røgfrie tobaksvarer".
4.8 Den væsentligste forskel mellem røgfri tobaksvarer og røgtobak er altså tilstedeværelsen eller
fraværet af en "forbrændingsproces". Med andre ord er de relevante produktkarakteristika ved
klassificeringen som røgfri eller røgtobak, uanset hvordan produktet anvendes, hvorvidt det
indebærer forbrænding eller ej.
4.9 Denne konklusion underbygges af en afgørelse fra forvaltningsretten i Stockholm, som
afgjorde, at det eneste kriterium for vurdering af, hvorvidt et THP er "røgtobak" eller et "røgfrit
tobaksprodukt", er, om der foregår forbrænding.29
4.10 Brugen af BATs THP, glo™, indebærer ikke en forbrændingsproces. Tobakken i disse
produkter opvarmes (den forbrændes ikke), og der produceres en nikotinholdig aerosol, der
generelt indeholder langt færre og lavere niveauer af giftige stoffer end almindelig cigaretrøg.
For eksempel opvarmer glo™ tobakken. Når cigaretter ryges, antændes tobakken, hvilket
resulterer i en eksotermisk proces, der fører til meget højere temperaturer samt kontinuerlig
forbrænding og ulmen.
4.11 Konklusionen om, at BATs THP er røgfri, underbygges af retslige kendelser.
Forvaltningsretten i Braunschweig (Tyskland) har f.eks. konkluderet, at THP'er er røgfri, fordi
29 Forvaltningsdomstolen i Stockholm, sag nr. 3803-22, Philip Morris Products SA v The Public Health
Authority, 26. september 2022.
15
de ikke indebærer en forbrændingsproces.30 Den tyske føderale tilsynsmyndighed
appellerede ikke denne kendelse, der nu er blevet inappellabel.
4.12 Den tyske domstol kom frem til denne konklusion efter at have overvejet ekspertudtalelsen
fra Mitchell Smooke, en internationalt anerkendt ekspert i forbrændingsteori og lektor ved Yale
University School of Engineering and Applied Science. En kopi af Mitchell Smookes råd findes
i appendix (1).
4.13 Mitchell Smooke forklarede i sin analyse over for retten, at tobak kun antændes ved
temperaturer på mellem 435 °C og 455 °C, hvilket er langt over driftstemperaturerne for THP-
enheder, og at der uden forbrænding ikke kan være nogen "forbrændingsproces". Mitchell
Smooke forklarede yderligere retten, at en opvarmet tobaksvareenhed opererer i en såkaldt
"før-antændingszone", hvor temperaturerne ikke er tilstrækkelige til hverken antændelse eller
forbrænding, og at THP-enheder derfor ikke genererer røg. Mitchell Smooke præciserede
over for retten, at materialer, der opvarmes til en "før-antændingszone" og ikke yderligere,
ikke undergår "forbrænding" eller en "forbrændingsproces".
4.14 Dette er i overensstemmelse med den amerikanske fødevare- og lægemiddeladministrations
("FDA") entydige konklusion om, at THP'er ikke indebærer en forbrændingsproces. I sin
seneste godkendelse af markedsføring og salg af en THP på det amerikanske marked (omtalt
nærmere nedenfor) omtalte FDA THP-enheden og relaterede forbrugsvarer som faldende
inden for underkategorien "ikke-forbrændt" produkt. I beskrivelsen af THP-forbrugsvarerne
angav FDA, at de er designet til at blive opvarmet elektrisk med henblik på at frigive
nikotinholdige aerosoler og ikke er beregnet til at blive forbrændt. I sin beskrivelse af THP-
enheden bemærkede FDA, at den elektroniske styring har til formål at opretholde et bestemt
temperaturinterval, der gør det muligt at generere aerosoler og forhindrer, at den når
temperaturer, hvor der kan forekomme forbrænding.31
4.15 Da BATs glo-THP'er er røgfri tobaksvarer, vil ethvert krav om at påklæbe
informationsmeddelelsen fra artikel 9, stk. 2, i tobaksvaredirektivet og de kombinerede
sundhedsadvarsler fra artikel 10 i tobaksvaredirektivet på glo-THP'er være ugyldigt.
4.16 Da der ikke foregår forbrænding, er den reducerede risikoprofil for opvarmede tobaksvarer
sammenlignet med brændbare cigaretter blevet anerkendt af en række offentlige
sundhedsorganisationer. Public Health England har eksempelvis konkluderet, "at de
foreliggende beviser tyder på, at opvarmede tobaksvarer kan være betydeligt mindre
skadelige end tobakscigaretter."32
4.17 På samme måde fandt undersøgelser udført af UK Committee on Toxicology, "at
eksponeringen for problematiske forbindelser ved brug af ikke-forbrændte, opvarmede
tobaksvarer er reduceret i forhold til eksponeringen fra almindelig cigaretrøg, og at det er
sandsynligt, at den samlede sundhedsrisiko reduceres for konventionelle rygere, der skifter
til ikke-forbrændte, opvarmede tobaksvarer."33
4.18 Senest har det hollandske institut for sundhed og miljø (RIVM) bemærket følgende:
"Overordnet set synes det at være en begrundet konklusion, at forbrug af THP'er i stedet for
30 Forvaltningsretten i Braunschweig, 4. kammer, sag nr. 4-A-427/20, British American Tobacco (Tyskland)
GmbH v Forbundsrepublikken Tyskland, repræsenteret af det føderale kontor for forbrugerbeskyttelse og
fødevaresikkerhed, den 23. september 2021.
31
Den amerikanske fødevare- og lægemiddeladministration, teknisk projektgennemgang af PMTA, s. 15,
den 29. april 2019, tilgængelig på https://www.fda.gov/media/124247/download.
32
McNeill A, Brose LS, Calder R, Bauld L & Robson D., Evidence review of e-cigarettes and heated tobacco
products 2018, A report commissioned by Public Health England, tilgængelig her, s. 220.
33 UK Committee on Toxicology, Toxicological Evaluation of novel heat-not-burn tobacco products – non-
technical summary, 2017, tilgængelig her, s. 4.
16
cigaretter vil være forbundet med en væsentlig stigning i den forventede levetid for den
undergruppe af rygere, der dør af kræft."34
4.19 Disse resultater understøttes af BATs forskning med peer-review, der viser, at niveauet af
giftige stoffer i emissioner fra BATs glo-THP reduceres betydeligt på tværs af adskillige
kemiske klasser i forhold til sammenlignelige brændbare cigaretter.35 Nylig klinisk forskning
med peer-review fra BAT har også udpeget væsentlige gunstige ændringer i biomarkører for
potentiel skade over seks måneder og et år, hvor rygere skifter over til udelukkende at bruge
BATs glo-THP, i forhold til fortsat at ryge cigaretter.36 Forskningen viser, at mange af de
gunstige ændringer i biomarkører for potentiel skade var af samme størrelsesorden som hos
de deltagere, der ved forsøgets start var holdt op med at ryge uden at begynde at bruge en
opvarmet tobaksvare. Denne forskning bidrager til dokumentationen af, at rygere, der skifter
over til opvarmede tobaksvarer, derfor kan reducere deres relative sundhedsrisici i forhold til
at fortsætte med at ryge.
4.20 Desuden viser de tilgængelige beviser, at der ikke er sket nogen betydelig stigning i unge,
der begynder at bruge THP'er, og dermed ingen dokumenteret grund til bekymring over, at
THP'er kunne fungere som gateway til øget brug af brændbar tobak eller øget påbegyndelse
af rygning.37 Dette underbygges af Kommissionens egen rapport, der som beskrevet ovenfor
fandt, at der ikke var sket nogen væsentlig stigning i udbredelsen af brugen af disse produkter
i gruppen af forbrugere under 25 år i Europa, og at den anden alternative betingelse for at
påvise en "væsentlig ændring i forholdene" dermed ikke er opfyldt.38
4.21 Markedsføringen af THP'er er derfor i overensstemmelse med princippet om at reducere
skader som følge af tobaksrygning, som er nedfældet i artikel 1, litra d), i WHO-rammeaftalen
om tobakskontrol, da det eliminerer eksponering for tobaksrøg for rygere, der skifter
fuldstændigt over til THP'er. Det delegerede direktiv er dog i strid med dette princip, da det
delegerede direktiv ved at forbyde THP'er, der angiver smagsstoffer eller indeholder
smagsstoffer i deres komponenter, gør opvarmede tobaksvarer mindre acceptable over for
eksisterende rygere og dermed afskrækker dem fra at skifte og viderefører mere skadelig
rygning (se afsnit [5] nedenfor).
4.22 EU-lovgiveren har selv anerkendt dette med hensyn til elektroniske cigaretter (et andet nyt
produkt med betydeligt potentiale for at reducere skader som følge af tobaksrygning) ved i
betragtning 47 i tobaksvaredirektivet at anføre, at "[d]et kunne være nyttigt for
medlemsstaterne at overveje at tillade markedsføringen af produkter med aromaer", og at
"[f]orbud mod sådanne produkter med aromaer vil skulle begrundes".
34
Slob W, Soeteman-Hernández LG, Bil W, Staal YCM, Stephens WE, Talhout R. A Method for Comparing
the Impact on Carcinogenicity of Tobacco Products: A Case Study on Heated Tobacco Versus Cigarettes.
Risk Anal. 2020 Jul;40(7):1355-1366, tilgængelig her, s. 1362.
35
Forster M, Fiebelkorn S, Yurteri C, Mariner D, Liu C, Wright C, McAdam K, Murphy J, Proctor C. Assessment
of novel tobacco heating product THP1.0. Part 3: Comprehensive chemical characterisation of harmful and
potentially harmful aerosol emissions. Regulatory Toxicology and Pharmacology. 2018 Mar;93:14-33,
tilgængelig her.
36 Gale, N., McEwan, M., Camacho, O.M. et al. Changes in biomarkers after 180 days of tobacco heating
product use: a randomised trial. Intern Emerg Med (2021) 16:2201–2212, tilgængelig her; og Gale, N.,
McEwan, M., Hardie, G, et al. Changes in biomarkers of exposure and biomarkers of potential harm after
360 days in smokers who either continue to smoke, switch to a tobacco heating product or quit smoking.
Intern Emerg Med (2022) 17:2017–2030, tilgængelig her.
37
Se f.eks. Jones, Joshua & Adamson, Jason & Kanitscheider, Claudia & Prasad, Krishna & Camacho, Oscar
& Beliaeva, Ekaterina & Bauer, Hans & Keralapura, Yoga & Murphy, James. (2020). A National Cross-
Sectional Survey to Assess Tobacco and Nicotine Product Usage Patterns and Behaviour Since the
Introduction of Tobacco Heating Products in Japan: Wave 1. Tobacco Regulatory Science, bind 7, nr. 3,
May 2021, s. 210-220 (11), tilgængelig her.
38
Kommissionens rapport, afsnit 2.1.1.
17
5. SUNDHEDSMÆSSIGE KONSEKVENSER VED IMPLEMENTERING AF DET
DELEGEREDE DIREKTIV
5.1 Lovforslaget og implementeringen af det delegerede direktiv vil med større sandsynlighed
underminere den offentlige sundhed end forbedre den.
5.2 Med hensyn til de foreslåede smagsbegrænsninger vil disse have en negativ indvirkning på
voksne rygere og sandsynligvis medføre utilsigtede konsekvenser for den offentlige sundhed.
BAT har bestilt en ekspertrapport fra Sally Satel, M.D., som blev indsendt som svar på
Europa-Kommissionens høring vedrørende tobaksvaredirektivet/evaluering af
tobaksreklamedirektivet (en kopi af Sally Satels rapport findes i Appendix [2]). Dr. Satel er
læge med speciale i misbrugspsykiatri og fast lektor ved American Enterprise Institute. Hun
har ekspertise inden for sundhedspolitik, misbrug og skadesreduktion. Dr. Satel beskriver sin
holdning til ikke-brændbare dampprodukters rolle med hensyn til at reducere skader som
følge af tobak. Hun adresserer mange misforståelser vedrørende sundhedsrisiciene ved og
effektiviteten af ikke-brændbare dampprodukter som erstatning for rygning, herunder
vigtigheden af smagsstoffer og potentielle utilsigtede konsekvenser, der ville kunne opstå som
følge af et smagsforbud.
5.3 I sin rapport bemærker Sally Satel, at en begrænsning af det, der gør ikke-brændbare
dampprodukter attraktive, ved at begrænse smagsstoffer vil påvirke voksne rygere, dvs. den
gruppe, som disse produkter er rettet mod. Baseret på den videnskabelige litteratur finder
sådanne rygere ikke-brændbare dampprodukter med smag mere acceptable end dem, der
har tobakssmag. Hun mener, at en begrænsning af tilgængeligheden af ikke-brændbare
dampprodukter med smag vil have en række utilsigtede konsekvenser, herunder at brugerne
genoptager rygning eller vender sig mod det uregulerede sorte marked, hvis deres foretrukne
smagsstoffer ikke længere er tilgængelige.39
5.4 Ved derudover at anvende regler på THP'er, der er møntet på brændbare tobaksvarer,
formidles det vildledende budskab, at de risici, der er forbundet med THP'er, er de samme
som dem, der er forbundet med forbrug af brændbare tobaksvarer. Dette ville afskrække
rygere fra at skifte over til RRP'er (reduced risk products). Disse synspunkter underbygges af
den anerkendte professor i jura, økonomi og ledelse, W. Kip Viscusi, ved Vanderbilt University
Law School i Nashville, USA, som også er en anerkendt ekspert i risikoopfattelse, og hvordan
de påvirker forbrugeradfærden. (En kopi af Viscusis rapport findes i appendix [3]).
5.5 Viscusi bemærker i sin rapport, at mange mennesker mener, at opvarmede tobaksvarer er
lige så skadelige eller mere skadelige end cigaretter. Cigaretrygere, der ikke mener, at THP'er
er mindre skadelige end cigaretter, "er ifølge rapporten mindre tilbøjelige til at prøve disse
produkter eller bruge dem for tiden"40, hvorimod "en tro på, at opvarmede tobaksvarer... er
mindre skadelige end cigaretter, har en positiv sammenhæng med brugen af disse produkter.
De respondenter, der opfatter opvarmede tobaksvarer som mindre skadelige end cigaretter,
er 15 % mere tilbøjelige til at bruge opvarmede tobaksprodukter..."41 Han konkluderer, "at det
er muligt, at den seneste lovgivningsmæssige indsats, der behandler disse alternative
produkter på samme måde som brændbare tobaksvarer, kan have udbredt denne fejlagtige
opfattelse vedrørende ikke-brændbar tobak og nikotinprodukter."42 Som sådan er det
påviseligt irrationelt at anvende foranstaltninger, der vil have den virkning, at de undergraver
brugen af alternative tobaksvarer og nikotinprodukter med en reduceret risikoprofil for rygere,
der ellers fortsat ville ryge, og dermed videreføre brugen af mere farlige brændbare
tobaksprodukter og underminere deres potentiale for at reducere skader som følge af
tobaksrygning.
39
Satels rapport s. VI og 97.
40
Viscusis rapport s. 73.
41 Viscusis rapport s. 18.
42
Viscusis rapport s. 107.
18
6. ALDERSKONTROL VED KØB
6.1 BAT Danmark støtter initiativer der kan understøtte en bedre aldersverificering ved køb af
røgfrie nikotin- eller tobaksprodukter. Ingen unge under 18 skal have et nikotinforbrug eller
have adgang til at købe nikotin- eller tobaksprodukter, og en bedre ID-kontrol ved salg af varer
der er underlagt aldersbegrænsning er et skridt i retning af at forhindre unge under 18 år
adgang til nikotin- og tobaksprodukter.
6.2 BAT Danmark ser derfor positivt på forslaget, men efterlyser en konkret model for
aldersverificering f.eks gennem krav om et system med to-faktorgodkendelse, og ønsker
generelt en bedre håndhævelse af reglerne omkring aldersverificering. I den seneste RØG
undersøgelse svarer 54,1% af respondenter mellem 15-17 årige at de køber deres røgfrie
nikotinprodukter i supermarkeder, mens 50,3% svarer at de køber røgfrie nikotinprodukter i
kiosker43. Dette er stærkt bekymrende, da det i mange tilfælde er op til den enkelte ekspedient
at bede om og kontrollere ID, hvilket kan løses gennem krav om elektronisk system med
tofaktorgodkendelse, hvor et køb af en aldersbegrænset vare, kun kan lad sig gøre, hvis
kunden er over 18 år. Køb foretaget med kontantbetaling skal forudsætte aldersverificering,
ved forevisning af gyldigt billedlegitimation.
6.3 På samme vis ønsker BAT at sidestille onlinehandel med handel i fysiske butikker, således
at der opnåes en symmetri i reglerne. I dag er der ikke i tilstrækkelig høj grad alderskontrol
ved onlinekøb af røgfrie nikotinprodukter, hvorfor det også her vil være oplagt at sikre en
systematisk aldersverificering gennem et system med to-faktor-godkendelse inden købet kan
gennemføres.
7. KONKLUSION
7.1 Af ovennævnte årsager er det delegerede direktiv ugyldigt ifølge EU-retten, da enhver lov der
implementerer det Delegerede Direktiv i Dansk lov vil være ugyldig. Sundhedsministeriet bør
derfor ikke omsætte det til dansk ret. Hvis Sundhedsministeriet alligevel fortsætter med
gennemførelsen, bør det dog vente til sidste øjeblik med omsætningen, på baggrund af de
igangværende retssager, og beholde den definition af THP, som er foreslået i det aktuelle
lovforslag.
7.2 Vi opfordrer på det kraftigste Sundhedsministeriet til at overveje vores kommentarer til
lovforslaget og arbejder gerne yderligere sammen med Sundhedsministeriet om dette.
43
Brug af røgfrie nikotinprodukter blandt unge (sst.dk)
An Assessment of the Combustion Characteristics of GloTM
Mitchell D. Smooke
Department of Mechanical Engineering
Yale University
New Haven, CT 06520-8284
1. Introduction
This report seeks to answer the following two questions:
1) During its intended operation, does GloTM
undergo the process of combustion?
and
2) Does the aerosol produced by GloTM
Neosticks constitute smoke?
To better understand the answers to these questions, this report focuses on a detailed discussion
of the basic concepts of combustion that are necessary to explain my conclusions. These include
chemistry, heat release, ignition, and the corresponding products of combustion with regard to the
behavior of fuels such as gaseous and liquid hydrocarbons and organic materials such as tobacco.
2. Overview
Aside from powering our transportation system and generating electricity for our homes, combustion
has been used in a variety of smaller systems such as gas appliances and small power tools to
recreational uses in camping, cook-outs and in the consumption of tobacco products. The last of
these topics forms the primary focus of this report.
There are a number of devices called tobacco heating products (THPs) that utilize tobacco materials
in a cylindrical shaped stick that is an alternative to the consumption of cigarettes. The GloTM
device electronically heats cylindrical Neostick rods that contain tobacco and are specially designed
to work only with the GloTM
device. THPs di↵er from cigarettes primarily in the mode of operation
for nicotine delivery.
In this report a systematic discussion of the process of combustion is provided and an assessment of
whether THPs and, in particular, British American Tobacco’s product GloTM
undergo combustion.
In the next section the importance of chemical reactions, ignition and heat release in the burning
of hydrocarbon fuels is discussed. Section 4 considers the burning of tobacco and the operation
of GloTM
. The report concludes with an assessment of whether GloTM
undergoes the process of
combustion and whether the aerosol produced by the GloTM
device is smoke. Reference material is
provided in the appendices that puts in perspective the fundamental physical and chemical aspects
of combustion.
1
British American Tobacco, bilag 1
3. Chemical Reactions, Ignition and Heat Release
Most combustion processes occur under what is termed forced ignition whereby a heat source is
applied to a fuel-air mixture. Fuel-air mixtures include, for example, wood (fuel) burning in a
fire place or gasoline (fuel) burning in an engine or tobacco (fuel) burning in a cigarette or pipe.
Assuming that the mixture is within the flammability limits (see Appendix H), combustion follows
a several step process.
As the system is heated, volatile gases begin to emerge from the fuel (pre-heat zone). As the
temperature of the system continues to increase, the volatile materials in the fuel are vaporized
(pre-ignition zone) which can be followed by a region of pyrolysis. As the temperature rises further
and the ignition temperature of the fuel is reached, combustion begins. Depending upon the organic
molecules being burned, organic nano-particles can be formed (soot) which are either oxidized in
the flame or, in some cases, released into the atmosphere as smoke.
For the purposes of this report, it is worthwhile to distinguish between an aerosol that is composed
of combustion (smoke) versus noncombustion products. From a combustion perspective, smoke
refers to the gaseous products of the burning of organic materials in which small solid and liquid
particles are dispersed [1]. Other definitions consider smoke to be the aerosol or condensed phase
component of the products of combustion. While particulate formation can occur from pyrolysis,
the temperature needs to be in the 325C-625C range [2]. An aerosol composed of noncombustion
products (e.g., water vapor and other vaporized liquids) is not smoke. Thus, while all smoke is an
aerosol, not all aerosols are smoke.
For any fuel-air system, it is essential to understand the temperature at which the pre-heat, pre-
ignition and ignition stages are reached. Detailed studies of ignition temperatures for a variety
of hydrocarbon fuels have been tabulated over the years and a sample is included in Figure 4 in
Appendix H [3]. What is clear is that the temperature plays a critical role in the combustion of
fuel-air systems. Irrespective of whether the fuel is a solid, a liquid or a gas, combustion will not
occur until the temperature is above the ignition value.
4. Tobacco, Tobacco Heating Products and the Operation of GloTM
Tobacco is a plant from the Solanaceae family, better known as Nicotiana (genus). This family
comprises some 2,000 species, including herbaceous plants, bushes, trees and vines. There are
several varieties of tobacco [4] such as Brightleaf, Burley, Corojo, Dokha, Habano, Latakia, Perique,
Shade, etc. Nicotiana tabacum, or common tobacco, is the primary source of tobacco in cigarette
manufacturing.
Tobacco plants are composed of a variety of chemicals, including: nicotine, chlorophyll, water,
sugars, a variety of minerals etc. For example, nicotine, a chemical naturally present in the tobacco
plant, is composed of carbon, hydrogen and nitrogen atoms with the chemical formula C10H14N2.
Nicotine has a specific evaporation temperature within the range of the GloTM
device operating
temperature [5].
The harvesting of tobacco occurs when it is ripe, i.e., when the leaves begin to turn yellow. The
tobacco leaves are then dried which provides a means of rapidly destroying chlorophyll (the leaf goes
2
from green to brown), converting starch into sugars, and reducing the moisture that is naturally
present in the leaves.
Of critical importance to the burning of tobacco is the ignition temperature. Studies that address
the ignition temperature for tobacco date back to the early 1900s ([6] and [7]). Other studies were
carried out in the 1940s ([8] and [9]). Most of these studies focused on leaf tobacco which required
a large number of leaves to minimize the e↵ects of tobacco leaf variability due to di↵ering levels of
moisture, fertilizer, chemical addition etc. To reduce such e↵ects, several studies employing ground
tobacco, which was formed into a pellet and subsequently burned, were undertaken by Weybrew
[10] as well as by Elliot and Vickery [11]. Additional studies were carried out by McKee [12] and
Tibbitts [13] in the late 1950s and early 1960s.
Specifically, in the results reported in [13], a 15 inch (in length) heating element with a uniform
temperature gradient was used to determine the tobacco ignition temperature. The heating element
consisted of a ceramic tube which was wound with Nichrome V wire. By adjusting spacing from
one turn to the next, it was possible to generate a linear temperature gradient along the tube.
Thermocouples were used to measure the temperature and the entire unit was enclosed to prevent
convective e↵ects from local air currents. The heating element temperature was regulated with a
variable transformer. Ignition temperatures were determined by sifting tobacco onto the heating
element. The sifting process started at the cooler end and continued across the element to the
hottest region of the ceramic element.
The point at which the majority of the ground tobacco ignited was recorded as the ignition tem-
perature of the sample [13]. Multiple tests were undertaken for each sample. The results of the
study were fairly consistent in that the ignition temperatures of the sample ranged from 442C to
488C. The study confirmed earlier results by McKee [12] where ignition temperatures were de-
termined to range between 435C and 455C. In spite of the age of these studies, the results are
consistent with more recent investigations carried out in 2005 and 2007 ([14] and [15]). Thus, these
studies reliably establish the ignition temperature of tobacco between 435C and 455C. Similarly,
peer-reviewed published thermogravimetric analysis indicates that ignition of the tobacco rod in
the GloTM
Neostick occurs at temperatures above 400C [16].
Factory made cigarettes are the main form of tobacco used globally. When smoked, the tobacco
is combusted at temperatures that can exceed 800C. In addition to the heat released, cigarette
burning produces smoke that can be composed of over 6500 identified chemicals [17] (see also [16]
and [18]). A number of these constituents are thought to be toxicants [19]. Prolonged exposure
to these chemicals over time can lead to a variety of health issues such as cardiovascular disease
and cancer [20]. As in the case of hydrocarbon fuels, the primary products of tobacco combustion
include H2O, CO2, CO and the oxides of nitrogen NO, NO2 and, more generally, NOx.
British American Tobacco’s GloTM
is a smoke free THP that uses an electronic battery-powered
device to heat specially designed tobacco sticks called Neosticks to produce an aerosol consisting
of primarily nicotine, glycerin, flavorings and water (see Figure 1). BAT’s GloTM
product di↵ers
from cigarettes in that the tobacco is heated to temperatures in the neighborhood of 242±5C with
an electrical heating device. These temperatures are significantly lower than the 800C range of
ordinary cigarettes.
3
Figure 1 – Illustration of the GloTM
Product. Reprinted with permission from British American Tobacco.
The Neostick contains the tobacco material and a filter. When heated, the user draws the aerosol
from the Neostick. An electronic battery-powered heating element provides the heat source. When
the Neostick is inserted into the heating element, the tobacco material is heated to approximately
242C and creates an aerosol that the user inhales.
The battery is a lithium-ion battery that can last for 30 sessions. A series of small holes at the
bottom of the device allows air to be brought into the device. The device has a micro USB charging
port and the heating device, Neostick and battery are contained within an aluminum sleeve which
protects the device and helps to maintain the temperature so that the device remains cool to the
touch.
As discussed above, when the temperature is below the ignition temperature of tobacco, combustion
does not take place and smoke is not formed. For the GloTM
device, this manifests itself with only
trace levels of toxicants such as CO, CO2, NO and NOx. Moreover, such low levels of toxicants
in GloTM
aerosol emissions (relative to smoke from traditional cigarettes) similarly compels a con-
clusion that GloTM
emissions do not constitute tobacco smoke. In fact, the low levels of reported
toxicants in GloTM
emissions result from heating processes occurring at temperatures well below
the ignition temperature required for tobacco combustion and smoke production. The extremely
reduced levels of such toxicants in the GloTM
aerosol as compared to cigarette smoke evidences the
absence during GloTM
operation of both a combustion process and the smoke formation known to
produce the high numbers and levels of toxicants in cigarette smoke.
5. Conclusion
The previous sections and the subsequent appendices discuss the complex interaction of fluid
mechanics, heat transfer, radiation and chemistry in the process of combustion of hydrocarbon
molecules. The burning of a fuel molecule undergoes a multistep procedure that includes a pre-
4
heat, pre-ignition, pyrolysis and ignition zone. For nonspontaneous combustion to take place, the
fuel must be heated with an outside ignition source. Each hydrocarbon molecule has a unique tem-
perature at which ignition occurs depending upon the pressure and flammability region. As noted
above, tobacco ignition takes place at temperatures at or above 435C. Once the fuel is heated above
the ignition temperature, a rapid rise in the temperature is observed and the primary products of
combustion are produced.
If the temperature does not get above the ignition limit, combustion does not take place and the
system operates in the pre-heat, pre-ignition or pyrolysis zone. Based upon the temperature and
heating specifications of British American Tobacco’s THP GloTM
and the fact that tobacco does
not ignite at temperatures below approximately 435C, the Neosticks product does not undergo
combustion.
Instead, GloTM
operates in a pre-ignition environment, i.e., in a temperature regime where the
primary products of combustion, such as CO, CO2, various hydrocarbon molecules and the oxides
of nitrogen are significantly reduced to only trace levels. In addition, since a tobacco combustion
process does not take place, the device does not produce an aerosol that can be classified as tobacco
smoke.
Disclaimer: This report does not endorse nor discourage the use of tobacco heating products.
The views expressed herein are those of the author.
5
Overview of the Appendices
Practical combustion systems are governed by large systems of strongly coupled, highly nonlinear
partial di↵erential equations (PDEs) and algebraic constraints that describe the conservation of
total mass, momentum, and energy, and the evolution of individual species mass under the mech-
anisms of convection, molecular di↵usion, and chemical reaction. In the Appendices that follow,
the various submodels that are inherent to the mathematical modeling of combustion processes are
discussed. The section ends with a discussion of flammability limits and ignition.
6
Appendix A
Governing Equations
It is possible to derive the governing equations from control volume considerations, as is often done
in textbooks. A more rigorous derivation is also possible using the Boltzmann equation of kinetic
theory, under the assumption that a continuum approximation is justifiable and departures from
local thermodynamic equilibrium are small. This is the case whenever the molecular mean free
path is much shorter than any other relevant length scales in the system, or equivalently, when the
Knudsen number is much less than unity. Statistical mechanics reveals that the mean free path is
directly proportional to temperature and inversely proportional to pressure, and that the Knudsen
number is about 1.5 times the ratio of the Mach number to the Reynolds number. It follows that
at terrestrial (or elevated) pressures and typical flame temperatures, there is no question about the
validity of the classical continuum equations for modeling deflagrations. Since their derivation is
presented in many other places (e.g., [21, 22]), they are reproduced here in vector form.
Conservation of total mass:
@⇢
@t
+ r · ⇢u = 0 (1)
Conservation of momentum:
@⇢u
@t
+ r · ⇢uu = r · S + f (2)
Conservation of energy:
@⇢e
@t
+ r · ⇢ue = r · (u·S) r · q + u·f + Q (3)
“Conservation” of individual species k:
@⇢Yk
@t
+ r · ⇢Yku = r · jk + Rk (4)
where here, as always, the species index k ranges over the Nsp members of the set of species in the
chemistry model, S. To this set of di↵erential equations must be added the equation of state for
an ideal gas, which relates the density to the other thermodynamic variables:
P = ⇢ R T
X
k2S
Yk
Wk
. (5)
The unknowns in the governing equations are the “primitive variables”: P, which denotes the total
pressure; u, fluid velocity vector; T, temperature; Yk, mass fraction of species k; and ⇢, density.
The other quantities appearing in the equations are t, time; S, stress tensor; f =
P
k2S fk, body
force vector, where the force can in theory vary depending on the chemical species (e.g., due to
electromagnetic fields in a plasma), though in this work it will simply be a constant force due to
7
gravity (g); e, specific total energy (chemical, sensible, and kinetic); q, di↵usive energy flux vector;
Q, volumetric energy source (e.g., due to an ignition source or a laser), to be ignored in this work;
jk, di↵usive mass flux of species k; Rk, volumetric mass production rate of species k due to chemical
reaction; R, universal gas constant; and Wk, molecular mass of species k. The symbol r is the
vector derivative operator. Note that whereas the total mass of each di↵erent chemical element is
conserved, strictly speaking, the mass of each of the species in S is not conserved.
A number of quantities in the governing equations must be defined in terms of the basic thermo-
chemical and fluid dynamic variables, including the stress tensor and the other transport fluxes
with their respective transport coefficients, as well as models for molecular di↵usion, chemical re-
action, and radiation. Experiments show that in a broad class of fluids, known as Newtonian, the
stress-strain relation is approximately linear. For such fluids, the two components of the vector
momentum conservation equation are known as the Navier-Stokes equations. The related transport
fluxes are written in Appendix B with mass conservation constraints and di↵usion models discussed
in Appendices C, and D, respectively. The evaluation of thermodynamic properties and transport
coefficients is a critical and often time-consuming part of detailed computations of reacting flows.
The thermodynamic properties appearing in the governing equations are the species and mixture
specific heats, the species enthalpies and, along with the required transport coefficients such as the
dynamic viscosity, the thermal conductivity, and the mixture-averaged di↵usion coefficients, are
discussed in Appendix E. In fact, all of the transport coefficients are formed by a kind of averaging
process given the relevant coefficients for each component in the mixture. This mixture-averaged
approach to transport modeling has long been the de facto standard in combustion modeling due
to its incorporation in various software packages.
8
Appendix B
Transport Fluxes
As discussed in Appendix A, the system of governing equations contains a number of quantities
which must be defined in terms of the basic thermochemical and fluid dynamic variables. Specifi-
cally, the stress tensor has the following familiar form:
S = PI + T (6)
T = µ (ru) + (ru)T 2
3
µ r · u I , (7)
i.e., the sum of the isotropic pressure tensor and the viscous stress tensor (T). Here, µ is the
dynamic viscosity of the mixture and I the unit tensor. As is common in the study of low speed
flows of dilute gases, the bulk viscosity is assumed to be negligible. The dynamic viscosity is
a function of the thermodynamic state of the mixture, like the other transport coefficients; The
di↵usive fluxes of energy and mass are given by the expressions:
q = rT +
X
k2S
hkjk + qrad (8)
jk = ⇢Ykuk . (9)
The di↵usion velocities uk will be discussed below. The terms in the energy flux relate to conduc-
tion (Fourier’s Law, with the coefficient of thermal conductivity), the transport of enthalpy by
molecular di↵usion (hk, specific enthalpy of species k), and the net e↵ect of radiation (qrad). The
divergence of the radiative flux will be treated separately from the other heat transfer phenom-
ena. The Dufour e↵ect, whereby an energy flux arises from concentration gradients, is typically
negligible in high-heat-release combustion processes, and hence is omitted above.
One change of note concerns the energy equation, which is transformed into an equation for temper-
ature using various thermodynamic relationships for energy and enthalpy. Its derivation is tedious
and, since this is sketched elsewhere [23], it is simply quoted here:
⇢cP
DT
Dt
= !0
T +
DP
Dt
+ r · ( rT) ⇢
X
k2S
cP,kYkuk
!
· rT r · qrad + T:ru . (10)
In this equation, cP and cP,k are the specific heats at constant pressure of the mixture and species
k, respectively; !0
T =
P
k2S hkWk ˙
!k, the heat source due to chemical reaction, with ˙
!k the molar
production rate of species k; and D/Dt denotes the material derivative. The term involving the
viscous tensor describes the addition of heat due to viscous e↵ects in the fluid (“friction”); both
it and the material derivative of pressure, related to mechanical work, are negligible for low speed
unconfined flows. The term arising from work due to body forces has been suppressed since it is
identically zero for the case of a constant force a↵ecting all species equally. This conclusion follows
from the second of the mass conservation constraints that are presented below.
9
Appendix C
Mass Conservation Constraints
From the definitions of the mixture density and mass-averaged velocity in terms of the (partial)
densities and flow velocities of the individual species, it follows that the Nsp mass fractions and the
Nsp di↵usion velocities are not a priori independent but satisfy the following constraints:
X
k2S
Yk = 1
X
k2S
Ykuk = 0 . (11)
To these one can add another mass conservation constraint that derives from the chemical source
terms: X
k2S
Rk =
X
k2S
Wk ˙
!k = 0 . (12)
These constraints give mathematical expression to the physical impossibility of a net creation of
mass or a net di↵usion of mass relative to the mass-averaged bulk flow. With them, it is easy to
show that the total mass conservation equation results from summing up all the species equations.
However, this proves yet again that the equation set is overdetermined, and raises questions about
which equations to include in the model and how to enforce the governing equations and constraints
simultaneously.
The first constraint on the sum of the mass fractions can be dealt with in two ways. For strongly
diluted flames burning in air, it is possible to compute YN2 from the constraint and to omit the
equation that governs its transport in the flow field. This “asymmetric” treatment of the mass
fractions lumps all the errors into the mass fraction of the (inert) diluent. Clearly, this will not
be satisfactory whenever these errors may be relatively large compared with its typical value, e.g.,
in oxyfuel flames [23, p. 16]. The more general (and perhaps more challenging) approach is to
treat all mass fractions similarly by solving the complete set of species balance laws. In this case,
the constraint cannot be imposed but must rather be “deduced from the governing equations” [24,
p. 8].
The second mass conservation constraint requires that the species di↵usion fluxes sum to zero at
every point in the flow. The calculation of the di↵usion velocities will be discussed shortly; for
now, it is enough to assume that they are available. When computing highly diluted flames with
approximate transport coefficients, a common and accepted approach is to “lump” all the di↵usion
velocity errors into the di↵usion velocity of nitrogen, i.e., to take
uN2 =
1
YN2
X
k2S,k6=N2
Ykuk , (13)
which indeed satisfies the constraint. As with the “asymmetric” treatment of the mass fraction
unknowns above, this approach could be problematic for flames where nitrogen is not present in
excess. A more general way of ensuring this constraint is satisfied is to add a correction velocity to
the di↵usion velocity of each species at each point in the flow field. This is an established approach
10
that was introduced a generation ago [25, 26]. The correction velocity is defined as
uc
=
X
k2S
Ykuk . (14)
Note that the problem to which this correction velocity is a solution arises from the mutual incom-
patibility of the di↵usion velocities as calculated from common approximate formulas; if the best
known model for these velocities were used to compute them, they would automatically satisfy the
constraint and the correction velocity would vanish.
11
Appendix D
Di↵usion Model
The modeling of molecular di↵usion in multicomponent gaseous mixtures is a very complicated
subject in its own right. As commonly formulated, the problem is to compute the di↵usion velocity
uk of each chemical species k at each point of the flow given the concentrations, concentration
gradients, and other thermodynamic variables throughout the flow field. This requires the solution
of linear systems of dimension Nsp at every point of the computational domain. These linear
systems derive from the so-called multicomponent di↵usion equations, which are a generalization
of the Stefan-Maxwell equations for binary di↵usion [21, App. E.2.1]:
rXk =
X
l2S
XlXk
Dlk
(ul uk) +
X
l2S

XlXk
⇢Dlk
✓
DT,l
Yl
DT,k
Yk
◆ ✓
rT
T
◆
+ (Yk Xk)
rP
P
. (15)
The first term relates mole fraction gradients to relative di↵usion velocities; the second to ther-
mophoresis, or the Soret e↵ect, which unlike its “reciprocal,” the Dufour e↵ect, is not necessarily
negligible in combustion; and the third to pressure gradients in the flow field, this being a di↵eren-
tial e↵ect only felt when the molecular weights of the species vary considerably from the average
molecular weight of the mixture. Here it is assumed that the body forces fk acting on each species
are equal, or else yet another term would arise. The mole fractions Xk are related to the mass
fractions by
Xk =
Yk
Wk
X
l2S
Yl
Wl
! 1
, (16)
where the quantity in parentheses is the inverse of the molecular weight of the mixture.
This typical formulation of the multicomponent di↵usion model is generally applicable when the
governing equations are integrated in time using an explicit method, i.e., when the state variables
are considered to be known at the beginning of each time step; however, when a fully implicit
solver is applied to a flame problem it is no longer strictly possible to fix these variables and solve
for the di↵usion velocities in this fashion [27, p. 15]. In this situation, the recommended approach
is to use a di↵erent (and more esoteric) formalism in which the di↵usion fluxes or, equivalently,
the di↵usion velocities are expressed as linear combinations of di↵usion driving forces. Here, the
di↵usion matrix that defines these linear combinations is populated by coefficients which must
themselves result from the solution of transport linear systems. The practical development of these
multicomponent transport models is largely the work of Giovangigli and Ern [24, 28]. Thanks to
their EGLIB software library, it is now possible to solve the full multicomponent di↵usion problem
much more efficiently than in the past [29].
This is not to say, however, that these fast transport algorithms are inexpensive, or a realistic option
in typical flame calculations; in general, they still require the approximate iterative solution of a
linear matrix equation for the di↵usion matrix at every point in the domain and at every time step
of a transient calculation. Moreover, the benefit of all this extra work is not always apparent. For
the study of either very light or very heavy fuels where the Soret e↵ect is expected to be significant,
12
it could be worthwhile and might, in some cases, be necessary for the accurate modeling of sensitive
phenomena, such as thermo-di↵usive instability [30–32]; but for a standard laminar hydrocarbon
flame, a sophisticated multicomponent di↵usion model is generally unnecessary. Instead, a highly
simplified di↵usion model can often be employed – Fick’s law with the mixture-averaged di↵usion
coefficients:
Yk uk = DkmrYk , (17)
where Dkm is an e↵ective average di↵usion coefficient of species k into the mixture. The calculation
of these di↵usion coefficients will be discussed below.
It needs to be clearly stated that this approximation is not the best simple di↵usion model available.
It can be shown that the Hirschfelder and Curtiss approximation with mixture-averaged di↵usion
coefficients, i.e.,
Xk uk = DkmrXk , (18)
leads, in conjunction with the correction velocity approach introduced in Appendix C, to the best
first-order approximation to the solution of the Stefan-Maxwell equations [23, p. 14]. Admittedly,
the di↵erence here with the Fick’s Law approximation appears to be slight. Nevertheless, the
Fickian approach based on mass fractions is often simpler to implement since the Yk are immediately
available, whereas Xk must be computed from Equation (16). Note that the two approximations
are equivalent if the spatial gradients of the molecular weight of the mixture vanish.
13
Appendix E
Thermodynamic Properties and Transport Coefficients
The evaluation of thermodynamic properties and transport coefficients is a critical and often time-
consuming part of detailed computations of reacting flows. The thermodynamic properties appear-
ing in the governing equations are the species and mixture specific heats and the species enthalpies.
The required transport coefficients are the dynamic viscosity, the thermal conductivity, and the
mixture-averaged di↵usion coefficients. In fact, all of the transport coefficients are formed by a
kind of averaging process given the relevant coefficients for each component in the mixture. This
mixture-averaged approach to transport modeling has long been the de facto standard in combus-
tion modeling due to its incorporation in the Chemkin software library; the utility of more complete
models, such as those available in the EGLIB software package, is measured against this standard.
The original Chemkin software was written at Sandia and published in two separate packages in
the early 1980s, one dealing with chemical kinetics and thermodynamics and the other with the
calculation of transport properties [33, 34]. In some places, it has been customary to refer to the
first package as “Chemkin” and the second as “Transport” (the latter name was not given by the
authors of the software). A second-generation Chemkin, known as Chemkin-II, was disseminated a
decade later, by which time an updated transport package had also been introduced [35, 36]. These
two versions of Chemkin each have their own “interpreter” software for reading specially formatted
chemical species and kinetic information. The versions are mutually incompatible. More recent
versions also exist in the form of commercial software. All the early versions of Chemkin were
written for scalar computers and hence were found to su↵er suboptimal performance on the newer
vector and parallel computers that were starting to be used in the late 1980s. This deficiency was
addressed originally by Giovangigli and Darabiha, who extracted many critical subroutines in both
Chemkin packages and vectorized them, leading to considerable speed-ups both in these routines
and, to some extent, in the overall flame solver [37].
The evaluation of the energy equation in the temperature variable requires the three thermodynamic
properties of the mixture mentioned above, as well as the mixture density, which is recovered from
the ideal gas law (also through a Chemkin call). The specific heat capacity at constant pressure for
the kth
species depends only on temperature. It is computed efficiently from polynomial fits based
on data in the JANNAF Thermochemical Tables, as found, for example, in the database of the
NASA chemical equilibrium code [38], which is also used by Chemkin. The mixture specific heat
at constant pressure is then taken as the mass average of the species specific heats. The species
specific enthalpies are given mathematically by a definite integral of the species specific heats over a
prescribed temperature range; in Chemkin, however, these quantities are computed more efficiently
as simple polynomial fits of the published data.
There is more than one way of defining mixture-averaged transport coefficients. For the thermal
conductivity and the viscosity, semi-empirical formulas are available as well as more complicated
expressions. An example of the latter is the formula for the mixture thermal conductivity due to
Wilke, which involves a double summation and ratios of species properties raised to integer and
non-integer powers (the equations can be found in many references, e.g., [37]). Because of the
expense of calculating Wilke’s formula, the mixture thermal conductivity is often computed from
14
the semi-empirical formula:
=
1
2
2
4
X
k2S
Xk k +
X
k2S
Xk k
! 1
3
5 , (19)
where the species thermal conductivities k are given by polynomial fits valid over a range of
temperatures, or to be precise, by the exponential of a polynomial in powers of the logarithm
of temperature. The mixture viscosity is calculated by a similar semi-empirical formula. The
mixture-averaged di↵usion coefficient is defined by
Dkm = (1 Yk)
. X
l2S,l6=k
Xl/Dkl , (20)
where Dkl = Dlk is the binary di↵usion coefficient of species k into species l, or vice-versa. As
with the other transport coefficients, the building blocks for the mixture-averaged di↵usion coef-
ficient, the binary species di↵usion coefficients, are functions of temperature, with log Dkl being
approximated by a polynomial in powers of log T. Although the mixture-averaged di↵usion model
represents an enormous simplification as compared with the full multicomponent di↵usion model,
it is important to stress that even using this simpler model can come at a considerable cost. Since
the computational expense of evaluating all the Dkm scales roughly as the square of the number
of species in S, chemistry models with a large number of species can lead to flame calculations in
which a significant proportion of the CPU time is spent in the transport module of the code.
15
Appendix F
Chemistry Models
One of the remaining frontiers of combustion science is the design of reliable detailed kinetic models
for realistic fuels, e.g., transportation, and the eventual deployment of such models to study chal-
lenging, poorly understood burning regimes in technologically relevant flame systems, for instance,
those characterized by pollutant and particulate formation or by strong interactions between fluid
dynamic and chemical e↵ects. A key requirement for progress on these fronts continues to be the
development of numerical codes that can handle such detailed chemistry models. The challenge
arises both from the size of the models and the amount of computation they demand, and from the
wide disparity of time scales supported by them, which leads to the problem of “sti↵ness.”
The reaction set of an arbitrarily complex, detailed chemistry model can be written in symbolic
form as
X
k2S
⌫0
kiXk *
)
X
k2S
⌫00
kiXk , i 2 R , (21)
where k and i are the species and reaction indices, respectively; ⌫0
ki and ⌫00
ki, the stoichiometric
coefficients of reactant k in both forward and reverse reaction i; Xk, the chemical symbol of species
k; and R, the set of Nreac reactions. A rate of progress Qi may be defined for each elementary
reaction i according to the law of mass action, and the sum of the rates of progress for all reactions
involving species k, multiplied by the appropriate net stoichiometric coefficient, gives the molar
production rate for this species:
Qi = kf
i (T)
Y
k2S
✓
⇢Yk
Wk
◆⌫0
ki
kr
i (T)
Y
k2S
✓
⇢Yk
Wk
◆⌫00
ki
(22)
˙
!k =
X
i2R
(⌫00
ki ⌫0
ki) Qi . (23)
The forward and reverse rate constants for reaction i are denoted by kf
i and kr
i , respectively.
These “constants” are not constant at all but rather strongly dependent on temperature, and the
relationship for the forward coefficient is modeled by a modified Arrhenius expression:
kf
i (T) = Ai T i
exp( Ei/RT) . (24)
The pre-exponential factor Ai, the temperature exponent i, and the activation energy Ei, all
specified by the kinetic mechanism, are typically estimated by experimental techniques and tuned
as needed to achieve certain benchmarks, such as the correct prediction of premixed laminar flame
speeds or ignition and extinction criteria. Although it is possible to specify Arrhenius parameters
separately for the reverse reaction, the Chemkin default is to back out the reverse rate constant
from the forward rate constant and the equilibrium constant, with the latter determined from a
16
thermodynamic calculation [33]. The empirical nature of the Arrhenius model is one reason for
this reliance on the equilibrium constant, the formula for which is well founded from a theoretical
point of view.
Table I illustrates a sample reaction mechanism for methane-air mixtures. The system includes
16 chemical species and 46 elementary reactions [39]. More complicated mechanisms can contain
hundreds of species and thousands of chemical reactions [40]. Detailed theoretical and experimental
studies have been undertaken to generate high fidelity networks of elementary reactions that can
be used in the prediction of combustion phenomena see, e.g., [41].
17
TABLE I
Reaction Mechanism Rate Coefficients In The Form kf = AT exp( E0/RT).
Units are moles, cubic centimeters, seconds, Kelvins and calories/mole.
REACTION A E
1. CH4 + M *
) CH3 + H + M 1.00E+17 0.000 86000.
2. CH4 + O2 *
) CH3 + HO2 7.90E+13 0.000 56000.
3. CH4 + H *
) CH3 + H2 2.20E+04 3.000 8750.
4. CH4 + O *
) CH3 + OH 1.60E+06 2.360 7400.
5. CH4 + OH *
) CH3 + H2O 1.60E+06 2.100 2460.
6. CH2O + OH *
) HCO + H2O 7.53E+12 0.000 167.
7. CH2O + H *
) HCO + H2 3.31E+14 0.000 10500.
8. CH2O + M *
) HCO + H + M 3.31E+16 0.000 81000.
9. CH2O + O *
) HCO + OH 1.81E+13 0.000 3082.
10. HCO + OH *
) CO + H2O 5.00E+12 0.000 0.
11. HCO + M *
) H + CO + M 1.60E+14 0.000 14700.
12. HCO + H *
) CO + H2 4.00E+13 0.000 0.
13. HCO + O *
) OH + CO 1.00E+13 0.000 0.
14. HCO + O2 *
) HO2 + CO 3.00E+12 0.000 0.
15. CO + O + M *
) CO2 + M 3.20E+13 0.000 -4200.
16. CO + OH *
) CO2 + H 1.51E+07 1.300 -758.
17. CO + O2 *
) CO2 + O 1.60E+13 0.000 41000.
18. CH3 + O2 *
) CH3O + O 7.00E+12 0.000 25652.
19. CH3O + M *
) CH2O + H + M 2.40E+13 0.000 28812.
20. CH3O + H *
) CH2O + H2 2.00E+13 0.000 0.
21. CH3O + OH *
) CH2O + H2O 1.00E+13 0.000 0.
22. CH3O + O *
) CH2O + OH 1.00E+13 0.000 0.
23. CH3O + O2 *
) CH2O + HO2 6.30E+10 0.000 2600.
24. CH3 + O2 *
) CH2O + OH 5.20E+13 0.000 34574.
25. CH3 + O *
) CH2O + H 6.80E+13 0.000 0.
26. CH3 + OH *
) CH2O + H2 7.50E+12 0.000 0.
27. HO2 + CO *
) CO2 + OH 5.80E+13 0.000 22934.
28. H2 + O2 *
) 2OH 1.70E+13 0.000 47780.
29. OH + H2 *
) H2O + H 1.17E+09 1.300 3626.
30. H + O2 *
) OH + O 2.20E+14 0.000 16800.
31. O + H2 *
) OH + H 1.80E+10 1.000 8826.
32. H + O2 + M *
) HO2 + Ma 2.10E+18 -1.000 0.
33. H + O2 + O2 *
) HO2 + O2 6.70E+19 -1.420 0.
34. H + O2 + N2 *
) HO2 + N2 6.70E+19 -1.420 0.
35. OH + HO2 *
) H2O + O2 5.00E+13 0.000 1000.
36. H + HO2 *
) 2OH 2.50E+14 0.000 1900.
37. O + HO2 *
) O2 + OH 4.80E+13 0.000 1000.
38. 2OH *
) O + H2O 6.00E+08 1.300 0.
39. H2 + M *
) H + H + Mb 2.23E+12 0.500 92600.
40. O2 + M *
) O + O + M 1.85E+11 0.500 95560.
41. H + OH + M *
) H2O + Mc 7.50E+23 -2.600 0.
42. H + HO2 *
) H2 + O2 2.50E+13 0.000 700.
43. HO2 + HO2 *
) H2O2 + O2 2.00E+12 0.000 0.
44. H2O2 + M *
) OH + OH + M 1.30E+17 0.000 45500.
45. H2O2 + H *
) HO2 + H2 1.60E+12 0.000 3800.
46. H2O2 + OH *
) H2O + HO2 1.00E+13 0.000 1800.
a Third body efficiencies: k5(H2O) = 21k5(Ar), k5(H2) = 3.3k5(Ar), k5(N2) = k5(O2) = 0.
b Third body efficiencies: k12(H2O) = 6k12(Ar), k12(H) = 2k12(Ar), k12(H2) = 3k12(Ar).
c Third body efficiency: k14(H2O) = 20k14(Ar).
18
Appendix G
Radiation Model
The final submodel that needs to be specified concerns the divergence of the net radiative flux in
the energy equation. In an unconfined geometry, gas radiation acts to cool the flame, typically with
non-negligible e↵ects on density, velocity, and reaction rates, as well as a number of other flame
properties. Radiative heat transfer is a complicated process involving emission, reabsorption, and
scattering of photons in a three-dimensional setting. Since the radiation that passes through a given
point in the flow field can originate at any other point and be attenuated in transit between them,
the physics must be modeled mathematically by a complicated integral over all space (all directions
of propagation) and all frequencies. However, if the reabsorption and scattering of radiant energy
can be neglected then the modeling is considerably simplified in what is called the “optically thin”
or emission-dominated limit applies, in which case the nonlocal, anisotropic term in the integrand
vanishes and the formula for the divergence of the radiative flux reduces to
r · qrad = 4⇡
Z 1
0
Ka(⌫) Ib(⌫, T) d⌫ , (25)
where ⌫ is a wavenumber variable (i.e., inverse wavelength), Ka is the frequency-dependent ab-
sorption coefficient, and Ib is the Planck function giving the spectral radiance emitted from a black
body at absolute temperature T.1
The discretization of this integral in wavenumber-space is guided
by the fact that almost all of the radiation absorbed and emitted by molecular gases is associated
with a few narrow regions, or “bands,” in their spectra. The Planck function is evaluated at the
centers of these bands, and is considered to be constant across each of them. The absorption co-
efficient for the nth
absorption band of species k is modeled by a peaked function of a specified
bandwidth, whose integral may be expressed as the product of an integrated band intensity and
the partial density of this species in the mixture. Values for these intensities (↵kn) and the central
wavenumbers of the bands (⌫
(0)
kn ) are tabulated in [43] for the most optically active species, H2O,
CO2, and CO. The result is a simple double sum for the radiation term:
r · qrad = 4⇡
X
k
X
n
↵kn ⇢k Ib(⌫
(0)
kn , T) . (26)
This quantity is important because it gives an upper bound on radiative losses in a flame. However,
in some conditions, e.g., at high pressures or low strain rates, the gas could be sufficiently dense or
the flame sufficiently thick that the optically thin approximation is no longer justifiable. In that
1
Here the formalism of [42] is used without completely following its notation. In particular, in keeping with [43],
⌫ is used for the wavenumber rather than !, since ! is very similar to the symbol introduced previously for the
molar production rate ( ˙
!). As it happens, ⌫ is also a common symbol for frequency, which is proportional to but
not equal to wavenumber. It is important to keep all these things straight when considering the Planck function so
as to avoid confusion. The Planck function is typically expressed in terms of either frequency or wavelength, with
the forms di↵ering in part by large constant factors that arise from the change of variables; however, in this work,
also following [43], it is expressed in terms of wavenumber as: Ib(⌫, T) = 2hc2
⌫3
/(exp(hc⌫/kBT) 1), where h is
Planck’s constant, c the speed of light, and kB the Boltzmann constant.
19
case, a more complicated radiation model would be necessary, an example of which is presented in
[42]. A good general discussion of radiation transport modeling for numerical combustion may be
found in [44].
20
Appendix H
Flammability Limits and Ignition
What distinguishes combustion from fluid mechanics is chemistry. When a fuel, e.g., a hydrocarbon
molecule, is heated beyond a given temperature, chemical reactions occur which consumes the fuel
in the presence of an oxidizer such as molecular oxygen. The resulting process can relinquish large
quantities of heat with a corresponding rise in the temperature of the system. While the ultimate
products of complete combustion are carbon dioxide and water, rarely are these the only products
that are formed. Instead, the oxidation of a fuel proceeds through hundreds (even thousands) of
elementary chemical steps with commensurate numbers of chemical species generated during the
process (see Appendix F). The combustion of fuels occurs in either a premixed or nonpremixed
mode. In the former, the fuel and oxidizer are mixed prior to combustion and in the latter the
fuel and oxidizer are separated before combustion takes place. Most practical combustion devices
operate (due to safety concerns) in the nonpremixed mode.
On occasion, combustion can occur spontaneously. In such cases combustible matter, such as hay
or coal, stored in bulk begins a slow oxidation process (as bacterial fermentation or atmospheric
oxidation) under conditions not permitting ready dissipation of heat, e.g., in the center of a haystack
or a pile of oily rags. Oxidation gradually raises the temperature inside the mass to the point at
which a fire starts. Crops are commonly dried before storage or, during storage, by forced circulation
of air, to prevent spontaneous combustion by inhibiting fermentation. For the same reason soft
coal is wetted to suppress aerial oxidation.
Arbitrary fuel-air mixtures may or may not burn. The mixture must fall within the flammability
limits for the specific fuel. The flammability limit defines the concentrations of fuel vapor that
can be ignited and thus sustain combustion. If the mixture falls outside these limits, combustion
cannot be sustained. This implies that, if there is too much fuel and not enough oxygen, the
mixture will be outside what is termed the rich flammability limit and, if there is too much oxygen
and not enough fuel, the mixture will be outside what is termed the lean flammability limit. These
limits are fuel and pressure dependent. Figure 2 illustrates an example of flammability limits for
methane-air mixtures.
To ignite a fuel-air mixture requires an outside supply of energy. The minimum amount of energy
that is needed for combustion of a fuel-air mixture is called the minimum ignition energy. Each fuel
has a di↵erent minimum ignition energy depending upon the amount of oxygen present. Minimum
ignition energies will vary depending upon where in the flammability region the fuel-air mixture
falls. Mixtures that are near the rich flammability limit will ordinarily require more energy to ignite
than those that fall in between the rich and lean flammability limit. The same concept applies to
mixtures near the lean flammability limit. Figures 3 and 4 list minimum ignition energies and the
minimum ignition temperatures for a variety of hydrocarbon fuels.
From Figure 4 one can see that the ignition temperature of alkanes, alkenes and alkynes generally
occur in the 225C-525C range. Once the temperature of the fuel-air mixture rises above the ignition
temperature, the system experiences a rapid temperature increase. This is a direct result of the
heat of combustion of the specific fuel. It is defined as the heat released for the complete combustion
of a compound in its standard state to form stable products in their standard state, i.e., hydrogen
21
is converted to water (in its liquid state), carbon is converted to carbon dioxide gas, and nitrogen
is converted to nitrogen gas. That is, the heat of combustion, Hcomb, is the heat of reaction of
the following process:
CxHyNzOn(std.) + O2(g) ! xCO2(g) +
y
2
H2O(l) +
z
2
N2(g)
where x, y, z and n are used to balance the equation.
22
Figure 2 – Flammability limits for Methane. From: Zabetakis, M.G., Flammability Characteristics of Com-
bustible Gases and Vapors, Bulletin 627, U.S. Department of the Interior, Bureau of Mines, 1965.
Figure 3 – Minimum Ignition Energy for a variety of hydrocarbon fuels.
23
Figure 4 – Minimum Ignition Temperatures for a variety of hydrocarbon fuels.
24
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27
1
Report of Dr. Sally Satel MD
Analysis of the role of non-combustible products in
tobacco harm reduction
14 June 2022
British American Tobacco, bilag 2
2
Sally Satel MD
I. INTRODUCTION
1. Almost one billion people around the world smoke cigarettes daily.1
2. Fortunately, smokers who do quit before they reach the age of 40 are very likely
to avoid most of the excess mortality associated with smoking, according to the
seminal British doctors' study.2
Indeed, quitting at any age confers a substantial
reduction in disease risk compared to continuing smoking, and the longer the
period of cessation the greater the reduction in disease risks. According to the US
Surgeon General Report on Smoking Cessation, “Although the benefits of quitting
are greater the earlier in life that an individual quits, this report confirms that it is
never too late to quit smoking. Even persons who have smoked for many years or
who have smoked heavily can realize health and financial benefits from quitting
smoking.”3
Yet, quit rates are very low, from 3 percent to 12 percent annually,
and relapse rates are also high, from 75 percent to 80 percent in the first six
months and between 30 percent and 40 percent even after one year of
abstinence.4
3. Therefore, reduced risk tobacco and nicotine products that provide an alternative
to conventional cigarettes and can thereby reduce smoking rates, demand serious
attention. Electronic cigarettes (e-cigarettes) and Heat Not Burn (“HNB”) devices
(together “non-combustibles”) present great promise in achieving this goal of
tobacco harm reduction by displacing smoking.
E-cigarettes
4. By way of background, e-cigarettes are battery-powered devices that heat a
flavored solution containing nicotine and convert it into an inhalable, or "vape-
able," aerosol. These products show great promise as reduced risk alternatives
for smokers who would not otherwise quit. Because e-cigarettes do not burn
tobacco, they emit a mere fraction of the carcinogens and hazardous gases than
do conventional cigarettes.
Heat Not Burn Products
5. HNB products are another form of non-combustible cigarette alternatives. Unlike
e-cigarettes, HNB products do contain tobacco, but do not burn it. Instead, they
warm the material enough to create an aerosol the user then inhales. In the
absence of combustion, the aerosol produced by HNB products contains far fewer
and lower levels of toxic chemicals than cigarette smoke.
Tobacco Harm Reduction
6. The philosophy of "tobacco harm reduction" is centered around the goal of
reducing harm to the health of cigarette smokers who are unwilling to stop using
nicotine through traditional methods (primarily cigarette smoking) by
encouraging the substitution of other non-combustible nicotine products.
II. BACKGROUND, MANDATE AND SUMMARY CONCLUSIONS
7. I am a physician specializing in addiction psychiatry and am a resident scholar at
the American Enterprise Institute with expertise in public health policy, addiction,
3
and harm reduction. I also serve on the current National Advisory Board of the
Substance Abuse and Mental Health Services Administration and in 2019 I
testified before the US House Labor, Health, and Education Appropriations
Subcommittee on teen vaping and balancing the protection of youth with the
health of smokers. Further details of my qualifications and experience are
contained in my CV which is attached to this report.
8. I have been asked by British American Tobacco to provide an opinion based on my
medical background, expertise, and review of the scientific literature and
scholarship on the role of non-combustible products in tobacco harm reduction. I
have been closely following the development of e-cigarettes and HNB products as
disruptive technologies in public health. For this expert report, I have been asked
to address five questions.
9. The first concerns the comparative risks of e-cigarettes and HNB products
compared to conventional cigarettes. Although e-cigarettes and HNB products
have not been in use long enough for there to be long-term epidemiological data
concerning any long-term health risks, experts consider e-cigarettes and HNB
products to be much safer than conventional cigarettes. Studies, in fact, show a
dramatic reduction in exposure to toxicants almost to the level of non-smokers or
quitters – accounting for the documented improvements in the health of smokers
who switch to e-cigarettes and HNB products.
10. The second point of my inquiry is conceptual: why does the advancement of
public health depend upon understanding comparative risk rather than absolute
risk? In this report, comparative risk compares health hazards of non-
combustibles to hazards of combustible tobacco products, whereas absolute risk
evaluates the risk of non-combustibles compared to not using any nicotine
products at all. It is a tenet of sound health policy that people make considered
choices for themselves. This is only possible if experts from the fields of public
health and medicine communicate the most accurate information on the costs
and benefits of alternatives.
11. The third question is whether non-combustibles are an effective substitute for
conventional smoking. In this report, I show how different types of scientific
evidence coalesce to demonstrate that, while not marketed as smoking cessation
devices, many smokers use non-combustibles to quit smoking. The evidence
includes data derived from large populations, from questionnaires administered
to large groups of people, and from randomized controlled trials (the latter
showing about twice the smoking cessation efficacy compared to nicotine
replacement therapy (“NRT”) in controlled conditions). In particular, vaping is
now the most popular and successful product used for quitting smoking.
12. The fourth domain of concern is flavors and their role in encouraging smokers to
switch from conventional cigarettes to e-cigarettes and HNB products. Data
consistently show that flavors are crucial to adults’ preference of vaping over
smoking and to easing the transition from combusted tobacco to aerosolized
nicotine. At the same time, surveys of youth who have vaped reveal that flavors
are not the primary attraction of vaping.
13. Fifth, I address the concern that e-cigarette (and to a lesser extent, HNB products)
use, particularly among young people, serves as an introduction to future
cigarette smoking (the gateway hypothesis). Evidence from the US and the UK
4
demonstrates that regular use of e-cigarettes by youth is rare and that the so-
called gateway effect has not materialized. To the contrary, studies show that
teens in the US now smoke cigarettes at the lowest rates in history and have
experienced unprecedented decreases in smoking prevalence precisely during the
period of vaping’s popularity. Thus, far from serving as a gateway to smoking,
teen vaping use where it does occur appears to serve as a substitute for teen
smoking. In this regard, I dispel anxiety surrounding the gateway theory by citing
large-sample studies that find a common vulnerability to both smoking and
vaping. In other words, youth who choose to vape share common risk factors
with youth who smoke, and, if not for e-cigarettes, may have smoked cigarettes
instead. Furthermore, the logic of smoking patterns is inconsistent with a causal
relationship between vaping and smoking. After all, if e-cigarettes led youth to
start smoking, we would have seen an increase in smoking following the
emergence of e-cigarettes. Yet, in reality, the opposite has happened. As
experimentation with e-cigarettes and, to a much lesser extent, regular youth
vaping has increased, smoking has declined. Finally, in response to those who
contend that non-combustible use has “re-normalized” smoking, reassurance is at
hand: data from two countries that have embraced e-cigarettes to varying
degrees, the UK and the US, show youth and adult smoking rates are at their
lowest levels ever.
14. Lastly, I discuss the implications of this current scientific knowledge for public
health policy. Naturally, there is more to learn about current, and future, lower-
risk products. Quoting Sir Austin Bradford Hill, the late English epidemiologist and
statistician,5
“All scientific work is incomplete - whether it be observational or
experimental. All scientific work is liable to be upset or modified by advancing
knowledge. That does not confer upon us a freedom to ignore the knowledge we
already have or postpone the action that it appears to demand at a given time.”6
Thus far, we have amassed considerable knowledge about e-cigarettes and HNB
products. Data consistently confirm a relative decrease in harmful exposure to
toxicants associated with non-combustible products compared to continued
smoking in addition to the improvement in users’ pulmonary and cardiovascular
health, combined with the effectiveness of non-combustible products as
substitutes for conventional cigarettes.
15. Accordingly, it is my confident medical and scientific opinion that policymakers
should make e-cigarettes and HNB products widely accessible to adult smokers so
that the products can fulfill their public health potential. By no means should
they be banned or subject to overly limiting caps on nicotine strength, flavor
bans, restrictive tobacco product regulation, or taxation at the high rates that
apply to combustible cigarettes.
III. COMPELLING EVIDENCE DEMONSTRATING THAT E-CIGARETTES AND HNB PRODUCTS
ARE SUBSTANTIALLY LESS HARMFUL THAN CONVENTIONAL CIGARETTES
E-cigarettes
16. Cigarettes contain roughly 7,000 chemicals, including 70 known human
carcinogens, carbon monoxide, nitrogen oxides, and other gaseous constituents.
Several analyses of e-cigarette aerosol show that while it contains some toxins
and carcinogens, they are far fewer in number and are present at much lower
levels than those found in cigarette smoke. The toxicants in conventional
5
cigarettes, for example, exceed that of e-cigarette aerosol by two orders of
magnitude.7
In other words, some toxicants in conventional cigarettes, for
example, exceed those in e-cigarette aerosol "by 100-fold." As expected, a
growing body of clinical evidence demonstrates that adult smokers’ exposure to
carcinogens and toxicants falls substantially following their transition to vaping.
In fact, those levels are comparable to those measured in unaided, ‘cold-turkey’
quitters.8
17. One of the earliest studies on e-cigarette aerosols appears in the journal Tobacco
Control in 2012.9
Researchers at Roswell Park Cancer Institute screened the vapor
generated from 12 brands of e-cigarettes, for four groups of potentially toxic and
carcinogenic compounds: carbonyls (such as formaldehyde and acetaldehyde),
volatile organic compounds, and nitrosamines. The study found that heavy
metals, such as cadmium, lead, and nickel may be present but in amounts and
forms considered nontoxic.10
“We found that the e-cigarette vapors contained
some toxic substances,” the authors write, going on to note that, “the levels of
the toxicants were 9–450 times lower than in cigarette smoke and were, in many
cases, comparable with trace amounts found in the reference product.”
18. In 2015, Public Health England (“PHE”) released a high-profile report on e-
cigarettes estimating that vaping is around 95 percent safer than smoking.11
Analysts derived this estimate from data demonstrating that the constituents of
cigarette smoke that harm health – including carcinogens – are either absent in e-
cigarette vapor or, if present, they are mostly at levels much below 5 percent of
smoking doses (mostly below 1 percent and far below safety limits for
occupational exposure).12
“While vaping may not be 100 percent safe, most of
the chemicals causing smoking-related disease are absent and the chemicals
which are present pose limited danger,” the agency stated. In 2016, the Royal
College of Physicians echoed the key findings of PHE: "[a]lthough it is not possible
to quantify the long-term health risks associated with e-cigarettes precisely, 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."13
19. In 2018, PHE updated the evidence in a review of both e-cigarettes and HNB
products. “Our new review reinforces the finding that vaping is a fraction of the
risk of smoking, at least 95 percent less harmful, and of negligible risk to
bystanders [save for those with asthma or other respiratory conditions, who are
vulnerable to myriad ambient irritants]. Yet over half of smokers either falsely
believe that vaping is as harmful as smoking or just don’t know,” they
summarize.14
20. Similarly, in 2018, the U.S. National Academies of Sciences, Engineering, and
Medicine, wrote that, “Laboratory tests of e-cigarette ingredients, in vitro
toxicological tests, and short-term human studies suggest that e-cigarettes are
likely to be far less harmful than combustible tobacco cigarettes.”15
21. The UK Committee on Toxicity’s ("COT") 2020 report, which addressed both
exposure to users and ambient exposure, found that in users, constituents such
as propylene glycol and glycerol elicited a “low level of concern.” Regarding
“other constituents,” the report states that, “Data from biomonitoring studies
support the conclusion that exposure to levels of tobacco-related toxicants
6
associated with E(N)NDS use is lower than from conventional cigarette smoking,
but not as low as in non-users of tobacco products.” Overall, the COT concluded:
“The use of E(N)NDS products, produced according to appropriate manufacturing
standards and used as recommended, as a replacement for [combustible
cigarette] smoking, is likely to be associated with a reduction in overall risk of
adverse health effects, although the magnitude of the decrease will depend on
the effect in question.”
22. Evidence also indicates improvements in cardiovascular and pulmonary function
in cigarette smokers who switch exclusively to e-cigarettes, according to a recent
review article in the American Journal of Public Health.16
Other reports show that
tests of lung and vascular function and hypertension17
find improvement in
smokers who switch to e-cigarettes. 18
In terms of perceived wellbeing, exclusive
users of e-cigarette, who were largely former smokers, report fewer respiratory
symptoms than do cigarette smokers and dual users.19
Heat Not Burn Products
23. HNB products are gaining popularity and because they do not burn tobacco, they
do not impose health risks comparable to traditional combustible tobacco
products. In a 2018 “evidence review” by Public Health England,20
the authors
stated that, “Compared with cigarette smoke, heated tobacco products are likely
to expose users and bystanders to lower levels of particulate matter and harmful
and potentially harmful compounds. The extent of the reduction found varies
between studies.”
24. In July 2020, the US Food and Drug Administration (FDA) authorized the
marketing of a HNB product. Makers were allowed to claim that the product
significantly reduces the production of harmful and potentially harmful chemicals,
and that scientific studies have shown that switching completely from
conventional cigarettes to the product significantly reduces the user’s exposure to
harmful or potentially harmful chemicals. Mitch Zeller, J.D., director of the FDA’s
Center for Tobacco Products was quoted as follows in the agency press release:
“Data submitted by the company shows that marketing these particular products
with the authorized information could help addicted adult smokers transition
away from combusted cigarettes and reduce their exposure to harmful chemicals,
but only if they completely switch.”21
25. HNB products produce higher levels of toxicants than do e-cigarettes, but the
levels are still considerably lower than found in cigarette smoke.22 The published
results of laboratory testing of a HNB product by Japanese researchers, found the
concentration of tobacco-specific nitrosamines (“TSNAs”) was one-fifth and
carbon monoxide (CO) was one-hundredth of those of conventional combustion
cigarettes.23 A toxicological product assessment conducted found levels of
aldehydes at approximately 80 percent–95 percent lower than cigarettes and
volatile organic compounds approximately 97 percent–99 percent lower.24
Another toxicological study using a “margin of exposure” analysis reported that a
HNB product reduced the risks from exposure to 9 out of the 20 most toxic
compounds in tobacco comparing the use of HNB with smoking conventional
tobacco products.25
7
26. Ikonomidis and colleagues 202126
randomized 50 smokers to regular cigarettes
and a HNB product. Users of the HNB product showed less compromise in
endothelial function, arterial stiffness, myocardial deformation, oxidative stress,
and platelet activation both acutely and after 1 month of switching exclusively to
HNB use. In late 2021, an international team of researchers confirmed in Nature
that almost 80 percent of cytotoxic effects on bronchial epithelial cells are due to
volatile compounds in the vapor phase of smoke and found “no cytotoxicity on
bronchial epithelial cells with any [HNB or e-cigarette] product.”27
Examining
separately carbon monoxide in a human subject clinical trial, 12 adult smokers
(6 male, 6 female) experienced no elevation in carbon monoxide levels, a risk
factor for cardiovascular disease, measured at intervals up to 45 minutes post-
use.28
27. In addition, a 2021 randomized control trial performed in the U.K. found that
biomarkers of exposure and potential harm are reduced when smokers switch
from smoking cigarettes to exclusive use of a tobacco heating product.29
The
product used in the study was glo THP device and Neostick tobacco consumables.
After 180 days of observation, biological markers of exposure and harm in the
smoking group remained stable, while glo users’ levels of most biological markers
of exposure, and thus harm, reduced significantly, becoming similar to those in
controls abstaining from cigarette smoking.
IV. SOUND HEALTH POLICY REQUIRES FOCUS ON COMPARATIVE RISKS, NOT ABSOLUTE
RISKS OF NON-COMBUSTIBLES IN A VACUUM
28. What are clinicians, policymakers, and smokers to make of claims that e-
cigarettes and HNB products are “not without harm”?30
To be sure, vaping and
HNB use are not risk free. Yet, the advancement of public health requires
evaluating the effects of non-combustible products in comparison to the impact
of conventional cigarettes. Analysis of such comparative risk is critical to a harm
reduction framework. Indeed, it is an ethical imperative for the public health and
medical fields to provide smokers information on less hazardous ways of
consuming nicotine and to encourage those smokers who would otherwise
continue to smoke, to try non-combustibles even if these less hazardous forms
are not risk-free.
29. Unfortunately, a number of high-profile international agencies mislead the public
about non-combustibles by presenting the absolute risks only. Doubtless, health
experts must be transparent about any negative consequences of e-cigarettes
and other non-combustibles, but when they present such information
inaccurately and, in a vacuum, that is, without comparing the comparative risks of
these products to combustible cigarettes, they can do more harm than good.
30. The World Health Organization ("WHO") prominently displays the following
warnings in its materials for the public: “ENDS [Electronic Nicotine Delivery
Systems] contain varying amounts of nicotine and harmful emissions”; “ENDS
expose non-smokers and bystanders to nicotine and other harmful chemicals";
and “There is a risk of the devices leaking, or of children swallowing the liquid,
and ENDS have been known to cause serious injuries, including burns, through
fires and explosions.”31
The European Union Scientific Committee on Health,
Environmental and Emerging Risks ("SCHEER") likewise only provides an absolute
assessment of harm, in its 2020 report. It warns of a “moderate weight of
8
evidence for risks of local irritative damage to the respiratory tract and moderate,
but a growing level of evidence from human data suggesting that electronic
cigarettes have harmful health effects, especially but not limited to the
cardiovascular system.”32
31. These publications stand out for their methodological flaws. Robert Beaglehole,
former director of the Department of Chronic Diseases and Health Promotion at
the WHO, highlighted these flaws and challenged the validity of the WHO’s
statements in a December 2020 keynote speech in the U.K. before an audience of
e-cigarette researchers.33
Beaglehole said the WHO had “lost its way” and urged
leadership to stop obstructing harm reduction efforts and recommended an
independent inquiry into the agency’s leadership.34
Likewise, the SCHEER report
flouted the tenets of sound public health analysis by focusing solely on absolute
risk, ignoring extensive scientific literature demonstrating that vape aerosols
contain fewer and substantially lower levels of harmful chemicals compared to
cigarette smoke.
Examples of exaggerated risk
32. Finding the proper risk-benefit balance is crucial to sound public health policy and
harm reduction for smokers, but that evaluation depends upon accurate
estimates of the risks and benefits. With respect to risks, it is important to
recognize that studies purporting to have identified vaping-related harms too
often exaggerate those negative effects. This makes the downside of vaping
appear larger than it actually is, and, inevitably, distorts evaluations of risk-benefit
trade-offs.
33. Take the example of investigations of cell damage. Experimenters typically
expose cells in laboratory settings and assume those settings resemble human
physiology. Yet our bodies possess protective and regenerative mechanisms that
can minimize the impact of exposure in real life. Thus, naive researchers may
over-interpret the results and conclude that their findings are of actual clinical
relevance. What’s more, such in vitro studies sometimes use excessive exposures
that fail to correlate with human experience and/or neglect to expose the cells to
cigarette smoke as a comparison condition.
34. In the realm of human subject research, the media tend to disseminate
worrisome findings under alarmist headlines. Notable examples of flawed
research include a January 2015 report in the New England of Medicine entitled
“Hidden Formaldehyde in E-Cigarette Aerosols.“35
The authors detected
formaldehyde in e-cigarette vapour after heating a vaping device to a high voltage
setting. Extrapolating from this finding the authors suggested that long-term
vaping is associated with an incremental lifetime cancer risk of five to 15 times as
high as the risk associated with long-term smoking. However -- and this is key --
no user would ever actually heat an e-cigarette high enough to produce the
recorded levels of formaldehyde in the study. The resultant vapor (known as a
“dry puff”) would be intolerably irritating to the throat. Indeed, when the NEJM
researchers tested the same device at a voltage level normally used by vapers
they detected no formaldehyde.36
In response, two experts made a formal
complaint to the NEJM calling for retraction of the paper; forty additional experts
wrote a supporting letter.37
The plea for retraction was unsuccessful, but the
journal Addiction published the complaint under the title, “Research letter on e-
9
cigarette cancer risk was so misleading it should be retracted.”38
PHE also
corrected the misinformation surrounding the formaldehyde study in its 2015
“evidence update.”39
35. In February 2020, the Journal of the American Heart Association retracted an
article purporting to show that vaping increased the risk of heart attacks40
— but
not until other scientists argued strenuously with the journal editors to withdraw
it from the scientific literature because its findings were false and invalid.41
36. A recent report in the American Journal of Preventive Medicine sought to
determine a possible association between vaping and chronic lung disease.42
Researchers used government data from a cohort of smokers and vapers that
were collected at three intervals over a four-year period. At each interval,
researchers asked subjects whether they had been diagnosed with chronic
pulmonary disease. Many of the vapers who did not report disease at the first
interval went on to report it subsequently, leading the authors to conclude that e-
cigarettes constituted a risk for chronic obstructive pulmonary disease, bronchitis,
and asthma. Confounding the results was the fact that over 99 percent of the
subjects studied were former smokers or dual users (that is, they vaped and
smoked), strongly suggesting that they had chronic lung problems long before the
study began, even if those conditions were not formally diagnosed. A subsequent
analysis of the same data that took into account whether the subjects were never
smokers, former smokers, or current smokers, found that current or former users
of e-cigarettes who had never smoked cigarettes had no greater prevalence of
respiratory disease than those who had never smoked combustible tobacco and
who had never used e-cigarettes.43
In short, vaping did not confer added risk for
the studied respiratory illness compared with people who neither vaped nor
smoked.
37. Lastly, consider an unpublished conference presentation publicized by a press
release in 2021 by the American Heart Association, AHA. The study reported a
fifteen percent higher stroke risk at a younger age for e-cigarettes users than for
traditional smokers. Although only an abstract, not a peer-reviewed journal
article, and therefore preliminary, the finding garnered significant media
attention. A number of experts, however, were quick to highlight the
shortcomings based on the abstract, calling attention to three facets of the study:
(1) that a number of e-cigarette users in this cohort – likely a large segment --
were smokers who may have switched to vaping only after they suffered a stroke;
(2) that no biologically plausible hypothesis could explain how e-cigarettes could
increase the risk of stroke at young ages but decrease it in the older groups, as
the study found; and (3) that vapers in this study were overall less likely to have
strokes than individuals who continued to smoke – a key, and expected, result
that the authors obscured in the presentation of findings.44
The authors
withdrew the abstract and press release, prior to the AHA conference.45
Nicotine
38. Nicotine as a chemical substance deserves attention in the context of risk-benefit
calculus because the public regularly considers it to be a high-risk component of
vaping. Not so. Nicotine is the addictive constituent in tobacco but it is the other
constituents of tobacco smoke, not nicotine itself, that primarily cause disease in
cigarette smokers’ consumption.46
Nicotine is not carcinogenic.47
In general,
10
“nicotine plays a minor role, if any, in causing smoking-induced diseases,”
according to Neal Benowitz MD of the UCSF Center for Tobacco Control,
Research, and Education in the New England Journal of Medicine.48
However, the
public tends to misconstrue the risks of nicotine as being the same or similar to
the risks of smoking tobacco.
39. Even many physicians do not know these facts. For example, a survey of 826 full-
time faculty members in the schools of medicine, public health, dentistry and
nursing at the University of Louisville (US) found that 38 percent believed that
nicotine, separate from smoking, is a high-risk factor for heart attack and stroke.49
Thirty-eight percent ranked nicotine a high-risk factor for cancer of all kinds and
another 37 percent rated the risk of nicotine as moderate; and for oral cancer,
the percentages were 32 percent and 40 percent, respectively. In a 2019 survey
of 256 European Union trainees in public health, the vast majority of respondents
believed nicotine contributes significantly to disease. Over four-fifths (82.2
percent) associated nicotine with all smoking-related diseases, 59.1 percent
indicated that nicotine is an important factor in the development of lung cancer,
62.1 percent thought nicotine was involved in vulnerability to cancer in other
organs, and 72.7 percent considered it responsible for atherosclerosis.50
Consequences of Exaggerated Risks
40. The stock warning issued by critics of tobacco harm reduction is that "vaping is
not safe." This is true but misleading. Relative safety compared to the grave
dangers of smoking is what smokers need to know. Worse, otherwise respected
agencies such as state departments of public health, health non-profits (such as
the American Lung Association and the American Academy of Pediatricians),51
and even some medical and public health schools, have disseminated information
that is outright false. Examples include the warning that e-liquid has been shown
to cause a very serious illness called “popcorn lung,” and to raise the risk for heart
attack and chronic obstructive pulmonary disease.52
41. Last January, for example, the American Heart Association posted a page called
“Is vaping safer than smoking?”53
Its answer: “many downsides, few potential
upsides.” Among other groundless, contrary-to-data claims it tells readers: “E-
cigarettes’ biggest threat to public health may be this: The increasing popularity
of vaping may “re-normalize” smoking, which has declined for years.” A more
general content analysis of media coverage reveals bias as well. For example, a
content analysis of e-cigarette topics and themes covered in US news articles
from 2015 to 2018 found that 70 percent of articles on vaping mentioned e-
cigarette risks, while only 37 percent noted the potential benefits.54
42. Over time, these presentations of the alleged risks of e-cigarettes have influenced
adult public opinion. In 2012, the Longitudinal Health Information National
Trends Survey conducted by the National Cancer Institute found that 39 percent
of respondents believed that e-cigarettes were "less harmful" or "much less
harmful" than smoking. 55
The next year, 40 percent held those beliefs.56
That
ascendant trajectory, unfortunately, started to turn down in 2014, eventually
declining to 17 percent in 2018 and to 14.8 percent in 2019.57
A 2019 Reuters poll
found that 63 percent of Americans disagreed with the statement that "vaping is
healthier than traditional cigarettes," a 16 percentage point increase from the
spring of 2016.58
In the U.K., public perception of vaping’s advantage relative to
11
smoking began to decline after 2015, according to the Smoking Tool Kit Study,59
which tracks national smoking patterns and cessation-related behavior among all
adults. Between 2013 (when tracking on vaping began) and 2015, over half of
respondents endorsed e-cigarettes as “less harmful.” In 2017, 44.2 percent
perceived vaping as less harmful than smoking.60
In 2020, 29 percent of current
smokers believed vaping was less harmful than smoking.61
43. PHE’s March 2020 evidence update62
found that: “[p]erceptions of harm from
vaping among smokers are increasingly out of line with the evidence. The
proportion who thought vaping was less harmful than cigarettes declined from
45% in 2014 to 34% in 2019. These misperceptions are particularly common
among smokers who do not vape.” The report also concluded that: “increasingly
incorrect perceptions among the public about the harms of vaping could prevent
some smokers using vaping products to quit smoking.” PHE's e-cigarette evidence
update report, published in February 2021, also found that: "[p]erceptions of the
harm caused by vaping compared with smoking are increasingly out of line with
the evidence" and recommended that: "[m]isperceptions of the relative harms of
smoking and vaping should be addressed."63
44. A University College London study64
reviewed the association between changes in
harm perceptions and e-cigarette use among current tobacco smokers in England
between 2014 and 2019. The authors found that for every 1 percent decrease in
the mean prevalence of current tobacco smokers who endorsed the belief that e-
cigarettes are less harmful than combustible cigarettes, the mean prevalence of
e-cigarette use decreased by 0.48 percent. The authors' state: “[…] our results
highlight the need for an increase in media portrayals and public health
campaigns focusing on the reduced health harms by switching from combustible
tobacco to e-cigarettes.”
45. In sum, exaggerating the risks of non-combustible tobacco and nicotine products
undermines public health goals of moving smokers away from conventional
cigarettes to less harmful products including e-cigarettes and HNB products.
V. COMPELLING EVIDENCE THAT E-CIGARETTES AND HNB PRODUCTS REDUCE SMOKING
46. A number of esteemed health agencies have attested to the reduced toxicity of
non-combustibles relative to conventional cigarettes. They have also urged
smokers to try non-combustibles when other options to quit smoking
conventional cigarettes have failed. For example, in 2020, New Zealand’s Ministry
of Health announced the following: “Evidence is growing that vaping can help
people to quit smoking,” and that “Stop smoking services must support smokers
who choose to use vaping products to quit.” The Ministry also “considers [that]
vaping products could disrupt inequities and contribute to Smokefree 2025.”65
47. Similarly, last year the Royal College of Physicians issued a forthright statement:
“E-cigarettes are an effective treatment for tobacco dependency and their use
should be included and encouraged in all treatment pathways.”66
48. In addition, in its annual “evidence update” of 2021, Public Health England also
endorses vaping as a means to stop smoking cigarettes. The 2021 PHE update
found that vaping products are the most popular quit aid used by smokers and
reported that vaping is positively associated with quitting smoking successfully.
Similarly, the UK National Health Service in 2017 reported that over 50,000
12
smokers in the UK stopped smoking with a vaping product and that “[a]lternative
nicotine delivery devices, such as nicotine vaping products, could play a crucial
role in reducing the enormous health burden caused by cigarette smoking.”67
In
addition, an early 2020 posting from the U.S. National Institutes of Health -- a
research update rather than a report or statement from the agency --
acknowledged that “e-cigarette use may lead some to quit traditional
cigarettes.”68
49. As discussed below, and notwithstanding the e-cigarettes are not marketed as
smoking cessation products, there is wide-ranging scientific support that
demonstrates the value of non-combustibles in reducing smoking.
E-cigarettes
50. Population studies -- retrospective analyses of large groups of individuals --
analyze changes in rates of smoking or cessation over time. Such analyses are
important in showing the association between e-cigarette use and smoking
cessation. With respect to e-cigarette use, they show dramatic declines in
smoking prevalence that coincide with population uptake of vaping.
51. For example, research from the CDC published in 2017 found that a greater
percentage of smokers seeking to quit substituted e-cigarettes in place of the
nicotine patch, nicotine gum, or other FDA-approved cessation aids. 69
Subsequent data discussed below, also suggest that the preference translates into
more successful quitting.
52. Many studies have examined the impact of e-cigarette use on smoking. A
representative sample follows.
53. A CDC study published in 2020 found that 15.1 percent of current exclusive users
of e-cigarettes reported recent successful smoking cessation for 6 months or
longer.70
Those data, collected in 2018, exceeded both the 3.3 percent quit rate
for people using other non-cigarette tobacco products, and the 6.6 percent quit
rate for those using no tobacco products. Notably, 7.1 percent of US adult
smokers reported recent successful quitting in 2018, thus e-cigarettes use
produced twice the quitting rate of all adult smokers that year.
54. A 2019 report in Addiction used cross-sectional survey data collected in the UK
monthly between 2006 and 2018 to reveal a near doubling of self-reported
cessation among users of e-cigarettes or varenicline compared with other
cessation products. “There was little evidence of benefits of using other cessation
aids,” the authors concluded.71
55. Late in 2021, a report published in JAMA Network Open, found that smokers who
started vaping daily were multiple times more likely to quit than those who never
used e-cigarettes.72
Specifically, 5.8 percent of adult daily cigarette smokers who
were not using e-cigarettes and had no plans to ever quit smoking were, in fact,
not smoking cigarettes at all at follow-up. By comparison, 28 percent of those
who vaped daily, without the intention to quit, were smoke-free. The data
comprised about 1,600 smokers from the FDA’s Population Assessment of
Tobacco and Health (PATH) Study (2014-2019) who, notably, did not plan to quit.
“These findings call for consideration of smokers who are not planning to quit
13
when evaluating the risk-benefit potential of e-cigarettes for smoking cessation in
the population,” the authors summarized.
56. International findings are comparable and point, as well, to the strong association
between vaping and a higher propensity to quit smoking. The 2017
Eurobarometer survey, for example, recorded the duration of smoking cessation
for former smokers as well as smoking duration for both current and former
smokers across the European Union ("EU"). Farsalinos and colleagues classified
smokers according to quit duration to help overcome the problem of analyzing all
former smokers, many of whom had quit long before e-cigarettes were available,
as one group. Their survey analysis revealed that current daily e-cigarette use in
the EU was rare among former smokers of greater than 10 years and was
positively associated with recent (5 years or fewer) smoking cessation. Former
daily e-cigarette use was also positively associated with recent 2 years or fewer
smoking cessation.73
Farsalinos encapsulated the findings: “we found a strong
association between current daily e-cigarette use and being a former (rather than
a current) smoker. Specifically, we found that daily e-cigarette use was
associated with 5-fold higher odds of having quit smoking in 2015-2017, and with
3-fold higher odds of having quit smoking in 2012-2015. Another important
finding of the study was that e-cigarette use was extremely rare among former
smokers who had quit before the availability of e-cigarettes, showing that e-
cigarettes do not result in relapse to an inhalational habit for these former
smokers.”74
The 2020 Eurobarometer study shows that 58 percent of European
smokers or ex-smokers who use, or have used, e-cigarettes and/or heated
tobacco products say that these products have helped them to either quit or
reduce smoking.75
57. In Australia, a nationally representative sample of 3,868 adult smokers in
Australia found that daily e-cigarette use was strongly associated with smoking
reduction/cessation, but occasional use was not.76
58. In addition to population studies like those outlined above, a number of
randomized clinical trials also provide further confirmatory evidence of the
effectiveness of e-cigarettes in helping smokers to quit cigarettes. Importantly,
randomized clinical trials give insight into causality – if variable X is manipulated
will outcome Y change? – as opposed to observations made in cross-sections or
over time. For example, a year-long study led by Peter Hajek, director of the
Wolfson Institute of Preventive Medicine's Tobacco Dependence Research Unit at
Queen Mary University of London, randomized 886 smokers to various cessation
methods. All subjects were motivated to quit. Those randomized to e-cigarettes
were 80 percent more likely to abstain from cigarettes for at least a year (18
percent) compared with those who used a range of NRTs (patch, gum, lozenge,
nasal spray, inhalator, mouth spray, mouth strip, and microtabs at 9.9 percent).77
The findings appeared in 2019 in the New England Journal of Medicine and
garnered considerable scientific and media attention.
59. The following year, in a six-month trial conducted in New Zealand, researchers
randomized 1,124 people to one of three groups: nicotine patches (21 mg) only,
patches plus a nicotine e-cigarette (18mg/L), or patches plus a nicotine-free e-
cigarette. Half of the participants in the patch only group withdrew or were lost
at follow-up by 6 months, compared to just under one-third of both of the other
groups. At six months, 2 percent of the patch-only group maintained continuous
14
abstinence from smoking, as verified by carbon monoxide testing, compared with
4 percent in the patch plus nicotine-free device and 7 percent in the patch plus
nicotine-containing e-cigarette.78
60. In 2021, Jonathan Foulds, a Professor of Public Health Sciences and Psychiatry
Penn State University, and his team published the results of a randomized trial of
520 smokers assigned to one of four 24-week conditions. 79
The study subjects
received either (1) a vaping device with no nicotine, (2) with 8 mg/ml nicotine, (3)
with 36 mg/ml nicotine, or (4) a cigarette-shaped tube containing no nicotine as a
cigarette substitute. The subjects reported being motivated to reduce nicotine
consumption but were not planning to quit consuming nicotine. At 24 weeks,
significantly more participants in the 36 mg/ml condition (10.8 percent) than in
the 0 mg/ml (.8 percent) condition or the “tube” condition (3.1 percent) were
abstinent from cigarettes. Among the set of subjects in the 8 mg/ml condition,
4.6 percent were abstinent. The authors concluded that if smokers continued to
vape with cigarette-like nicotine delivery, a greater proportion completely
switched to an e-cigarette, as compared with placebo or a cigarette substitute.
61. A number of reviews of randomized trials have also concluded that e-cigarettes
are more effective in helping smokers quit.
62. For example, in September 2021, the Cochrane Collaboration published an update
to its ongoing review into the effect and safety of using e-cigarettes to help
smokers achieve long-term smoking abstinence. This version of the report
assessed the results of 61 studies, representing 16,759 participants, of which 34
studies are randomized controlled trials. The authors found that “[m]ore people
probably stop smoking for at least six months using nicotine e-cigarettes than
using NRT (4 studies, 1,924 people), or nicotine-free e-cigarettes (5-cigarettes,
1,447 people)." It further noted that, "Nicotine e-cigarettes may help more
people to stop smoking than no support or behavioural support only (6 studies,
2,886 people)." The authors also found no evidence of harm from nicotine e-
cigarettes based on a two year follow up period.80
63. In 2021 an Austrian team reviewed 12 randomized controlled trials studies
encompassing 8,512 participants and found that “pooling current evidence points
toward a potential for e-cigarettes as a smoking cessation tool.”81
Across the
studies, e-cigarettes containing nicotine were compared with non-nicotine
versions or with established smoking cessation interventions (NRT and or
counseling) published between January 2014 and June 2020. The results, which
appeared in Nicotine & Tobacco Research, indicated that e-cigarettes performed
as well if not better than standard interventions. "The proportion of smokers
achieving abstinence was 1.71 (95 CI: 1.02–2.84) times higher in nicotine EC users
compared with non-nicotine EC users. The proportion of abstinent smokers was
1.69 (95 CI: 1.25–2.27) times higher in EC users compared with participants
receiving NRT. EC users showed a 2.04 (95 CI: 0.90–4.64) times higher proportion
of abstinent smokers in comparison with participants solely receiving counseling."
64. Another review published last year by a research group in the Centre for Youth
Substance Abuse Research, at the University of Queensland, Australia, included
randomized controlled trials that allocated individuals to use nicotine e-
cigarettes, compared to those that used licensed NRTs, or a nicotine-free control
condition such as receiving placebo (nicotine-free) e-cigarettes or usual
15
intervention.82
While noting the need for more high quality studies, the authors
found that participants randomised to receive nicotine e-cigarettes were almost
50 percent more likely to remain abstinent from smoking than those who
received NRTs. Those randomised to receive nicotine e-cigarettes were twice as
likely to remain abstinent from smoking than those in control conditions where
no nicotine was supplied.
Heat Not Burn products
65. While the data on HNB products leading to reductions in smoking rates is limited,
data indicates that these products are displacing combusted cigarettes in the
marketplace. For example, HNB products are becoming very popular in a number
of countries, including Japan (where e-cigarettes are not available) and South
Korea. A particular appeal of HNB products for Japanese smokers is eliminating
the social disapproval of the smell of second-hand smoke.83
Japan has 90 percent
of the global market for HNB products.84
An analysis by Cummings et al. (2020)
found a five-fold increase in the annual percentage decline in cigarette sales in
Japan following the introduction of HNB products in late 2015. The authors
stated: “[b]etween 2011 and 2015, cigarette sales in Japan were declining at a
slow but steady pace. However, the pace of decline in cigarette sales accelerated
beginning in 2016, corresponding to the introduction of [HNB products] into the
marketplace.”85
66. In South Korea, sales of HNB products increased from 79 million packs in 2017 to
332 million packs in 2018 86
and are expected to increase 21 percent annually.87
In other major markets for HNB products, sales increased rapidly from 2017 to
2018 as follows: 30 percent in Italy and over 50 percent in Russia.88
67. What emerges from both the population data, observational studies, and
randomized-controlled experiments described above is strong and consistent
evidence suggesting that non-combustibles improve rates of smoking cessation
and lower overall rates of smoking. From a harm reduction perspective,
therefore, regulations that promote access to and knowledge of non-combustible
products should themselves promote the harm reduction potential of these
products, as they grow in popularity.
VI. WHY FLAVORS ARE IMPORTANT TO SMOKING CESSATION
68. The rationale for banning flavors may seem plausible on its face: if teens are
attracted to flavors, banning them will dissuade teens from vaping. However,
the problem is that limiting the appeal of vaping will also affect adult
smokers. These smokers are the very group for whom e-cigarettes are
intended. Such smokers also find e-cigarettes with flavor beyond tobacco
more appealing than e-cigarettes with tobacco flavor. Also, contrary to
popular belief, teens are not primarily drawn to e-cigarettes because of
flavors. According to a CDC survey, among students who ever used e-
cigarettes, the two most common reasons for first use were “a friend used
them” (57.8 percent), and “I was curious about them” (47.6 percent). Flavors
came in seventh, at 13.5 percent.89
69. Surveys routinely report that vapers strongly prefer fruit flavors over tobacco
flavor once they make the shift to e-cigarettes. Classic behavioral theory
would predict as much: to prevent relapse, a smoker trying to quit should
16
dissociate from the taste of smoking. A 2018 preference survey of 20,836
adult vapers in the U.S. found that fruit and dessert flavors are the most
popular by far, with only a minority using tobacco flavors – between 10 and
20 percent.90
Fruit flavors were preferred by over two-thirds of those who
were using e-cigarettes on a frequent basis (of whom 15,807, 75.9 percent,
had completely switched from smoking cigarettes to using e-cigarettes.)
Results indicated that adults who have completely switched from smoking
cigarettes to using e-cigarettes in the past 5 years are increasingly likely to
have initiated e-cigarette use with vapor products not flavored to taste like
tobacco.
70. Observational studies also demonstrate the importance of flavors in assisting
smokers to switch to e-cigarettes. A 2020 U.S. cohort study in JAMA with
17,929 participants used in waves 1-4 (2013-18) of the Population
Assessment of Tobacco and Health Study (collected from 2013 to 2018) found
that among adults who smoked and began vaping, the odds of smoking
cessation for those using non-tobacco flavors were 2.3 times that of those
who used tobacco-flavored e-cigarettes.91
Notably, flavored e-cigarettes
were not associated with greater youth smoking initiation.92
“Critically, this
study’s findings suggest that efforts to ban flavored e-cigarettes could
increase smoking,” the authors caution.
71. A 2021 study published in Nicotine & Tobacco Research found that smokers
who use flavored vapes to quit smoking were 43 percent more likely to
succeed than someone using an unflavored or tobacco-flavored vape.93
Researchers examined 886 concurrent (at least weekly) users of nicotine-
containing vaping products and cigarettes who were first surveyed in 2016
and then successfully re-contacted in 2018. The participants were part of a
survey project conducted in Australia, Canada, England, and the United
States. Compared with users of tobacco flavors, those vaping “sweet” flavors
were more likely to quit smoking between surveys (13.8 percent vs. 9.6
percent). In addition, there was a net shift away from tobacco flavor among
those who continued to vape at follow-up.
72. Prohibitions on flavors also have predictable consequences. Users would be
likely to resume cigarettes if their preferred flavors are no longer available.
73. A 2021 paper published in Addictive Behaviors94
reports on findings from the
2020 ITC Smoking and Vaping Survey wherein researchers collected data from
851 regular vapers (all current or ex-smokers) across the U.S., Canada, and
England. They found that 28.3 percent of respondents reported they would
find a way to get their banned flavor(s) and 17.1 percent would stop vaping
and smoke instead.
74. A study on teens in the wake of a 2018 San Francisco ban on flavors
published last year in JAMA Pediatrics95
drew data from the 2011-2019 Youth
Risk Behavior Surveillance System school district surveys. Authors found that
San Francisco’s flavor ban was associated with more than doubled odds of
recent smoking among underage high school students relative to concurrent
changes in other districts. “This raises concerns,” the researchers caution,
“that reducing access to flavored electronic nicotine delivery systems may
motivate youths who would otherwise vape to substitute smoking.”
17
75. Similarly, online reports and social media posts describe smokers going back
to cigarettes or patronizing black markets, which are breeding grounds for
the worst manufacturing practices such as tainted nicotine liquids, defective
batteries, and heating coils are accumulating.
76. HNB products are available in tobacco and a limited number of other flavors,
including menthol and mint.96
In light of negligible use of HNB products by
teens -- according to the 2021 U.S. National Youth Tobacco Survey, 1.8
percent of U.S. middle and high school students reported ever use of an HNB
product, and 0.7 percent reported current use97
-- concern about motives to
use amongst youth has not attracted much attention.
VII. E-CIGARETTES AND HNBS DO NOT SERVE AS A GATEWAY TO SMOKING
77. Understandably, the possibility that non-smoking youth who initiate vaping
will then turn to smoking is of vast concern to public health officials,
politicians, and parents. Hence, the question of whether e-cigarettes serve
as a “gateway” to smoking has been extensively researched, with many
tobacco control advocates routinely suggesting this is in fact the case. The
EU Scientific Committee on Health, Environmental and Emerging Risks
(SCHEER) Final Opinion on Electronic Cigarettes98
and the “WHO Report on
the global tobacco epidemic 2021: New and Emerging Products” have
sounded similar notes of caution that allowing vaping will serve as a
“gateway” to initiation to smoking.99
As will be discussed below, robust data
analyses show that vaping is more of a “gateway” out of a smoking addiction
for teens than it is a passage into a new smoking habit for those who have
never smoked. Indeed, just as the data suggest that vaping and other non-
combustibles reduce smoking by increasing rates of cessation, so too do the
data suggest that non-combustibles reduce rates of smoking initiation in
adolescents and young adults – the time in life when most smokers start
experimenting with cigarettes for the first time.
78. Reassuringly, there is little evidence that teens who vape move on to
smoking. Data from the U.S., in fact, shows the exact opposite trend wherein
smoking rates of minors have declined at unprecedented speed in the last
decade. More specifically, current youth smoking dropped more steeply in
the years that teen vaping increased most sharply, between 2013 and 2019,
reaching a record low in 2020 of 4.6 percent.100
Another analysis shows that
U.S. youth smoking rates fell to 6.0 percent by 2019 (thereby surpassing the
Healthy People 2020 objective of 16 percent by 386 percent).101
This pattern, and
other analyses, suggest that vaping serves as more of an off-ramp from smoking
or as an alternative for adolescents and young adults who would have otherwise
initiated smoking. In addition, most adolescent and young adult users of vaping
products are infrequent users or experimenters; the minority that use e-
cigarettes frequently (defined as 20 to 30 days in the past month) largely
comprises those who have already used tobacco. In 2018, only 1 percent of teens
who never used tobacco frequently vaped.102
79. Furthermore, the most recent data from the U.S. Centers for Disease Control
show that vaping among U.S. teens has decreased since 2019. That year, 10.5
percent of middle school students and 27.5 percent of high schoolers used an e-
cigarette at least once in the past month. In 2020, 4.7 percent of middle and 19.6
18
percent high school students reported using e-cigarettes within the past 30 days
(current use), according to the CDC. In 2021, 2.8 percent of middle school
students and 11.3 percent of high school reported current e-cigarette use.103
For
perspective, 5.4 percent of 12th
graders vape daily (while 6.9 percent use
marijuana daily and 16.8 percent report binge drinking (more than five drinks in a
row in the last two weeks.))104
80. The situation is similar in the UK, where the evidence shows that "[r]egular use of
electronic cigarettes amongst children and young people is rare and is confined
almost entirely to those who currently or have previously smoked." A 2021
factsheet by UK ASH on the use of e-cigarettes among young people in Great
Britain found that "while some people, particularly those who have tried smoking,
experiment with e-cigarettes, regular use remains low." ASH also found that:
"[u]se of e-cigarettes remains largely confined to current or former smokers. The
overwhelming majority, 95.4% in total, of 11-17 year old never smokers have
either never used an e-cigarette (84.3%) or are not aware of them (10.7%)" and
"[o]f 11-17 year old never smokers, 3.3% have tried e-cigarettes once or twice,
0.5% use them less than weekly, and 0.2% use e-cigarettes more than once a
week. Only 1 single never smoker reported vaping daily, and only 0.3% were
previous users of e-cigarettes."105
81. It should also be noted that the gateway claim itself is ambiguous, in part
because commentators use the term "gateway" in various ways. Sometimes
“gateway” simply refers to a sequence (action B came after action A); and at
other times it refers to a predictive, causal statement (a person engaged in
action B because he first engaged in A). It is the latter that policymakers
should care about – that is, but for the use of A would B have happened – but
causality is very hard to prove by examining observational data.
82. After all, it is possible that action B would have happened independent of
behavior A. For example, a teen with a high tendency toward risk-taking
behavior, such as alcohol and marijuana use, or one who is subject to peer
and familial influences that promote risk-seeking behavior, would be prone to
try or use both e-cigarettes and cigarettes independently of each other. This
phenomenon is known as “the common liability theory” of associated
behaviors.106
Such a teen, therefore, might well have smoked, whether or
not he first vaped, based on shared innate and experiential factors. A
number of large studies confirm this “third-factor” dynamic.107
It would be
wrong to infer, therefore, that someone who vaped and then went on to
smoke did so because vaping was a causal “gateway” to smoking, when
personal, peer and family influences that correlate with a higher propensity
to vape are similar to the same factors that correlate with a higher propensity
to smoke.
83. This common liability theory is supported by data from Wave 1 (2013-2014)
of the Population Assessment of Tobacco and Health (PATH) by Nicksic and
others. The researchers found that general interest in vaping, peer
influences, social norms, desirable attributes, and goal-directed reasons
influence e-cigarette uptake in both teens and adults.108
These same factors
are influential in prompting adolescent smoking initiation. Researchers also
enquired about flavors in the context of “reasons to use” e-cigarettes and
found that “It comes in flavors I like” lagged sixth in an array of reasons,
19
including the fact that they “might be less harmful to people around me,”
“they do not smell,” and others.
84. Likewise, researchers in a 2020 study published in Nicotine & Tobacco
Research, examined respondents to the 2015–2016 waves of US Monitoring
the Future survey109
using propensity score methods to robustly adjust for
shared risks in estimating the relationship between e-cigarette use and
conventional smoking. Among those 14 shared risk factors were: disciplinary
problems, current alcohol or marijuana, or lifetime illicit drug consumption,
and the highest level of education completed by the father. After accounting
for the propensity for using e-cigarettes based on these 14 risk factors, both
lifetime and current e-cigarette use did not significantly increase the risk of
current conventional cigarette smoking. The authors state that these findings
do not support “the concerns that e-cigarettes act as a ‘gateway’ to
conventional cigarette smoking….”
85. These data indicate that e-cigarettes do not exert a causal effect on
concurrent conventional smoking among adolescents and young adults. Such
findings also parallel already well-established predictors of progression from
the first few puffs to daily smoking. As reviewed by Wellman and colleagues
in the American Journal of Prevention, these factors include male sex, lower
socio-economic status, poor academic performance, sensation-seeking or
rebelliousness, intention to smoke in the future, receptivity to tobacco
promotion efforts, susceptibility to smoking, family members’ smoking, and
having friends who smoke. Higher self-esteem and high parental
monitoring/supervision of the child appeared to protect against smoking
onset.110
86. Consistent with these data, one research team confirmed that associations
between adolescent e-cigarette use and subsequent smoking are more likely to
arise from common risk factors in a 2020 paper entitled, “The Relationship
Between Electronic Cigarette Use and Conventional Cigarette Smoking Is Largely
Attributable to Shared Risk Factor.”111
Examining cross-sectional data from 8th
and 10th graders drawn from the 2015–2016 waves of U.S. Monitoring the Future
survey, the authors inferred that “the apparent relationship between e-cigarette
use and current conventional smoking is fully explained by shared risk factors,
thus failing to support claims that e-cigarettes have a causal effect on concurrent
conventional smoking among youth.” Along those lines, another article entitled,
“High School Seniors Who Used E-Cigarettes May Have Otherwise Been Cigarette
Smokers: Evidence from Monitoring the Future (United States, 2009–2018),”112
found that among non-smoking youth, vaping is largely concentrated among
those who would have likely smoked prior to the introduction of e-cigarettes.
Furthermore, and strikingly, the introduction of e-cigarettes coincided with an
acceleration in the decline in youth smoking rates, the report revealed.
87. Reviewing the most recent (2020) longitudinal data from the U.S. Population
Assessment of Tobacco and Health (PATH), a team of epidemiologists integrated
data over six years, expressed in waves (wave 1: 2013–2014; wave 2: 2014–2015;
wave 3: 2015–2016; wave 4: 2016–2017; wave 4.5: 2017–2018; and wave 5:
2018–2019).113
Notably, this study, which appeared in Nicotine and Tobacco
Research in December 2021 included an unprecedented set of dependent
variables (e.g., the adolescents’ exposure to tobacco users (family members who
20
use tobacco, secondhand smoke exposure, friends who use tobacco); cigarette
smoking susceptibility; and behavioral risk factors, specifically including
respondents’ previous use of other tobacco products, alcohol, and marijuana as
measures of adolescents’ proclivity for use of psychoactive substances.) The
study aimed to determine whether a more substantial set of covariates affected
the finding of a statistically significant association between vaping at baseline and
subsequent smoking. The answer was 'yes': adjusting for a full set of confounders
weakened substantially the association of ever e-cigarette use with subsequent
smoking and even became non-significant in some waves, using both past 12-
month and past 30-day smoking as outcomes. In brief, the researchers report
having found “no direct association between ever vaping and subsequent
cigarette smoking among adolescents.”
88. A recent study published in Addiction114
which was carried out by researchers
from the Department of Behavioural Science and Health, University College
London, UK, assesses how changes in the prevalence of e-cigarette use among
young adults have been associated with changes in the uptake of smoking in
England between 2007 and 2018. The authors use a time series analysis. The
researchers found that there was evidence for no association between the
prevalence of e-cigarette use and ever-regular smoking among those aged 16–24.
VIII. IMPLICATIONS FOR PUBLIC HEALTH POLICY
89. Adverse health consequences of combustible tobacco products are significant.
The WHO estimates that there are 1.3 billion tobacco users worldwide and that
tobacco kills more than 8 million people each year.
90. The products of combustion of tobacco, such as tar and other toxins and gases,
are the overwhelming source of carcinogens and the cause of hypertension, lung
disease, and cardiovascular pathology associated with smoking. In general,
nicotine products that do not involve combustion, including e-cigarettes and HNB
products, are less hazardous than those that burn tobacco leaves.
91. In my opinion, current smokers must have access to and be properly informed
about safer options. This imperative is aligned with the WHO FCTC, which
includes tobacco harm reduction within its principles.
92. In their campaigns against e-cigarettes, many health agencies and advocates
breach two fundamental tenets of public-health practice: dispassionate and
nuanced analysis of risk and honest communication about that risk to the public.
Opponents of vaping often define the problem solely as a matter of teen vaping
while abdicating their responsibility to address the problem of adult smoking.
Youth should not vape, nor should adults smoke. Both imperatives need to be
taken into account and trade-offs made. Unfortunately, a vast swath of the
tobacco-control community seem to forget that the purview of public health is
the nation’s entire population of vulnerable people, not just youth, and
particularly groups that smoke at disproportionately high rates, including people
suffering mental illness, working-class men and women, indigenous people and
LGBT+ adults.
93. The ultimate loss of perspective, jarring in its significance to anyone who looks
beyond the vaping debate, is that regulation which restricts access or awareness
of safer alternatives is liable to have an adverse impact on public health by
21
perpetuating the use of more hazardous combustible cigarettes. In an essay
published in September 2021115
, fifteen past presidents of a leading professional
academic society in the field of tobacco control, the Society for Research on
Nicotine and Tobacco (SRNT), concluded: "While evidence suggests that vaping is
currently increasing smoking cessation, the impact could be much larger if the
public health community paid serious attention to vaping’s potential to help adult
smokers, smokers received accurate information about the relative risks of vaping
and smoking, and policies were designed with the potential effects on smokers in
mind. That is not happening."
94. Public health policy should be directed to educating smokers about the
comparative risks of different tobacco and nicotine products and facilitating a
switch to less risky substitutes, and not be such as to discourage or make that
switch more difficult.
95. However, national and local governments are proposing and implementing a
growing number of restrictive measures on non-combustibles. Product bans, too,
have been implemented. Other restrictions include prohibiting flavors other than
tobacco, restricting nicotine content, applying the same restrictions for tobacco
products to non-combustibles, such as tobacco style large graphic health
warnings, standardized packaging of products, retail display bans, and higher
taxes. In my opinion, these types of restrictive measures are ill-advised.
96. There is no doubt that these measures will cause many smokers to refrain from
switching to safer alternatives, to lure those who have already switched back to
smoking or to patronize illicit markets. Banning the sale of non-combustibles
outright virtually guarantees that smokers will continue smoking. It also puts
teens — the very stimulus for the ban — at increased risk for smoking.
97. As noted above, when flavored vapes are no longer available, many nicotine users
won’t just quit. Some will use cigarettes. Others will turn to the unregulated
black market to continue buying flavored e-cigarettes, for which vapers have a
strong preference.
98. Similarly restricting the nicotine content of alternative products to low levels
would likely discourage switching and increase relapse. As noted above, research
indicates that regulations that unduly restrict the nicotine level in e-cigarettes to
levels that smokers find unsatisfactory undermine the potential for smokers to
switch away from smoking.
99. Regulating non-combustibles in the same way as combustible products, including
requiring the same style of warnings, requiring the same standardized packaging
as tobacco products, and banning product displays, conveys the message that
these products pose the same health risks as combustible tobacco products. As
noted above, existing misperceptions are likely preventing some smokers from
switching to non-combustibles. Recognized public health experts Lyn Kozlowski
and David Sweanor state that, "[t]he error of presenting products with no
meaningful risk reduction as if they were safer cannot be redressed by
committing the equally life-threatening error of presenting products with large
risk reductions as if they are not safer or by concealing this information." Omitting
health-relevant information for consumers, the duo states, "effectively blindfolds
them and impairs their making informed personal choices."116
22
100. Policymakers should also make non-combustibles more accessible to smokers
by eschewing hefty taxes. While high cigarette taxation can be justified by
the adverse health effects of smoking, such rationale does not apply to safer
alternatives. Imposing significant taxes on non-combustible products would
make them less accessible as alternatives to smoking and will predictably
perpetuate the demand for combustibles.
101. As for concerns regarding youth, everyone agrees they should not vape.
However, as discussed above, an extremely small percentage of teenagers
use e-cigarettes regularly, and one of the biggest concerns — namely, that
teen vaping leads to teen smoking through a so-called gateway effect — is
unsubstantiated. There is also evidence that vaping is diverting some youth
away from more dangerous smoking.
102. Policymakers should require reliable, informative labeling and safe manufacturing
standards for e-cigarettes. They should also allay concerns about potential
gateway use and youth addiction to nicotine by banning the marketing and sale of
e-cigarettes to minors. However, they should not be heavy-handed in restricting
marketing and sales to adults. Instead, promoting electronic cigarettes to
smokers should be a public health priority.
103. Given the direct medical costs of smoking as well as the productivity losses
from premature deaths, persuading more smokers to switch would result in
significant cost savings — as well as millions of lives saved each year. As
noted by David Abrams of the NYU College of Global Public Health “If we lose
this opportunity, I think we will have blown the single biggest public health
opportunity we've ever had in 120 years to get rid of cigarettes and replace
them with a much safer form of nicotine for everybody.”117
IX. CONCLUSION
104. The purview of public health is the nation’s entire population. That includes adult
smokers, particularly those who smoke at disproportionately high rates, namely,
people suffering mental illness, working-class men and women, those who live in
rural areas, indigenous people, and LGBT+ adults. Governments and regulators
must not allow the intense focus on teen use – warranted though it is – to divert
all attention from the benefits of vaping for adult smokers, millions of who die
each year from smoking-related diseases.
105. Intrinsic to the controversy in relation to non-combustibles is the fact that the
benefits of these products to smokers are not widely appreciated. What’s more,
studies purporting to have identified vaping-related harms often exaggerate
those alleged negative effects. Researchers cannot conduct an optimal analysis of
the risks and benefits of vaping to the population as a whole – a public health
imperative –unless they take into account the significant advantages of non-
combustibles to smokers. Finally, when the known realities are considered, it
becomes clear that it is irrational to impose bans or overly restrictive regulations
on non-combustibles which will inhibit the tobacco harm reduction potential of
these products for smokers.
106. A number of harmful unintended consequences will likely result from bans and
overly restrictive regulation. An outright ban on non-combustibles or overly
restrictive regulation (including overly restrictive caps on nicotine strength, flavor
24
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Reuters Graphics (2019) "Better than cigarettes?". Available at: https://graphics.reuters.com/HEALTH-
VAPING-POLL/0100B2BZ1F4/index.html
59
Fidler, J.A., Shahab, L., West, O. et al. (2011) "'The smoking toolkit study': a national study of smoking
and smoking cessation in England", BMC Public Health 11, 479. https://doi.org/10.1186/1471-2458-11-
479
60
McNeill 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". London: Public Health
England. Available at:
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/6
84963/Evidence_review_of_e-cigarettes_and_heated_tobacco_products_2018.pdf.
61
Public Health England (2021), "Vaping in England: 2021 evidence update summary". Available at:
https://www.gov.uk/government/publications/vaping-in-england-evidence-update-february-
2021/vaping-in-england-2021-evidence-update-summary
62
McNeill, A., Brose, L.S., Calder, R., Simonavicius, E. and Robson, D. (2021). "Vaping in England: An
evidence update including vaping for smoking cessation, February 2021: a report commissioned by
Public Health England". London: Public Health England.
63
Ibid.
64
Perski O., Beard E., Brown J., (2020), “Association between changes in harm perceptions and e-
cigarette use among current tobacco smokers in England: a time series analysis” BMC Medicine (2020)
18:98
65
New Zealand Ministry of Health (2020), " Position statement on vaping". Available at:
https://www.health.govt.nz/our-work/preventative-health-wellness/tobacco-control/vaping-
smokefree-environments-and-regulated-products/position-statement-vaping
66
Royal College of Physicians. (2021), "Smoking and health 2021: a coming of age for tobacco control?".
Available at: https://www.rcplondon.ac.uk/projects/outputs/smoking-and-health-2021-coming-age-
tobacco-control
28
67
Gov.uk (2021), "Vaping in England: evidence update February 2021". Available at:
https://www.gov.uk/government/publications/vaping-in-england-evidence-update-february-2021
68
National Institutes of Health (2022), "E-cigarette use may lead some to quit traditional cigarettes".
Available at: https://www.nih.gov/news-events/nih-research-matters/e-cigarette-use-may-lead-some-
quit-traditional-cigarettes
69
Caraballo RS, Shafer PR, Patel D, Davis KC, McAfee TA. (2017) "Quit methods used by US adult cigarette
smokers, 2014–2016 ". Prev Chronic Dis. 2017;14:E32. Available at:
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Walton K, Wang TW, Prutzman Y, Jamal A, Babb SD. (2020) "Characteristics and Correlates of Recent
Successful Cessation Among Adult Cigarette Smokers, United States, 2018". Prev Chronic Dis. 2020 Dec
10;17:E154. doi: 10.5888/pcd17.200173. PMID: 33301394; PMCID: PMC7769075.
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Kasza KA, Edwards KC, Kimmel HL, et al. (2021), "Association of e-Cigarette Use With Discontinuation of
Cigarette Smoking Among Adult Smokers Who Were Initially Never Planning to Quit". JAMA Netw
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73
Farsalinos KE, Barbouni A. (2021), "Association between electronic cigarette use and smoking cessation
in the European Union in 2017: analysis of a representative sample of 13 057 Europeans from 28
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Sun, T. et. al., (2022) "Is smoking reduction and cessation associated with increased e-cigarette use?
Findings from a nationally representative sample of adult smokers in Australia", Addictive Behaviors,
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Walker N, Parag V, Verbiest M, Laking G, Laugesen M, Bullen C. (2020) "Nicotine patches used in
combination with e-cigarettes (with and without nicotine) for smoking cessation: a pragmatic,
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Foulds J, et al. (2021), "Effect of Electronic Nicotine Delivery Systems on Cigarette Abstinence in
Smokers with no Plans to Quit: Exploratory Analysis of a Randomized Placebo-Controlled Trial".
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Hartmann-Boyce J, McRobbie H, Butler AR, Lindson N, Bullen C, Begh R, Theodoulou A, Notley C,
Rigotti NA, Turner T, Fanshawe TR, Hajek P. (2021) "Electronic cigarettes for smoking cessation".
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Grabovac I, Oberndorfer M, Fischer J, Wiesinger W, Haider S, Dorner TE. (2021) "Effectiveness of
electronic cigarettes in smoking cessation: a systematic review and meta-analysis". Nicotine Tob Res.
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Chan GCK, Stjepanović D, Lim C, Sun T, Shanmuga Anandan A, Connor JP, Gartner C, Hall WD, Leung J.
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Hair, E.C., Bennett, M., Sheen, E., Cantrell, J., Briggs, J., Fenn, Z., Willett, J.G. and Vallone, D. (2018),
“Examining perceptions about IQOS heated tobacco product: consumer studies in Japan and
Switzerland”, Tobacco Control, Vol. 27, pp. s70-s73.;
Tabuchi, T., Gallus, S., Shinozaki, T., Nakaya, T., Kunugita, N. and Colwell, B. (2018), “Heat-not-burn
tobacco product use in Japan: its prevalence, predictors and perceived symptoms from exposure to
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29
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Filter Magazine (2019), “Rise of heat-not-burn products coincides with a decrease in cigarette sales”,
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K. Michael Cummings, Georges J Nahhas and David T Sweanor., (2021) “What Is Accounting for the
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Filter Magazine (2019), “Rise of heat-not-burn products coincides with a decrease in cigarette sales”,
January 29, available at: https://filtermag.org/rise-of-heat-not-burn-products-correlates-with-
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Wang TW, Gentzke AS, Creamer MR, et al. (2019) "Tobacco Product Use and Associated Factors Among
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Volume 23, Issue 9, September 2021, Pages 1490–1497, https://doi.org/10.1093/ntr/ntab033
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Gravely, Shannon et. al., (2022) "Responses to potential nicotine vaping product flavor restrictions
among regular vapers using non-tobacco flavors: Findings from the 2020 ITC Smoking and Vaping
Survey in Canada, England and the United States", Addictive Behaviors Volume 125, February 2022,
107152.
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Abigail S. Friedman (2021) "A Difference-in-Differences Analysis of Youth Smoking and a Ban on Sales of
Flavored Tobacco Products in San Francisco", California JAMA Pediatr. 2021;175(8):863-865.
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http://dx.doi.org/10.15585/mmwr.mm6950a1
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SCHEER (Scientific Committee on Health, Environmental and Emerging Risks), (2021), "Scientific
Opinion on electronic cigarettes", 16 April 2021. Available at:
https://ec.europa.eu/health/sites/default/files/scientific_committees/scheer/docs/scheer_o_017.pdf
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addressing new and emerging products". Licence: CC BY-NC-SA 3.0 IGO. Available at:
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United States, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1881–1888.
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Glasser A, Johnson A, Niaura R, et al., (2020) Youth Vaping and Tobacco Use in Context in the United
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30
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https://ash.org.uk/wp-content/uploads/2021/07/Use-of-e-cigarettes-among-young-people-in-Great-
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1
Sally L. Satel, M.D.
Curriculum Vitae
Date CV Prepared: April 19, 2019
Personal Data
Name: Sally L. Satel, M.D.
Contact Information: Division of Behavioral Health Services and Policy
Research, New York State Psychiatric Institute
1051 Riverside Drive Box 100
New York, NY 10032
Phone: 202-489-6654
Email: slsatel@gmail.com
Birth place: New York, NY
Citizenship: USA
Academic Appointments, Hospital Appointments, and Other Work Experience
2019 - Present Vising Professor of Psychiatry, Department of Psychiatry, Columbia
University Irving Medical Center, Department of Behavioral Health
Services and Policy Research
2018 - Present Clinical Consultant, Ironton-Lawrence Community Action Organization,
Addiction treatment
2010 - Present Psychiatric consultant, Partners in Drug Abuse Rehab and Counseling
(PIDARC)
2002 - Present resident scholar, American Enterprise Institute
2000 - Present Resident Scholar, American Enterprise Institute Project
1995 - Present Lecturer, Yale University School of Medicine
1997 - 2009 Staff Psychiatrist, Oasis Clinic
1996 - 1997 Professional Staff, U.S. Senate Veterans' Affairs Committee
1995 - 1996 Staff Psychiatrist, District of Columbia Superior Court Pretrial Program
1995 - 1996 Consultant to the U.S. Senate Special Committee on Aging
1994 - 1996 Visiting Research Scientist, University of Pennsylvania School of
Medicine
1988 – 1995 Assistant Professor of Psychiatry, Yale University School of Medicine
2
1993 – 1994 Robert Wood Johnson Health Policy Fellow, Office of Senator Nancy L.
Kassebaum (R-KS)
1990 - 1993 Member medical school admissions committee
1988 – 1993 Staff psychiatrist, West Haven VA Medical Center, Yale University
School of Medicine
Education
8/1982-6/1984 M.D., Warren Alpert Medical School of Brown University, Boston, MA
7/1977-6/1982 M.S. in Anatomy, University of Chicago
8/1973-6/1977 B.S. in Biology, Cornell University
Training
1985 – 1988 Resident in Psychiatry, Yale University School of Medicine
1984 – 1985 Intern, Flexible Internship, Hospital of St. Raphael, Yale University
School of Medicine
Board Certification
1997 Board of Psychiatry and Neurology
Honors and Awards
1993 - 1994 Laughlin Fellowship (American College of Psychiatrists) for outstanding resident
1988 Robert Wood Johnson Health Policy Fellowship
Academic Services
2018 - 2021 Member, National Advisory Council of the Substance Abuse and Mental Health
Services Administration
2002 – 2006 Member, Advisory Council, Center for Mental Health Services
2003 – 2003 Member, Advisory Council, Center for Mental Health Services
1996 – 2003 Member, Editorial Board, Psychiatric Services
Fellowship and Grant Support
1999 – 2000 Robert Wood Johnson Foundation President's Grant
Co-Investigator; wrote a paper on Drugs in courts
$50,000.00
3
Publications
Peer-Reviewed Research Publications in Print or other Media
1. Satel, S. L.*, & Lilienfeld, S.O. (2016). If addiction is not best conceptualized a brain
disease, then what kind of disease is it? Neuroethics Nov 17.
2. Satel, S.*, & Cronin D.C. (2015). Time to test incentives to increase organ donation
(Commentary) JAMA Intern Med. 175(8):1329-30.
3. Satel, S.*, Morrison, J.C., & Jones, R.K. (2014) State organ-donation incentives under
the National Organs Transplant Act. Law and Contemporary Problems 77:217-252.
4. Satel, S.* (2014) Delivering services to individuals with severe mental illness: SAMHSA
Falls Short. Psychiatr Serv. 65(9):1160-1.
5. Satel S.*, & Lilienfeld, S.O. Addiction and the brain-disease fallacy. Front Psychiatry
3;4:141.
6. Working Group on Incentives for Living Donation. (2012). International guidelines for
organ incentives. American Journal of Transplantation, 12: 306-312.
7. Satel, S.*, & Lilienfeld, S. O. (2010). Singing the brain disease blues. American Journal
of Bioethics Neuroscience, 1(1):46-54.
8. Satel, S.* (2010). The physician’s voice is only one of many. American Journal of
Transplantation, July 15.
9. Matas, A.J., Hippen, B., & Satel, S. (2008). In defense of a regulated system of
compensation for living donation. Current Opinion in Organ Transplantation, 13(4):
379-85.
10. Satel, S. L.* (2007). 9/11: Mental health in the wake of terrorist attacks. Psychiatric
Services, 58(February):276-77.
11. Satel, S. L.*, & Hippen, B. E. (2007). When altruism is not enough: The worsening
organ shortage and what it means for the elderly. The Elder Law Journal, 15(1):101-152.
12. Satel, S.* (2006). Is caffeine addictive? – A review of the literature. American Journal of
Drug and Alcohol Abuse, 32(4): 493-502.
4
13. Satel, S.* (2005). Physician substance abuse. Journal of the American Medical
Association, 294(4): 426-7; author reply 427.
14. Satel, S.* (2005). Posttraumatic Stress Disorder: Issues and Controversies. Psychiatric
Services, 56:758-759.
15. Satel, S.*, & Klick, J. (2005). The Institute of Medicine report: too quick to diagnose
bias. Perspectives in Biology and Medicine, 48(1 Suppl): S15-25.
16. Satel, S. L.* (2003). A war of nerves: Soldiers and psychiatrists in the twentieth century.
Psychiatric Services, 54(3): 405-406.
17. Satel, S. L.* (2003) The mental health crisis that wasn’t. Psychiatric Services,
54(12):1571.
18. Satel, S. L.* (2001). Commentary: Who needs trauma initiatives? Psychiatric Services,
52(6):815.
19. Satel, S.* (2000). Addiction is a choice. Psychiatric Services, 52(4): 539-540.
20. Caulkins, J., & Satel, S. (1999). Methadone patients should not be allowed to persist in
cocaine use. FAS Drug Policy Analysis Bulletin, 6(January).
21. Satel, S. L.*, & Aeschbach, E. (1999). The Swiss heroin trials. Scientifically sound?
Journal of Substance Abuse Treatment, 17(4):331-5.
22. Satel, S. L.* (1999). What should we expect from drug abusers? Psychiatric Services,
50(7):861.
23. Gelernter, J., Kranzler, H., & Satel, S. L. (1999). No association between D2 dopamine
receptor (DRD2) alleles or haplotypes and cocaine dependence or severity of cocaine
dependence in European- and African-Americans. Biological Psychiatry, 45(3):340-5.
24. Satel, S. L.* (1998). Are women’s health needs really “special”? Psychiatric Services,
49(5):565.
25. Satel, S.* (1997). Drug addicts and disability payments. FAS Drug Policy Analysis
Bulletin, 3(September).
26. Satel, S.*, Reuter, P., Hartley, D., Rosenheck, R., & Mintz, J. (1997). Influence of
retroactive disability payments on recipients' compliance with substance abuse treatment.
Psychiatric Services, 48(6):796-9.
27. Freimer, M., Kranzler, H., Satel, S., Lacobelle, J., Skipsey, K., Charney, D., & Gelernter,
J. (1996). No association between D3 dopamine receptor (DRD3) alleles and cocaine
dependence. Addiction Biology, 1(3):281-7.
5
28. Satel, S. L.* (1995). When disability benefits make patients sicker. New England Journal
of Medicine, 333(12):794-6.
29. Satel, S. L.*, Krystal, J. H., Delgado, P. L., Kosten, T. R., & Charney, D. S. (1995).
Tryptophan depletion and attenuation of cue-induced craving for cocaine. American
Journal of Psychiatry, 152(5):778-83.
30. Gelernter, J., Kranzler, H. R., Satel, S. L., & Rao, P. A. (1994). Genetic association
between dopamine transporter protein alleles and cocaine-induced paranoia.
Neuropsychopharmacology, 11(3):195-200.
31. Kranzler, H. R. Satel, S., & Apter, A. (1994). Personality disorders and associated
features in cocaine-dependent inpatients. Comprehensive Psychiatry, 35(5):335-40.
32. Satel, S.* (1994). Health care reform: a reality check. Hospital and Community
Psychiatry,45(9):849.
33. Satel, S. L.*, Becker, B. R., & Dan, E. (1993). Reducing obstacles to affiliation with
alcoholics anonymous among veterans with PTSD and alcoholism. Hospital and
Community Psychiatry, 44(11):1061-5.
34. Satel, S. L.*, & Glazer, W. M. (1993). Supporting addiction with public funds. Hospital
and Community Psychiatry, 44(10):913.
35. Satel, S. L.* (1993). The diagnostic limits of "addiction". Journal of Clinical Psychiatry,
54(6):237-8.
36. Hoffman, R. E., & Satel, S. L. (1993). Language therapy for schizophrenic patients with
persistent ‘voices’. British Journal of Psychiatry, 162:755-8.
37. Satel, S. L.*, Kosten, T. R., Schuckit, M. A., & Fischman, M. W. (1993). Should
protracted withdrawal from drugs by included in the DSM-IV? American Journal of
Psychiatry, 150(5):695-704.
38. Satel, S. L.*, & Swann, A. C. (1993). Extrapyramidal symptoms and cocaine abuse.
American Journal of Psychiatry, 150(2):347.
39. Seibly, J. P., Satel, S. L., Anthony, D., Southwick, S. M., Krystal, J. H., & Charney, D.
S. (1993). Effects of cocaine on hospital course in schizophrenia. Journal of Nervous and
Mental Disease, 181(1):31-7.
40. Satel, S. L.*, & Howland, F. C. (1992). Multiple personality disorder presenting as
postpartum depression. Hospital and Community Psychiatry, 43(12):1241-3.
41. Satel, S. L.*, Price, L. H., Palumbo, J. M., McDouble, C. J., Krystal, J. H., Gawin, F.,
6
Charney, D. S., Heninger, G. R., Kleber, H. D. (1991). Clinical phenomenology and
neurobiology of cocaine abstinence: a prospective inpatient study. American Journal of
Psychiatry, 148(12):1712-6.
42. Satel, S. L.*, & Edell, W. S. (1991). Cocaine-induced paranoia and psychosis proneness.
American Journal of Psychiatry, 148(12):1708-11.
43. Satel, S. L.*, Seibyl, J. P., & Charney, D. S. (1991). Prolonged cocaine psychosis implies
underlying major psychopathy. Journal of Clinical Psychiatry, 52(8):349-50.
44. Satel, S. L.*, & Seibyl, J. P. (1991). DSM-III-R criteria for cocaine disorders. American
Journal of Psychiatry, 148(8):1088.
45. Satel, S. L.*, & McDougle, C. J. (1991). Obsessions and compulsions associated with
cocaine abuse. American Journal of Psychiatry, 148(7):947.
46. Satel, S. L.*, Southwick, S. M., & Gawin, F. H. (1991). Clinical features of cocaine-
induced paranoia. American Journal of Psychiatry, 148(4):495-8.
47. Satel, S. L.*, & Kosten, T. R. (1991). Designing drug efficacy trials in the treatment of
cocaine abuse. Journal of Nervous and Mental Disease, 179(2):89-96.
48. Satel, S. L.*, Southwick, S. M., & Gawin, F. H. (1990). Clinical features of cocaine
induced paranoia. NIDA Research Monographs, 105:371.
49. Satel, S. L.* (1990). Mental status changes in children receiving glucocorticoids. Review
of the literature. Clinical Pediatrics, 29(7):383-8.
50. Southwick, S. M., & Satel, S. L. (1990). Exploring the meanings of substance abuse: an
important dimension of early work with borderline patients. American Journal of
Psychotherapy, 44(1):61-67
51. Satel, S. L.* (1989). Audiotape playback as a technique in the treatment of schizophrenic
patients. American Journal of Psychiatry, 146(8):1012-6.
52. Satel, S. L.*, & Nelson, J. C. (1989). Stimulants in the treatment of depression: a critical
overview. Journal of Clinical Psychiatry, 50(7):241-9.
53. Satel, S. L.*, & Gawin, F. H. (1989). Migrainelike headache and cocaine use. Journal of
the American Medical Association, 261(20):2995-6.
54. Satel, S. L.*, & Gawin, F. H. (1989). Seasonal cocaine abuse. American Journal of
Psychiatry, 146(4):534-5.
55. Satel, S.*, Southwich, S., & Denton, C. (1988). Use of imipramine for attention deficit
disorder in a borderline patient. Journal of Nervous and Mental Disease, 176(5):305-7.
7
Reviews, Chapters, Monographs, Editorials
1. Satel, S.* (2019, April 14). Pain patients get relief from regulation. Wall Street Journal.
2. Satel, S.* (2019, March 7). Chronic pain patients are unwitting casualties in the push to
limit opioids — The CDC could change that. AEIdeas.
3. Satel, S.* (2019, February 13). Vaping Is Harm Reduction: The surgeon general is right
on opioids, but wrong on tobacco. Wall Street Journal.
4. Satel, S.* (2019, January 18). Psychologists want to change how they treat men. That’s a
problem. Washington Post.
5. Hale, C., & Satel S. (2018, November 18). From Basketball to Overdose Capital: The
Story of Rural America, Schools, and the Opioid Crisis. In McShane, M. & Smarick, S.
(Eds.). No Longer Forgotten: The Triumphs and Struggles of Rural Education in
America. Lanham: Rowman & Littlefield.
6. Satel, S.* (2018, November 7). The FDA was wise to approve a new opioid: The use of
Dsuvia is limited, and wounded soldiers need it. Wall Street Journal.
7. Satel, S.*, & Kertesz, S. (2018, August 17). Oregon overshoots on opioids. Wall Street
Journal.
8. Satel, S.* (2018, August 8). ‘Dopesick’ and ‘The Addiction Solution’ review: Examining
an epidemic. Wall Street Journal.
9. Satel, S.* (2018, May 15). Vapin’ in the boys’ room. Wall Street Journal.
10. Rich, J., & Satel, S.* (2018, May 8). Access to maintenance medications for opioid
addiction is expanding. Prisons need to get on board. Slate.
11. Satel, S.* (2018, April 11). Why the panic over JUUL and teen vaping may have deadly
results. Forbes.
12. Satel, S.*, & Kertesz, S. (2018, March 30). Pill limits are not a smart way to fight the
opioid crisis. Slate.
13. Satel, S.* (2018, March 19). Naloxone, yes, but 3 other drugs are essential to fight the
opioid epidemic. Forbes.
14. Satel, S.* (2018, February 21). The myth of what’s driving the opioid crisis. Politico.
8
15. Kertesz, S., Gordon, A. J., & Satel, S.* (2018, January 19). Opioid prescription control:
When the corrective goes too far. Health Affairs Blog.
16. Satel, S.* (2018, January 17). Does it take a shrink to evaluate Trump? Wall Street
Journal.
17. Satel, S.*, & Bentley, G. (2017, December 4). Feds owe the public ‘corrective
statements’ on vaping. RealClear Health.
18. Satel, S.* (2017, November 27). Study shows two addiction medications similar but
dropout rates high: three possible remedies. Forbes.
19. Satel, S.*, & Morse, S. J. (2017, October 27). May court send drug-using thief to jail for
violating no-drugs probation condition? Washington Post.
20. Satel, S.*, & Morse, S. J. (2017, October 2). Addiction shouldn’t excuse criminal acts.
The Wall Street Journal.
21. Satel, S.* (2017, September 25). Why I admire Anthony Weiner. New York Times.
22. Satel, S.* (2017, September 20). What the new surgeon general should do about e-
cigarettes. Forbes.
23. Satel, S.*, & Kramer, P. (2017, August 29). Who decides whether trump is unfit to
govern? New York Times.
24. Satel, S.*, & Kertesz, S. (2017, August 17). Some people still need opioids. Slate.
25. Satel, S.* (2017, Summer). Taking on the scourge of opioids. National Affairs.
26. Satel, S.* (2017, June 22). Calling it ‘brain disease’ makes addiction harder to treat.
Boston Globe.
27. Satel, S.*, & Viard, A. D. (2017, June 12). The kindest (tax) cut: a federal tax credit for
organ donations. Tax Notes.
28. Satel, S.* (2017, May 31). Senators’ letter to FDA commissioner Gottlieb perpetuates
misconceptions about e-cigarettes. Forbes.
29. Satel, S.* (2017, May 31). Fighting the opioid epidemic: A Q&A with Sally Satel. AEI.
30. Satel, S.* (2017, April 20). What the New York Times gets wrong on vaping regulation.
Forbes.
31. Satel, S.* (2017, April 9). Saving lives is the first imperative in the opioid epidemic. Wall
Street Journal.
9
32. Satel, S.*, & Schuler, K. (2017, February 9). Organs for the mentally disabled. National
Review.
33. Satel, S.* (2017, March 23). A defense department hotline that keeps smokers hooked.
Forbes.
34. Satel, S.* (2017, February 21). Right to try, right to buy, right to test. Washington Post.
35. Satel, S.* (2017, February 9). Her damaged brain forgot new experiences but she still
improved on the viola. Washington Post.
36. Satel, S.*, & Hendrickson, K. (2017, January 18). Use disabilities law to avoid violent
confrontations with mentally disabled people. San Francisco Chronicle.
37. Satel, S.* (2017, January 13). How to treat an opioid epidemic. Wall Street Journal.
38. Satel, S.* (2016, December 31). The year in e-cigarettes: the good, the bad, and some
reasons for optimism. Forbes.
39. Satel, S.* (2016, December 27). Advocacy from the edge: Carrie Fisher spent decades
advocating for mental health treatment and against stigma. Here’s how we should honor
her. Slate.
40. Satel, S.*, & Sweanor, D. (2016, December 19). Dear surgeon general and public health
agencies, anti-vaping polices are bad for public health. RealClearHealth.
41. Satel, S.* (2016, December 8). Big tobacco is giving away money: Researchers should
take it. Forbes.
42. Satel, S.* (2016, December 7). Shortcuts to addiction. Wall Street Journal.
43. Satel, S.*, & Lilienfeld, S.O. (2016, November 30). What the surgeon general gets wrong
about addiction. RealClear Health.
44. Satel, S*. (2016, November 20). The addiction doctor isn’t in. RealClearHealth.
45. Satel, S*. (2016, November 15). You’ve heard of trump steaks, now trump kidneys.
Forbes.
46. Satel, S.*, & Bates, C. (2016, November 8). Could changes to a global tobacco treaty
harm health? Slate.
47. Satel, S.* (2016, October 17). California ballot choices: to protect porn stars but not
smokers? Forbes.
10
48. Satel, S.* (2016, October 13). It’s ok to speculate about trump’s mental health. Slate.
49. Satel, S.* (2016, September 26). Shameless campaign for tobacco-free kids tries to
censor researchers. Forbes.
50. Satel, S.* (2016, September 15). What to do about heroin addicts who keep OD’ing. New
York Post.
51. Satel, S.* (2016, September 13). Vouchers and incentives can increase kidney donations
and save lives. Stat News.
52. Satel, S.* (2016, September 13). A college tuition payment for your spare kidney? Slate.
53. Satel, S.* (2016, September 11). The Ritalin generation. Wall Street Journal.
54. Satel, S.* (2016, August 16). Vapers wary of FDA deeming rules. Forbes.
55. Satel, S.* (2016, August 9). Obamacare is hazardous to smokers’ health. Forbes.
56. Satel, S.* (2016, July 15). What’s the best way to battle the expanding Zika epidemic?
Washington Post.
57. Satel, S.* (2016, June 27). The dearth of donors: In-kind compensation for organs would
save lives. National Review.
58. Satel, S.* (2016, June 8). Mental Health Reform Desperately Needed To Pass House And
Senate. Forbes.
59. Satel, S.* (2016, June). Getting Meds: Why does government make it so hard?
Washington Monthly.
60. Satel, S.* (2016, May 10). Is addiction a brain disease? The Conversation.
61. Satel, S.* (2016, May 9). What the U.S. should learn from the UK’s wisdom on e-
cigarettes. Forbes.
62. Satel, S.* (2016, April 29). When our reason is hijacked by an uncontrollable urge.
Washington Post.
63. Satel, S.* (2016, April 25). What’s really killing India’s smokers: Misinformation about
e-cigarettes and vaping presents a growing threat to public health. Wall Street Journal.
64. Satel, S.* (2016, April 11). Congress, save e-cigarettes from the FDA. Forbes.
65. Satel, S.* (2016, April 11). What smart folk snort coke. Wall Street Journal.
11
66. Satel, S.*, & Fuller Torrey, E. (2016, Spring). A prescription for mental-health policy.
National Affairs.
67. Satel, S.* (2016, March 29). You won’t believe the government is supporting this
crackpot mental health therapy. Forbes.
68. Satel, S.* (2016, March 24). When harm reduction harms heroin addicts. Forbes.
69. Satel, S.* (2016, March 4). Precision psychiatry: Hype or promise? Los Angeles Review
of Books.
70. Satel, S.* (2016, February 29). What government researchers get wrong about addiction.
Forbes.
71. Satel, S.* (2016, February 5). Exploring the mind’s power over the body. Washington
Post.
72. Satel, S.* (2016, January 23). Can shame be useful? New York Times.
73. Satel, S.* (2015, December 31). The year in e-cigarettes: The good, the bad, the reason
for optimism. Forbes.
74. Satel, S.* (2015, December 28). Generosity won’t fix our shortage of organs for
transplants. Washington Post.
75. Satel, S.* (2015, December 14). What drug czar Botticelli got wrong on ’60 minutes’.
Forbes.
76. Satel, S.*, & Fuller Torrey, E. (2015, December 11). How bad can a federal agency be?
National Review.
77. Satel, S.* (2015, November 17). Why HUD should allow vaping in public housing.
Forbes.
78. Satel, S.* (2015, November 13). Treatment alone won’t stop heroin epidemic.
Bloomberg.
79. Satel, S.* (2015, November 11). Should drug addicts be forced into treatment?
Compelled drug addiction treatment works because of retention. New York Times.
80. Satel, S.* (2015, November 4). In fight against opioid crisis, civil commitment can save
lives. Boston Globe.
81. Satel, S.* (2015, October 30). Diagnosing the urge to run for office. Politico.
12
82. Satel, S.* (2015, October 21). Keep vaping China, don’t listen to the World Health
Organization on e-cigarettes. Forbes.
83. Satel, S.* (2015, October 6). How vapers can help smokers quit. Forbes.
84. Satel, S.* (2015, September 15). The bioethics dilemma. Pacific Standard Magazine.
85. Satel, S.* (2015, September 9). Why public health advocates care more about heroin
addicts than smokers. Forbes.
86. Satel, S.*, & Volokh, E. (2015, August 6). Dr. Sally Satel on why James Holmes (the
Aurora movie theater killer) shouldn’t get the death penalty. Washington Post.
87. Satel, S.* (2015, July 30). Double standard: E-cigarettes vs. medical marijuana. Forbes.
88. Satel, S.* (2015, July 21). Why heroin use is surging among women–and what to do
about it. Forbes.
89. Satel, S.* (2015, July 21). Kicking the habit: If addiction is a brain disease, addicts are
mad, sick and defective. If it’s a failure of will, users are bad, immoral and weak. Wall
Street Journal.
90. Satel, S.* (2015, June 19). Nicotine itself isn’t the real villain. Forbes.
91. Fuller T. E., & Satel, S.* (2015, June 17). Fixing America’s mental-health system.
National Review.
92. Satel, S.* (2015, June 1). The tarring of e-cigarettes. National Review.
93. Satel, S.*, & Lilienfeld, S. O. (2015, May 18). The adolescent brain defense: The
Tsarnaev death sentence and beyond. Washington Post.
94. Satel, S. L.*, & Yeh, S. (2015, May 14). Smokeless China. Project Syndicate.
95. Satel, S.*, & Lilienfeld, S. O. (2015, May 11). Neuro-expert testifies for Tsarnaev.
Washington Post.
96. Satel, S.*, & Lilienfeld, S. O. (2015, May 7). The ‘immature teen brain’ defense and the
Dzhokhar Tsarnaev trial. Washington Post.
97. Satel, S.* (2015, April 23). Why the CDC has it wrong about the rise in teen vaping.
Forbes.
98. Satel, S.* (2015, April 14). Their product is doubt--deceptive government campaign
against electronic cigarettes. Forbes.
13
99. Satel, S.* (2015, April 1). People who get paid by big tobacco should be able to advise
the FDA. Forbes.
100. Satel, S.* (2015, March 12). The case for compensating kidney donors. Pacific
Standard.
101.Satel, S.* (2015, March 4). Breakthrough on e-cigarette bans: how British adoption
authorities regained their sanity. Forbes.
102.Satel, S.* (2015, March 2). The enigma of survival. Pacific Standard.
103.Satel, S.* (2015, February 23). Two heads are better than one. Wall Street Journal.
104.Satel, S.* (2015, January 12). New Surgeon General should prescribe scientific honesty
on e-cigarettes. Forbes.
105.Satel, S.* (2015, January 19). It’s getting better all the time. Review of Shermer’s “The
Moral Arc.” Wall Street Journal.
106.Satel, S. L.* (2015, January 18). Will the FDA kill off e-cigs? New York Times.
107.Satel, S.* (2015, January 12). How to convince people to solve the organ shortage.
Forbes.
108.Satel, S.* (2014, December 1). Why anti-smoking groups should endorse snus and e-
cigarettes. Forbes.
109.Satel, S.* (2014, December 1).Don't execute schizophrenic killers. Bloomberg Opinion.
110.Satel, S.* (2014, November 10). How the FDA can help smokers quit. Forbes.
111.Satel, S.* (2014, November/December). Happy birthday methadone. Washington
Monthly.
112.Satel, S.* (2014, October 21). The True Impetus Behind Egg-Freezing. Forbes.
113.Satel, S.*, & Frueh, B. C. (2014, August 25). The other VA scandal. National Review.
114.Satel, S.* (2014 August 22). Test incentives for organ donations — there’s no reason not
to. New York Times.
115.Frueh, B. C., & Satel, S.* (2014, June 27). Veterans affairs needs to get a clue about ptsd
treatment. Time.
116.Satel, S.* & McLendon, M. H. (2014, June 15). Hospitals aren’t the VA’s only scandal.
Boston Globe.
14
117.Satel, S. L.* (2014, May 29). Loosen Restrictions for Therapists to Report Danger. New
York Times.
118.Satel, S. L.* (2014, May 3). Why People Don’t Donate Their Kidneys. New York Times.
119.Satel, S.*, & Rodu, B. (2014, April 29). Everyone Is Asking the Wrong Questions About
E-Cigarettes. The New Republic.
120.Satel, S.*, Viard, A.D., & Brill, A. (2014, April 14). Should e-cigarettes be taxed? Tax
Notes
121.Satel, S. L.* (2014, March 31). Wall Street Is Not a Death Trap. Bloomberg Opinion.
122.Satel, S.* (2014, March 5). Descendant of Fear: On Scott Stossel’s My Age of Anxiety.
The Millions.
123.Satel, S. L.* (2014, February 14). Where was I? New York Times.
124.Satel, S.* (2014, February 14). How e-cigarettes could save lives. Washington Post.
125.Satel, S.* (2014, January 31). Clean the air on addiction. The Globe and Mail.
126.Satel, S.* (2014, January 23). Are Hollywood Starlets Glamorizing Smoking By Using
E-Cigarettes? Forbes.
127.Satel, S.* (2013, November 6). We’re Not Powerless Against Oreos. Bloomberg
Opinion.
128.Satel, S.* (2013, September 30). The Science of Choice in Addiction. The Atlantic.
129.Satel, S.* (2013, September 19). We have the tools to prevent another shooting spree.
Bloomberg.
130.Lilienfeld, S.O., & Satel, S.* (2013, September 16). Neuro-backlash? What backlash?
Rationally Speaking.
131.Satel, S.* (2013, June 20). 50 shades of grey matter. The Chronicle of Higher
Education’s The Conversation.
132.Satel, S.* (2013, June 19). How to fix the organ transplant shortage. Slate.
133.Raine, A., & Satel, S.* (2013, June 10). Can brain scans explain crime? Washington
Post.
134.Satel, S.* (2013, June 6). Letting a child die for a voluntary ideal: compensate organ
15
donors so patients like Sarah Murnaghan can live. USA Today.
135.Lilienfeld, S.O., & Satel, S.* (2013, June 4). Good news for liars. Slate.
136.Lilienfeld, S.O., & Satel, S.* (2013, June 2). Brain science not ready to replace Mad
Men. Bloomberg.
137.Satel, S.* (2013, May 30). Don’t read too much into brain scans. Time.
138.Satel, S.* (2013, May 11). Why the fuss over the D.S.M.-5? New York Times.
139.Satel, S.* (2013, April 25). Organ donors behind bars. New York Times Room for
Debate.
140. Satel, S.* (2013, April 15). A kidney for a kidney. Slate.
141.Satel, S.* (2013, March 21). Humanitarian and financial motives intertwine all the time.
Modern Medicine.
142.Satel, S.* (2013, March 6). A PTSD knighthood, and narrative. Time.
143.Satel, S.* (2013, February 23). Primed for controversy. New York Times.
144.Satel, S.* (2013, January 17). Enforce the laws, don’t add to them. New York Times.
145.Satel, S.* (2012, July 9). An organ ‘donor’ revolution: it’s now legal to compensate
bone-marrow donors. Wall Street Journal.
146.Satel, S.* (2012, May 15). Are you dead yet? The New Republic.
147.Satel, S.* (2012, May 7). Facebook’s organ donation success needs follow-up.
Bloomberg.
148.Satel, S.* (2012, March 2). This is your brain on drugs. Wall Street Journal.
149.Satel, S.* (2011, December 6). A lifesaving legal ruling on organ donation. Wall Street
Journal.
150.Satel, S.* (2011, November 8). The market for kidneys, livers and lungs. Wall Street
Journal.
151.Satel, S.* (2011, August 19). The wrong way to help veterans. New York Times.
152.Satel, S.* (2011, July 27). Amy Winehouse’s killers. Wall Street Journal.
153.Satel, S.* (2011, June 13). Yuan a kidney? China’s proposals to pay organ donors flout
16
the status quo. That’s a good thing. Slate.
154.Satel, S.* (2011, May 12). Ordering disorder. The New Republic.
155.Satel, S.* (2011, February 1). PTSD’s diagnostic trap. Policy Review., 165.
156.Satel, S.* (2011, January 18). Time to mandate reporting of mental health concerns.
USA Today.
157. Satel, S.* (2011, January 13). Dealing with mental disorders on campus: involuntary
treatment laws. New York Times Room for Debate.
158.Satel, S.* (2011, January 6). A modest proposal on kidney donation. Wall Street
Journal.
159.Satel, S.* (2010, December 6). Cutting human lives: what should we make of Arizona’s
new law for rationing organ transplants? Slate.
160.Satel, S.* (2010, October 19). Drugs and money. The New Republic.
161.Satel, S.* (2010). Is it ever right to buy or sell human organs? New Internationalist
Magazine., 436.
162.Satel, S.* (2010, September 17). Physician, humanize thyself. Wall Street Journal.
163.Satel, S.* (2010, July 17). The battle over battle fatigue. Wall Street Journal.
164.Satel, S.* (2010, July 8). Should more veterans get P.T.S.D. benefits? New York Times
Room for Debate.
165.Satel, S.* (2010, June 11). Altruism + incentive = more organ donations. The Times
166.Satel, S.* (2010, May 2). The cost of an altruism-only policy. New York Times Room for
Debate
167.Satel, S.* (2010, March 15). Addiction and freedom. The New Republic
168.Satel, S.*, & Perry, M. (2010, March 7). More kidney donors are needed to meet a rising
demand. Washington Post
169.Satel, S.* (2010, February 19). Prescriptions for psychiatric trouble. Wall Street Journal.
170.Satel, S.* (2010, February/March). The limits of bioethics: Where the profession ends
and politics begins. Policy Review.
17
171.Satel, S.* (2010, January 27). Kidney mitzvah: Israel’s remarkable new steps to solve its
organ shortage. Slate.
172.Satel, S.* (2010, January 13). The right (and wrong) answers. The New Republic.
173.Satel, S.* (2009, December 21). A ‘gift of life’ with money attached. New York Times.
174.Satel, S.* (2009, December 21). Expel students who might kill themselves? Minding the
Campus.
175.Satel, S.* (2009, December 8). Weird science. Forbes.
176.Satel, S.* (2009, November 25). Tempest in a c-cup. Forbes.
177.Satel, S.* (2009, October 18). The case for paying organ donors: There is no indignity in
financial gain. Wall Street Journal.
178.Satel, S.* (2009, August 7). Clinical trials, wrapped in red tape. New York Times.
179.Satel, S.* (2009, July 26). About that New Jersey organ scandal. Wall Street Journal.
180.Satel, S.* (2009, July 12). Body & sold: It’s time to offer people incentives to donate
organs. New York Post.
181.Satel, S.* (2009, June 21). Steve Jobs’ liver. Forbes.
182.Satel, S.* (2009, June 11). The National Kidney Foundation’s bizarre logic. The
American.
183.Satel, S.* (2009, April 20). To fight stigmas, start with treatment. New York Times.
184.Satel, S.* (2009, April 3). Reward organ donors: Singapore’s new law is a positive step
toward making the transplant market more transparent. Wall Street Journal.
185.Satel, S.* (2009, March 30). How Marion Barry could help the organ shortage.
Washington Examiner.
186.Satel, S.* (2009, March 10). Kidney for sale: Let’s legally reward the donor. Globe and
Mail.
187.Satel, S.* (2009, January 30). When altruism isn’t moral. The American.
188.Satel, S.* (2009, January 15). Dopamine made me do it. Forbes.
189.Satel, S.* (2009, January 8). Take my kidney, please. The Daily Beast.
18
190.Satel, S. L.*, & Frueh, B. C. (2009) Sociopolitical aspects of psychiatry: Posttraumatic
stress disorder. In Sadock, B. J., Sadock, V. A., & Ruiz, P. (Eds.). Kaplan & Sadock’s
comprehensive textbook of psychiatry (9th
ed.). Philadelphia, PA: Lippincott Williams &
Wilkins.
191.Satel, S.* (2008, November 14). It’s all in your head. Wall Street Journal.
192.Satel, S.* (2008, October 30). A way to reward organ donors. Forbes.
193.Satel, S.* (2008, September 2). Addiction doesn’t discriminate? Wrong. New York
Times.
194.Satel, S.* (2008, August 15). Organ failure: Doing battle with the National Kidney
Foundation. Slate.
195.Satel, S.*, & Hakim, N. (2008, June 20). What’s wrong with selling kidneys?
International Herald Tribune.
196.Satel, S.* (2008, June 17). The God committee: Should criminals have equal access to
scarce medical treatments? Slate.
197.Satel, S.* (2008, May 16). Why we need a market for human organs. Wall Street Journal.
198.Satel, S.* (2008, May 7). What the doctor ordered. National Review Online.
199.Satel, S.* (2008, May 2). Transplant tourism: Treating patients when they return to the
U.S. AMA Virtual Mentor.
200.Satel, S.* (2008, April 28). Sources of medical research funding. Medical Progress
Today.
201.Satel, S.* & Hippen, B. (2008, April 14). Code red. National Review Online.
202.Satel, S.* (2008, February 27). Science and sorrow. The New Republic.
203.Satel, S.* (2008, February 26). A helping hand for vets. Wall Street Journal.
204.Satel, S.* (2007, December 16). Desperately seeking a kidney. New York Times.
205.Satel, S.* (2007, September 13). Mind over manual. New York Times.
206.Satel, S.* (2007, August/September). Supply, demand, and kidney transplants. Policy
Review.
207.Satel, S.* (2007, July 25). Addiction isn't a brain disease, Congress. Slate.
19
208.Satel, S.* (2007, July 12). Guns and needles. New York Times.
209.Satel, S.* (2007, July 10). The human factor. American.com
210.Satel, S.* (2007, June 12). "Been there?" Sometimes that isn't the point. New York
Times.
211.Satel, S.* (2007, May 29). Who wants to be a kidney recipient?. The Huffington Post.
212.Satel, S.* (2007, May 28). Sane mental health laws? Don't hold your breath. Federal
"advocates" are standing in the way of reform. Weekly Standard.
213.Satel, S.* (2007, May 15). Oxy morons. Wall Street Journal.
214.Kushner, H. I., & Satel, S.*(reviewers). (2007, May). Health gulf: Medical apartheid by
Harriet A. Washington. Commentary Magazine.
215.Satel, S.* (2007, April 30). Paying for kidneys. Washington Post.
216.Satel, S.* (2007, April 8). Mismanaged care. New York Times.
217.Satel, S.* (2007, April 3). One harsh prescription: A doctor vs. cyber humanitarianism.
National Review Online.
218.Satel, S.* (2007, March 16). Doing well by doing good. Wall Street Journal.
219.Satel, S.* (2007, February 19). The trouble with traumatology. Weekly Standard.
220.Satel, S.* (2007, February 5). First, Do Harm. Weekly Standard.
221.Satel, S.* (2007). In praise of stigma. In Henningfield, J. E., Santora, P. B., & W. K.
Bickel (Eds.), Addiction treatment: science and policy for the twenty-first century.
Baltimore, MD: Johns Hopkins University Press.
222.Satel, S.* (2006, December 19). Sometimes, the Why Really Isn't Crucial. New York
Times.
223.Satel, S.* (2006, November/December). Organs for Sale. The American
224.Satel, S.* (2006, October 25). Organ donations in the USA: Recipient: A living donor let
me live on. USA Today.
225.Satel, S.* (2006, August 29). Measuring the psychic pain of war. Slate.
226.Satel, S.* (2006, August 21). Stressed out vets: Believing the worst about post-traumatic
stress disorder. The Weekly Standard.
20
227.Satel, S.* (2006, August 15). For addicts, firm hand can be the best medicine. New York
Times.
228.Humphrey, K., & Satel, S.* (2006, August 11). Think Before You Drink: Talking under
the influence? They’re still your words. National Review Online.
229.Satel, S.* (2006, June 5). Pharmutopia: Antidepressants and the numbing-down of
America. Weekly Standard.
230.Satel, S.* (2006, May). The waiting game: The struggle to find organ donors is more
difficult with a less-than-generous public policy. In Character.
231.Satel, S.* (2006, May 29). The kindness of strangers: And the cruelty of some medical
ethicists. Weekly Standard.
232.Satel, S.* (2006, May 15). Death's waiting list. New York Times.
233.Satel, S.* (2006, April 19). Patients adrift in a sea of clinical trials. Medical Progress
Today.
234.Satel, S.*( (2006, April 5). A statement of madness. National Review.
235.Satel, S.*, & Klick, J. (2006, April & May). Are Doctors Biased? Policy Review,
136:40-54.
236.Satel, S.* (2006, March 1). For some, the war won't end. New York Times.
237.Satel, S.* (2006, February 26). A better breed of American. New York Times.
238.Satel, S.* (2006, February 23). Biased doctors? Don’t rush to pull out the race card.
National Review.
239.Satel, S.* (2006, February 14). A pill to treat your addiction? Don't bet the rent. New
York Times.
240.Satel, S.* (2006, February 2). Smoking out cliches about race. Medical Progress Today.
241.Satel, S.* (2006, January 12). Suicide risks and SSRIs: New data should change the
equation. Medical Progress Today.
242.Klick, J., & Satel, S.* (2006). The health disparities myth: Diagnosing the treatment gap.
Washington, DC: AEI Press.
243.Satel, S.* (2005, November 22). An internet lifeline, in search of a kidney. New York
Times.
21
244.Satel, S.* (2005, November 4). Much ado about meth? Tech Central Station.
245.Satel, S.* (2005, October 31). Political science: Is the GOP the elephant in the
laboratory? Weekly Standard.
246.Satel, S.* (2005, September 27). Prescription: Flexibility. National Review.
247.Satel, S.* (2005, August 22). Where's the choice? National Review.
248.Satel, S.* (2005, August 16). A whiff of 'reefer madness' in U.S. drug policy. New York
Times.
249.Satel, S.* & Sommers, C. (2005, August 14). Defining down mental illness. Washington
Post.
250.Satel, S.* (2005, June 19). ‘The Ethical Brain': Mind over gray matter. New York Times.
251.Satel, S.* (2005, June 15). Veterans: Beware of the disability trap. The Record, pp. L11.
252.Sommers, H. C., & Satel, S.* (2005, June 19). Therapy nation: Really, we’re ok.
Orlando Sentinel.
253.Satel, S.* (2005, June 14). A cautionary tale. Tech Central Station.
254.Satel, S.* (2005, June 13). Saving our vets once they're home: The right kind of mental
health treatment is vital. Los Angeles Times.
255.Satel, S.* (2005, June 10). Marijuana as RX is a worthy goal. The Seattle Post-
Intelligencer, pp. B7.
256.Satel, S.* (2005, June 8). Good to grow. New York Times.
257.Satel, S.* (2005, June 7). An infantile policy. Tech Central Station.
258.Satel, S.* (2005, May 12). The children of Ground Zero. New York Post.
259.Satel, S.* (2005, April 12). Just the facts, ma’am. National Review Online.
260.Satel, S.* (2005, April 11). Data do not support ban on silicone breast implants. USA
Today.
261.Satel, S.* (2005, March 29). Bread and shelter, yes. Psychiatrists, no. New York Times.
262.Satel, S.* (2005, March 29). An infamy of one’s own. Wall Street Journal.
22
263.Sommers, C. H., & Satel, S.* (2005, March 29). Where were you on 1/14? Wall Street
Journal.
264.Satel, S.* (2005, February 25). Should our TV programs be “quick-acting” or “long-
lasting”? Advertising Age, pp. 28.
265.Satel, S.* (2005, February 20). Brain-based leniency would give teen killers a pass. USA
Today.
266.Satel, S.* (2005, February 16). TCS Convention on Biodiversity coverage: Diminishing
biodiverse returns. Tech Central Station.
267.Humphreys, K., & Satel, S.* (2005, January 18). Some gene research just isn't worth the
money. New York Times.
268.Satel, S.* (2005, January 14). The therapy reflex. National Review Online.
269.Eberstadt, N., & Satel, S.* (2004). Health, inequality, and the scholars. Public Interest,
157:100-118.
270.Satel, S.* (2004, December 10). Race and medicine can mix without prejudice. Medical
Progress Today.
271.Satel, S.* (2004, October 19). Doctors behind bars: Treating pain is now risky business.
New York Times.
272.Satel, S.* (2004, October 10). Are you normal? Think again. New York Times.
273.Satel, S.* (2004, September 20). The rush to black label (or blackball) SSRIs. Medical
Progress Today.
274.Satel, S.* (2004, September 12). Bad medicine? The data on anti-depressants and child
suicide aren't conclusive. National Review Online.
275.Satel, S.* (2004, September 10). Drugged and confused. Wall Street Journal.
276.Satel, S.* (2004, September 6). Painful correction. Forbes Magazine.
277.Satel, S.* (2004, August 6). A case of colorblind care. Wall Street Journal.
278.Satel, S.* (2004, July 13). Blind rush toward AIDS therapy may prove disastrous. Los
Angeles Times, pp. A7.
279.Satel, S.* (2004, July 7). Unproved AIDS medicines risk lives. Newsday, pp. A35.
280.Satel, S.* (2004, July 1). WHO's dubious bag of HIV medicines. Los Angeles Times.
23
281.Satel, S.* (2004, June 29). The perils of putting national leaders on the couch. New York
Times.
282.Satel, S.* (2004, May 25). Two countries, two views on antidepressants. New York
Times.
283.Satel, S.* (2004, May 7). Where there's smoke. Wall Street Journal.
284.Satel, S.* (2004, April 20). Do less harm? Use of an alternative smokeless tobacco
should be encouraged to reduce the damage of nicotine addiction. Pittsburgh Post-
Gazette, pp. F5.
285.Satel, S.* (2004, April 12). Science fiction. Weekly Standard.
286.Satel, S.* (2004, April 6). A smokeless alternative to quitting. New York Times.
287.Satel, S.* (2004, March 5). Returning from Iraq, still fighting Vietnam. New York Times.
288.Satel, S.*, & Klick, J. (2004, March 1). Don't despair over disparities. Weekly Standard.
289.Eberstadt, N., & Satel, S.* (2004, January). Health and the income inequality
hypothesis:
A doctrine in search of data. Washington, DC: AEI Press.
290.Satel, S.* (2003, November 4). The worst place for them. Plain Dealer, S11.
291.Satel, S.* (2003, November 1). Out of the asylum, into the cell. New York Times.
292.Satel, S.* (2003, October 26). OxyContin half-truths can cause suffering. USA Today.
293. Satel, S.*, & Humphreys, K. (2003). Mind games: The Senate’s mental health parity
bill is ill-conceived. Weekly Standard.
294.Satel, S.*, & Zdanowicz. (2003, July 29). Commission’s omission: The president’s
mental health commission in denial. National Review Online.
295.Satel, S.* (2003, July 24). Symptoms of modern life or ADD. National Post, A16.
296.Satel, S.* (2003, July 23). ADD overdose? Wall Street Journal.
297.Satel, S.* (2003, May 19). The trauma society. New Republic.
298.Satel, S.* (2003, May 2). Talk about trauma! Wall Street Journal.
299.Satel, S.* (2003, March 11). Fast food ‘addiction’ feeds only lawyers. USA Today.
24
300.Satel, S.* (2003, March 3). Insanity goes back on trial. New York Times.
301.Satel, S.* (2003, February 3). OxyMorons. Tech Central Station.
302.Satel, S.* (2002, October 18). Kumbayah medicine: Why is the government paying for
research into wacky alternative treatments? Forbes.
303.Satel, S.* (2002, July 26). New Yorkers don’t need therapy. Wall Street Journal.
304.Satel, S.* (2002, May 5). I am a racially profiling doctor . New York Times.
305.Satel, S.* (2002, April 4). Racist doctors? Don't believe the media hype. Wall Street
Journal.
306.Satel, S.* (2002, March 14). It's crazy to execute the insane. Wall Street Journal.
307.Satel, S.* (2002, Winter). Menopause envy: Not all guys have changed since September
11. Women’s Quarterly
308.Satel, S.* (2002). Is drug addiction a brain disease? In Musto, D. F. (Ed.). One hundred
years of heroin. Westport, CT: Auburn House.
309.Satel, S.* (2001, December 13). Public health? Forget it; Cosmic issues beckon. Wall
Street Journal.
310.Satel, S.* (2001, December 11). ‘You dirty rats’: Activists jeopardize biomedical
research. Tech Central Station.
311.Satel, S.* (2001, December 7). The sorry CSAP flap: It’s worse than it looks. Tech
Central Station.
312.Satel, S.* (2001, December). Medicine’s Race Problem. Policy Review, 110.
313.Satel, S.* (2001, November). In focus: Guest editorial: Affirmative action. Medscape.
314.Satel, S.*, & Sommers, C. H. (2001, October 15). Manager's journal: Good grief: Don't
get taken by the trauma industry. Wall Street Journal.
315.Satel, S.* (2001, September 11). The newest feminist icon -- a killer mom. Wall Street
Journal.
316.Entine, J., & Satel, S.* (2001, September 9). Race belongs in the stem cell debate.
Washington Post.
317.Satel, S.* (2001, August 29). Crazed and confused. Slate.
25
318.Satel, S.* (2001, August 11). Keeping OxyContin out of the wrong hands. Boston Globe.
319.Satel, S.*, & Marmor, T. R. (2001, July 16). Does inequality make you sick?: The
dangers of the new public health crusade. Weekly Standard.
320.Satel, S.* (2001, July 3). Mommy undearest. Slate.
321.Satel, S.* (2001, May 10). When shedding pounds meant courting danger. Wall Street
Journal.
322.Satel, S.* (2001, May 7). It’s all in her head. American Prospect, pp. 49.
323.Satel. S.* (2001, April 27). Drugs: A decision, not a disease. Wall Street Journal.
324.nSatel, S.* (2001, April 23). When quackery kills. National Review Online.
325.Satel, S.* (2001, April 1). A misguided medical entanglement. Orlando Sentinel, pp. G1.
326.Satel, S.* (2001, March 6). A critic takes on psychiatric trauma. New York Times, pp.
F5.
327.Satel, S.* (2001, March 3). Feminism is bad for women's health care. Wall Street
Journal.
328.Satel, S.*, & Stolba, C. (2001, February). Who needs medical ethics? Commentary.
329.Satel, S.* (2001, January 31). How racial preferences refuse to die. New York Post.com
330.Satel, S.*, & O’Mathuna, D. P. (2000, January 31). New age nurses: Forget Florence
Nightingale. Women’s Quarterly, pp. 22.
331.Satel, S.* (2001, January). The indoctrinologists are coming. The Atlantic Online.
332.Satel, S.* (2000, October). The truth about anti-depressants will cheer you up. Ex
Femina.
333.Satel, S.* (2000, July 14). Learning to say ‘I've had enough.’ New York Times.
334.Satel, S.* (2000, April 24). Isn't a commando raid ‘psychologically abusive’? Wall
Street Journal.
335.Satel, S.* (2000, April 3). Prime-time psychosis. New York Times.
336.Satel, S.* (2000, January 1). Baseball is off its rocker. Wall Street Journal.
26
337.Satel, S.* (2000). The role of coercion in treating and curing addictions. In Furton, E. J.,
& Dort, V. M. (Eds.). Addiction and compulsive behaviors: Proceedings of the seventh
workshop for bishops. Philadelphia, PA: National Catholic Bioethics Center.
338.Satel, S.*(1999). The fallacies of no-fault addiction. Public Interest, 134 (Winter):52-67.
339.Satel, S.* (1999, December 15). Mentally ill or just feeling sad? New York Times, pp.
A23.
340.Satel, S.* (1999, August 15). Perspective on hate; Badness or madness? Los Angeles
Times.
341.Satel, S.* (1999, June 11). ‘Parity’ isn't charity. Wall Street Journal.
342.Satel, S.* (1999, April 23). An overabundance of counseling? New York Times.
343.Satel, S.* (1999, January 7). Real help for the mentally ill. New York Times, pp. A31.
344.Satel, S.* (1998, Winter). The abuse excuse. Women’s Quarterly.
345.Satel, S.* (1998, October 12). Bookshelf: A battle plan for the drug war. Wall Street
Journal.
346.Satel, S.* (1998, September 21). Is Clinton out of control? Wall Street Journal.
347.Satel, S.* (1998, August 18). The war on drugs. Slate.
348.Satel, S.* (1998, August 5). Bookshelf: Addicted to abolition. Wall Street Journal.
349.Satel, S.* (1998, Summer). Do drug courts really work? City Journal.
350.Satel, S.* (1998, July 22). Methadone works, usually. New York Times, pp. A19.
351.Satel, S.* (1998, July 20). Can this stick win the drug war? New York Post, pp. 21.
352.Satel, S.*, & Jaffe, D. J. (1998, July 20). Psychobabble, violent fantasies. National
Review.
353.Satel, S.* (1998, June 13). Battle of the drug warriors. Globe and Mail, pp. D9.
354.Satel, S.* (1998, June 8). Opiates for the masses. Wall Street Journal.
355.Satel, S.* (1998, May 2). Refurbishing Sigmund Freud. Ottawa Citizen, pp. B7.
356.Satel, S. (1998, April 4). Don't forget the addict's role in addiction. New York Times.
27
357.Satel, S.* (1998, January 6). For addicts, force is the best medicine. Wall Street Journal.
358.Satel, S. L.*, (1998). There is no women’s health crisis. National Affairs, 130:21-33.
359.Satel, S.* (1998) Drug Treatment: The Case for Coercion. Washington, DC: AEI Press.
360.Satel, S.*, & Goodwin, F. K. (1998) Is drug addiction a brain disease? Washington, DC:
Ethics and Public Policy Center.
361.Satel, S.* (1997, November 17). Letters to the editor: Those who really need marijuana.
Wall Street Journal.
362.Satel, S.* (1997, October 30). Medical marijuana: Research, don’t legalize. Wall Street
Journal, pp. A22.
363.Satel, S.* (1997, July 11). NOW's time is past. Wall Street Journal.
364.Satel, S.* (1997, May 10). When work is the cure. New York Times.
365.Satel, S.* (1996, December 12). The politicization of public health. Wall Street Journal.
366.Satel, S.* (1996, September 26). Is your kid on drugs? The FDA makes it hard to know.
Wall Street Journal.
367.Satel, S.* (1996, July 16). Where there's smoke, there's ire. Wall Street Journal.
368.Satel, S.* (1996, May 5). Psychiatric apartheid. Wall Street Journal.
369.Satel, S.* (1996, February 20). The madness of deinstitutionalization. Wall Street
Journal.
370.Satel, S.* (1995, Summer). Yes, drug treatment can work. City Journal.
371.Satel, S.* (1995, July 17). The wrong fix. Wall Street Journal.
372.Satel, S.* (1995, Winter). Treating insanity reasonably. City Journal.
373.Satel, S. L.* (1995, February 27). Science by quota: P. C. medicine. The New Republic,
212(9):14, 16.
Books
1. Lilienfeld, S. O., & Satel, S. (2013). Brainwashed: The seductive appeal of mindless
neuroscience. New York, NY: Basic Books.
2. Satel, S. (ed.). (2009). When altruism isn’t enough: The case for compensating kidney
28
donors. Washington, DC: AEI Press.
3. Hoff Sommers, C., & Satel, S. (2005). One nation under therapy: How the helping
culture is eroding self-reliance. New York, NY: St. Martin’s Press.
4. Satel, S.*, & Farabee, D. J. (2004) The role of coercion in drug treatment. In Lowinson,
J. H., Ruiz, P., Millman, R. B., & Langrod, J. G. (Eds.). Substance abuse: A
comprehensive textbook (4th
ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
5. Satel, S. (2001). PC, M.D. How political correctness is corrupting medicine. New York,
NY: Basic Books.
Congressional Testimony
1. Satel, S.* (2013, May 22). Examining SAMHSA’s role in delivering services to the
severely mentally ill. Testimony before House Committee on Energy and Commerce’s
Subcommittee on Oversight and Investigations.
2. Satel, S.* (2011, June 14). Bridging the gap between care and compensation for
veterans. Testimony before the House Committee on Veterans’ Affairs.
3. Satel, S.* (2009, June 12). Health disparities. Testimony before the Commission on Civil
Rights.
4. Satel, S.* (2008, June 24). Health Equity and Accountability Act of 2007. Testimony
before the House Committee on Energy and Commerce.
5. Satel, S.* (2008, June 10). Addressing disparities in health and health care: Issues for
reform. Testimony before the House Committee on Ways and Means.
6. Satel, S.* (2008, May 21). Veterans’ Mental Health Treatment First Act. Testimony
before the Senate Committee on Veterans’ Affairs.
7. Satel, S.* (2007, July 25). PTSD and personality disorders: Challenges for the VA.
Testimony before the House Committee on Veterans’ Affairs.
8. Satel, S.* (2004, March 11). Post-traumatic stress disorder and Iraq veterans. Testimony
before the House Committee on Veterans’ Affairs.
Amicus Briefs
1. Heyman, G. M., Morse, S. J., Lilienfeld, S. O., Satel, S. L., Commonwealth v. J
29
1
Analysis of Risk Beliefs and Usage of E-Cigarettes and other Potentially Reduced Risk Nicotine
Products in Europe
W. Kip Viscusi*
December 17, 2020
*
University Distinguished Professor of Law, Economics, and Management, Vanderbilt Law School, 131 21st Ave.
South, Nashville, TN, 37203. kip.viscusi@vanderbilt.edu.
British American Tobacco, bilag 3
2
I. INTRODUCTION
1. I am the University Distinguished Professor of Law, Economics, and Management at
Vanderbilt University. I hold a bachelor’s degree in Economics, two master’s degrees,
and a Ph.D. in economics, all from Harvard University. I have published almost 400
articles and over 30 books dealing primarily with health and safety risks, and I have been
ranked among the top 25 economists in the world based on citations in economics
journals. I worked extensively with the U.S. Environmental Protection Agency (“EPA”)
on a continuous basis from 1983 to 2012, where much of my work was focused on the
development of guidelines for hazard warnings for dangerous pesticides and chemicals.
2. In addition to my extensive work for EPA, I have consulted for several other
governmental entities on a variety of issues, including the U.S. Department of
Transportation, the U.S. Department of Labor, the U.S. Department of Justice, the U.S.
General Accounting Office, the U.S. Department of Health and Human Services, the U.S.
Office of Management and Budget, and the National Oceanic and Atmospheric
Administration. I have also taught courses about risk, uncertainty, risk analysis, and
hazard warnings to hundreds of Food and Drug Administration officials, congressional
staff, and federal and state judges. I served as the Associate Reporter on The American
Law Institute Study on Enterprise Responsibility for Personal Injury and co-wrote the
chapter on Product Defects and Warnings. I have also testified before the U.S. Congress
on nine occasions as an expert in economics and risk analysis. This testimony addressed
such topics as, for example, alcoholic beverage warnings.
3. Apart from my academic and governmental work, I have consulted on matters such as
risk perception, hazard warnings design, and safety devices for large companies,
3
including Bic, DuPont, Becton Dickinson, R.J. Reynolds, Bristol-Meyers Squibb,
Anheuser-Busch, Black & Decker, and Medline Industries. I have submitted several
expert reports on behalf of British American Tobacco group companies in relation to
proposed tobacco regulation, including the introduction of graphic health warning
requirements and legal challenges to such regulation. I have also served as a
consultant/expert witness for the United States Department of Justice in a variety of
cases. These include an analysis of natural resource damages issues in connection with
the Exxon Valdez oil spill. I have also testified on behalf of the Province of Quebec on
risks and warnings for video lottery terminals.
4. I am a founding editor of two journals: the Journal of Risk and Uncertainty, which
publishes peer reviewed articles on issues relating to risk perception and analysis; and
Foundations and Trends: Microeconomics. I am currently on the board of several other
academic journals, including Regulation; Journal of Law, Economics and Policy; Journal
of Tort Law; Contemporary Economic Policy; Regulation and Governance; Managerial
and Decision Economics; Journal of Risk and Insurance; Journal of Benefit-Cost
Analysis; and The Geneva Risk and Insurance Review. I have also held editorial
positions with such journals as American Economic Review, which is the official journal
of the American Economic Association; Review of Economics and Statistics, a journal
specializing in quantitative applied economics and based at Harvard University; Journal
of Environmental Economics & Management; Public Policy; International Review of
Law and Economics; and Journal of Regulatory Economics. I have served as a peer
reviewer for dozens of other publications and for government agencies in countries
throughout the world.
4
5. I have won several awards for my books and articles. These include the “Article of the
Year” award from the Western Economic Association for an article on the valuation of
life; the “Article of the Year” award from the Royal Economic Society, an international
economic society based in England, for an analysis of how ambiguous risk information
influences decision-making; the “Article of the Year” award from the American Risk and
Insurance Association for an article on automobile insurance regulation; and two “Article
of the Year” awards from the Society for Benefit-Cost Analysis. I am also a five-time
winner of the Kulp-Wright Award for “Book of the Year,” given out by the American
Risk and Insurance Association. Other recent professional awards include being named
an Honorary Member of the Academy of Economics and Finance; winning the University
of Chicago Law School’s Ronald H. Coase Prize for an article on risk perception; and
winning the 2019 Vanderbilt University Earl Sutherland prize, which is the school’s most
prestigious university-wide award for scholarly accomplishment.
6. Much of my scholarly research and writing has focused on issues of risk and health
relating to smoking. My work on risk analysis, risk perception, consumer behavior, and
regulation as it relates to smoking has included extensive research into the history of the
tobacco industry and the related public health discussions, as well as current events as
they pertain to these issues. These articles have been widely disseminated and subject to
peer review.
7. I have also written two books exclusively related to smoking. The first, Smoking:
Making the Risky Decision (Oxford University Press, 1992) is about smoking and
smoking risks, and analyzes how the available information about smoking has changed
over time, how people have assessed the risks of smoking, and how those risk perceptions
5
affect smoking behavior. The book also explains how changes in the price of cigarettes
affect cigarette consumption. The second book, Smoke-Filled Rooms: A Postmortem on
the Tobacco Deal (University of Chicago Press, 2002), includes chapters on risk
perceptions and addiction, youth smoking, environmental tobacco smoke, the promotion
of potentially safer cigarettes, the settlement of the U.S. state litigation against the
tobacco industry, the U.S. Master Settlement Agreement, and the financial costs of
smoking. Both books were subject to peer review. A full copy of my Curriculum Vitae is
available at https://law.vanderbilt.edu/phd/faculty/w-kip-viscusi/ViscusiCV.pdf.
8. I have been asked by British American Tobacco to provide a report that examines the
evidence on e-cigarette risk beliefs and the relationship of these beliefs to e-cigarette
usage, as well as presenting an analysis of data from a new survey conducted in selected
European markets. I assisted in the design of this survey, which examines the e-cigarette
risk beliefs of a sample of smokers, dual users, and exclusive e-cigarette users, as well as
their risk beliefs for heated tobacco products and oral nicotine pouch products. In this
report, I present an analysis of the risk beliefs regarding these different products and the
impact of those beliefs on product usage. I also consider the implications of current risk
beliefs for informed consumer choice and the potential public health benefits that these
alternative potentially reduced risk products offer. Drawing on the implications of these
empirical results, I propose several policy recommendations for Governments/regulators.
II. EXECUTIVE SUMMARY
9. Numerous studies and comprehensive reviews by public health authorities have stated
that e-cigarettes are less harmful than conventional tobacco cigarettes. Nevertheless,
6
surveys in the UK and the US report that many people believe that e-cigarettes are as
harmful or more harmful than cigarettes. Failure to understand the lower estimated risks
associated with e-cigarettes will discourage e-cigarette use.
10. The trend in survey reports indicating beliefs that e-cigarettes are as harmful or more
harmful than cigarettes is not favorable. The percentage of the population who regard e-
cigarettes as being as harmful or more harmful than cigarettes has been increasing over
time, particularly in recent survey waves.
11. This report analyzes data from a survey in 2020 of adults who currently smoke cigarettes
exclusively, currently smoke cigarettes and use e-cigarettes, or use e-cigarettes but do not
currently smoke cigarettes. The countries included in the sample are the United
Kingdom, Belgium, Denmark, the Netherlands, France, Germany, and Italy.
12. The focus of the survey was on respondents’ perceptions of the estimated harm of e-
cigarettes compared to conventional cigarettes, and their usage of e-cigarettes. In
addition, the survey also obtained information on other potentially reduced risk
alternatives to cigarettes, specifically heated tobacco products,1
and oral nicotine
pouches.2
1
Heated tobacco products (also known as ‘heat-not-burn’ tobacco products) are devices that heat tobacco to
generate a nicotine-containing aerosol which the user inhales. Because the tobacco is only heated and not burned,
the resulting aerosol can potentially contain substantially lower levels of the toxicants found in the smoke produced
when tobacco is burned. In a review of the available evidence carried out for Public Health England in 2018, the
authors, while noting the need for further research, concluded that "[t]he available evidence suggests that heated
tobacco products may be considerably less harmful than tobacco cigarettes." and that "[c]ompared with cigarettes,
heated tobacco products are likely to expose users and bystanders to lower levels of particulate matter and harmful
and potentially harmful compounds (HPHC). The extent of the reduction found varies between studies." McNeill 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. London: Public Health England.
2
Oral nicotine pouches are pre-portioned porous pouches containing nicotine (but no tobacco). The user puts a
pouch between the upper lip and gum and leaves it there while the nicotine and taste are released. No combustion is
involved. As oral nicotine pouches do not contain any tobacco, they contain far fewer and lower levels of toxicants
than cigarettes and other tobacco products like snus.
7
13. Beliefs that e-cigarettes are less harmful than tobacco burning cigarettes are positively
correlated with e-cigarette use. Those who consider e-cigarettes to be less harmful than
cigarettes are 33% more likely to currently use e-cigarettes. For nonsmokers who
formerly smoked, those who consider e-cigarettes to be less harmful than cigarettes are
9% more likely to currently use e-cigarettes and not smoke conventional cigarettes.
14. Respondents in the UK, a market that has taken a more progressive approach to the
regulation of e-cigarettes than many of the other European countries analyzed in this
study, are significantly more likely to believe that e-cigarettes are less harmful than
respondents in any other country other than Italy, for which the difference in the levels of
beliefs compared to the UK is not statistically significant.
15. Controlling for personal characteristics and the respondents’ country, e-cigarette use is
negatively related to being a cigarette smoker, with e-cigarette users being 48% less
likely to also be a current smoker.
16. Not knowing enough about e-cigarettes and not believing that they are less harmful are
the two principal reasons that people cite for not using e-cigarettes, while beliefs that they
will help cut down or stop smoking are the main reasons given for using e-cigarettes.
17. A substantial number of the survey respondents were unfamiliar with heated tobacco
products and oral nicotine pouches, with 35% of respondents stating that they had not
heard of a heated tobacco product and 53% of respondents stating that they had not heard
of oral nicotine pouches.
18. Beliefs that heated tobacco products and nicotine pouches are less harmful than cigarettes
are positively correlated with usage of these products. Respondents who perceive heated
tobacco products as being less harmful than cigarettes are 15% more likely to currently
8
use heated tobacco products, while the comparable increase in the use of oral nicotine
pouches for those who perceive them as being less harmful is 4%.
19. The use of heated tobacco products and oral nicotine pouches is also negatively related to
being a current smoker. Users of heated tobacco are 4% less likely to also be a current
smoker, and users of oral nicotine pouches are 9% less likely to also be a current smoker.
20. Substantial opportunities remain for more effective risk communication efforts. The
current failure by consumers to appreciate the estimated lower risk of these alternative
products compared to cigarettes is a major shortfall of consumer knowledge. These
beliefs in turn play an instrumental role in consumer decisions regarding the use of these
products.
21. Recommended policy changes include both a more vigorous role for informational
initiatives by governments as well as framing warnings information so that they facilitate
informed consumer choices. Reducing the restrictions that manufacturers face in
communicating the comparative estimated risks of these products would also facilitate
efforts to inform consumers about the product risks.
III. THE ESTIMATED RISKS OF E-CIGARETTES
22. A principal driver of interest in e-cigarettes (EC) is their estimated risk levels compared
to conventional cigarettes that burn tobacco. Because e-cigarettes have been available for
a relatively short time compared to cigarettes and other traditional tobacco products, there
are no epidemiological studies that have assessed their possible long-term health
consequences. There is, however, a substantial literature that has analyzed the chemical
composition of e-cigarette vapors and assessed the possible short-term health effects.
9
The general consensus is that e-cigarettes are estimated to be much less risky than
conventional cigarettes.
23. Public Health England has commissioned reviews of the literature in 20153
and 2018,4
each of which provided an extensive assessment of the literature. The 2015 report
provided an update of Public Health England’s earlier reports on e-cigarettes in the light
of new evidence, stating (p. 12): “It has been previously estimated that EC are around
95% safer than smoking. This appears to remain a reasonable estimate.” Public Health
England (2018, p. 150) reiterated the principal conclusion of the 2015 report: “Since the
2015 Public Health England report, the Royal College of Physicians (RCP) has also
reviewed evidence on the safety of EC and concluded that they were ‘unlikely to exceed
5% of the harm from smoking to tobacco.’” With respect to the cancer risks posed by e-
cigarettes, Public Health England (2018, p. 157) report concluded: “In summary, a study
of cancer potencies of EC emissions suggested that these are largely less than 0.4% of
smoking.” The Public Health England (2018, p. 162) report similarly noted that there was
no evidence of significant health risks from passive vaping.
24. The 2018 Public Health England report also included a discussion of what is known at
this point about the risks posed by heated tobacco products. While noting that the current
evidence for heated tobacco products was limited, the report concluded that compared to
conventional cigarettes, heated tobacco products are likely to expose users and bystanders
to lower levels of particulate matter and harmful compounds, but pose more risk than e-
cigarettes (p. 23). Their overall assessment (p. 24) is that heated tobacco products
3
Ann McNeill, et al. Evidence Review of E-Cigarettes and Heated Tobacco Products 2015: A Report
Commissioned by Public Health England. London: Public Health England, 2015.
4
Ann McNeill, et al., Evidence Review of E-Cigarettes and Heated Tobacco Products 2018: A Report
Commissioned by Public Health England. London: Public Health England, 2018.
10
“…may be considerably less harmful than tobacco cigarettes and more harmful than e-
cigarettes.”
25. The 2020 Public Health England evidence update5
included some cautionary information
regarding the absolute risk of e-cigarettes along with the lower comparative risk message
from its previous reports (p. 27), noting that “vaping regulated nicotine products has a
small fraction of the risks of smoking, but this does not mean it is ‘safe’.”
26. The US National Academies of Sciences, Engineering, and Medicine (NASEM)
undertook a large-scale systematic review of the scientific literature for the US Food and
Drug Administration in 2018.6
While noting the need for studies of the long-run effects
of e-cigarettes, the report concludes (p.1) that the current evidence, based on laboratory
tests of e-cigarette ingredients, in vitro toxicological tests, and short-term human studies,
suggests that e-cigarettes are likely to be far less harmful than combustible tobacco
cigarettes. The report also concluded (p. 11): "The evidence about harm reduction
suggests that across a range of studies and outcomes, e-cigarettes pose less risk to an
individual than combustible tobacco cigarettes."
27. Other prominent studies have reached similar conclusions. Farsalinos and Polosa (2014)
also undertook a systematic review of the literature and concluded that the currently
available evidence indicates that electronic cigarettes are by far a less harmful alternative
to smoking and significant health benefits are expected in smokers who switch from
tobacco to electronic cigarettes.7
5
A. McNeill, L.S. Brose, R. Calder, L. Bauld, and D. Robson. Vaping in England: An Evidence update Including
Mental Health and Pregnancy March 2020: A Report Commissioned by Public Health England. London: Public
Health England, 2020
6
National Academies of Sciences, Engineering, and Medicine. 2018. Public Health Consequences of E-Cigarettes.
Washington, D.C.: National Academies Press.
7
K. E. Farsalinos, and R. Polosa. 2014. “Safety Evaluation and Risk Assessment of Electronic Cigarettes as
Tobacco Substitutes: A Systematic Review,” Therapeutic Advances in Drug Safety, 5(2), 67-86.
11
28. A more recent study by Stephens (2018) found that the cancer potencies of e-cigarettes
were less than 1% of tobacco smoke.8
Heat-not-burn devices were found to have an
order of magnitude lower level of potency than tobacco cigarettes but had a higher level
of potency than e- cigarettes.
29. Estimates of the health benefits that may result by switching from conventional tobacco
cigarettes to e-cigarettes are substantial. Abrams et al. (2018, p. 205) provided the
following estimates for the United States smoking population: “Replacement of most
cigarette use by e-cigarette use over a 10-year period yields up to 6.6 million fewer
premature deaths with 86.7 million fewer life years lost.”9
30. Recently, the UK Committee on Toxicity of Chemicals in Food, Consumer Products and
the Environment (COT) concluded that the current evidence indicates that electronic
cigarettes are substantially reduced risk compared with combustible cigarettes. COT,
which is made up of independent experts, was commissioned by the UK Department of
Health and Social Care and Public Health England to review the potential toxicological
risks from electronic cigarettes.10
The review concluded that, although the magnitude of
the decrease will depend on the effect in question, the relative risk of adverse health
effects would be expected to be substantially lower from e-cigarettes for smokers who
completely switch to e-cigarettes, or if e-cigarettes are taken up instead of combustible
cigarettes.11
8
William E. Stephens, “Comparing the Cancer Potencies of Emissions from Vapourised Nicotine Products
Including E-Cigarettes with Those of Tobacco Smoke,” Tobacco Control, Vol. 27, 2018, pp. 10-17.
9
David B. Abrams, et al. 2018. “Harm Minimization and Tobacco Control: Reframing Societal Views of Nicotine
Use to Rapidly Save Lives,” Annual Review of Public Health, Vol. 39, pp. 193-213.
10
The review included electronic nicotine delivery systems and devices that use an e-liquid that does not contain any
nicotine, collectively abbreviated as E(N)NDS
11
The Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment., Statement on the
potential toxicological risks from electronic nicotine (and non-nicotine) delivery systems (E(N)NDS – e-cigarettes)
July 2020 - A report commissioned by the Department of Health and Social Care and Public Health England.
12
IV. PREVIOUS STUDIES OF THE PERCEPTION OF E-CIGARETTE RISKS
31. There has been an extensive analysis of the perceived harm of e-cigarettes based on
surveys of beliefs in the UK and the US. These studies have framed this assessment on a
comparative basis using tobacco-burning cigarettes as the reference point. The wording
used has usually been in terms of whether e-cigarettes are less harmful, more harmful, or
just as harmful as conventional cigarettes. A couple of studies have framed the question
in terms of whether e-cigarettes pose less risk, more risk, or just as much risk as
conventional cigarettes. For both survey wordings, a substantial segment of the
population either does not know whether e-cigarettes pose less harm or believes that e-
cigarettes are either just as harmful or more harmful than conventional cigarettes. There
has also been evidence of an increase over time in the fraction of the population who
regard e-cigarettes as just as harmful or more harmful than conventional cigarettes.
Comparison of the survey results in the different studies is sometimes hindered by the
fact that some respondents may not be familiar with e-cigarettes, which would lead to a
“don’t know” response in many surveys. Such “don’t know” responses are quite
different than that of informed respondents who are not willing to make a judgment on
whether e-cigarettes are less harmful. These “don’t know” respondents may be similar to
viewing the products as being equally harmful.
E-Cigarette Perceptions in the UK
32. Assessing the degree to which the population regards e-cigarettes as less harmful is
potentially important from the standpoint of the number of smokers who might switch to
e- cigarettes. In a study in England from 2014 to 2019 that followed the behavior of 300
13
smokers who were surveyed monthly, Perski et al. (2020)12
found that declines in the
belief among current smokers that e-cigarettes are less harmful than combustible
cigarettes were strongly associated with declines in the use of e-cigarettes among current
tobacco smokers. For every 1% decrease in the mean prevalence of current tobacco
smokers who endorsed the belief that e-cigarettes are less harmful than combustible
cigarettes, the mean prevalence of e-cigarette use decreased by 0.48%. The authors state:
“The reduction in the proportion of tobacco smokers who perceive e-cigarettes to
be less harmful than combustible cigarettes from 2014 to 2019 and the associated
reduction in the use of e-cigarettes may reflect smokers’ concerns about the
uncertainty about the long-term health effects of e-cigarettes. These concerns may
have been amplified by frequent media reports focusing on the absolute (as
opposed to relative) health risks of e-cigarettes or graphic, highly emotive
depictions of e-cigarette explosions or e-cigarette or vaping product use-
associated lung injury (EVALI) in the US. In line with Huang and colleagues’ call
for an increase in the availability of accurate risk information about e-cigarettes
in mainstream media, our results highlight the need for an increase in media
portrayals and public health campaigns focusing on the reduced health harms by
switching from combustible tobacco to e-cigarettes and a reduction in alarmist
media coverage of events such as EVALI.”.
33. Some studies of beliefs in the UK also include more than one country in the sample. The
summaries below present them in rough chronological order of the survey years. The
12
Olga Perski, Emma Beard, and Jamie Brown. 2020. “Association between Changes in Harm Perceptions and E-
Cigarette Use among Current Tobacco Smokers in England: A Time Series Analysis,” BMC Medicine, 18:98, pp. 1-
10. In this study, each 1% decrease in the belief that e-cigarettes are less harmful is associated with a 0.5% decrease
in e-cigarette use.
14
article by Adkinson et al. (2013) used a sample of current and former smokers from mid-
2010 to mid-2011 and found that the percentage of respondents who viewed e-cigarettes
as being less harmful than conventional cigarettes was 82% in the UK, 71% in Australia,
66% in the US, and 64% in Canada.13
The average percentage across these studies was
70%. Most respondents--80%-- indicated that they used e-cigarettes because they were
less harmful than conventional cigarettes, 75% said that they did so to reduce their
smoking, and 85% said it was to help them quit smoking.
34. Another result from UK samples over two years reported that, excluding “don’t know”
responses, the percentage of the population who viewed e-cigarettes as less harmful than
cigarettes decreased from 86.4% in 2013 to 78.2% in 2014.14
35. Public Health England (2015) reported the results of a series of surveys for the UK and
Europe, noting that the trend in risk beliefs displayed a disturbing pattern (p. 6): “There
has been an overall shift towards the inaccurate perception of e-cigarettes being as
harmful as cigarettes over the last year in contrast to the current expert estimate that using
e-cigarettes is around 95% safer than smoking.” The Internet Cohort Great Britain
Surveys reported by Public Health England (2015) covered the years from 2012 to 2014.
The percentage who viewed e-cigarettes as less harmful than cigarettes was 67% in 2012,
67% in 2013, and 60% in 2014. The beliefs that the products are equally harmful rose
from 9% in 2012 to 11% in 2013 and to 17% in 2014. The percentage who viewed e-
cigarettes as more harmful than cigarettes remained at 2% throughout that period, while
the “don’t know” percentage declined from 23% in 2012 and to 21% in 2013 and 2014.
13
Sarah E. Adkinson, et al. 2013. “Electronic Nicotine Delivery Systems: International Tobacco Control Four-
Country Survey,” Am. J. Prev. Med., Vol. 44, No. 3, pp. 207-215.
14
Leonie S. Brose, et al. 2015. “Perceived Relative Harm of Electronic Cigarettes over Time and Impact on
Subsequent Use. A Survey with 1-Year and 2-Year Follow-ups,” Drug and Alcohol Dependence, Vol. 157, 106-111.
15
The ASH Smokefree Great Britain Surveys reported by Public Health England (2015)
show somewhat different levels of harm beliefs. The percentage who viewed e-cigarettes
as less harmful than cigarettes rose from 52% in 2013 to 54% in 2014 and 2015. The
equally harmful beliefs rose from 6% in 2013 to 14% in 2014 and 20% in 2015. The
percentage who viewed e-cigarettes as more harmful than cigarettes remained low at 1%
in 2013 and 2% in 2014 and 2015. There was a decline over time in the “don’t know”
percentage from 40% in 2013 to 30% in 2014 and 23% in 2015. However, the ASH
Smokefree Great Britain Youth Surveys reported a decline in the belief that e-cigarettes
are less risky than cigarettes from 74% in 2013 to 66% in 2014 and 67% in 2015, coupled
with an almost doubling of the equally-risky beliefs from 12% in 2013 to 21% in 2015.
36. Action on Smoking and Health (ASH 2019) reported survey results among adults in
Great Britain who have heard of e-cigarettes.15
Those who viewed e-cigarettes as equally
harmful or more harmful rose from 7% in 2013 to 15% in 2014, and subsequently to 26%
in 2019. Among adult smokers, the percent who viewed e-cigarettes as equally harmful
or more harmful was 8% in 2013 and 10% in 2014, rising to the much higher value of
22% in 2019.
37. The Public Health England (2020) report by A. McNeill et al. presented survey results for
2019 and compared them with results for an adult sample in 2014 (p. 97). The
percentage of respondents who regarded e-cigarettes as less harmful than cigarettes
dropped from 45% in 2014 to 34% in 2019. The report stated these misperceptions are
particularly common among smokers who do not vape. The response group exhibiting
the greatest change was that in which e-cigarettes and conventional tobacco-burning
16
Action on Smoking and Health (ASH). 2020. “Use of E-Cigarettes (Vapes) among Adults in Great Britain,
October 2020.”
16
cigarettes are viewed as being equally harmful, as that fraction rose from 26% in 2014 to
42% in 2019. The remaining categories in 2019 consisted of 14% who viewed e-
cigarettes as more harmful than cigarettes and 10% who indicated that they did not know.
Similar changes in harm beliefs were also evident for the ASH-Y data for youths, as two-
thirds of respondents viewed e-cigarettes as less harmful than cigarettes in 2014 and just
over one-half did so in 2019 (p. 53).
38. An article by Wilson, et al. (2019) reported perception of harm results for a longitudinal
UK sample interviewed in 2017. Overall, 57% believed that e-cigarettes are less harmful
than cigarettes, 22% believed that e-cigarettes and cigarettes are equally harmful, 3%
believed that e-cigarettes are more harmful than cigarettes, and 18% indicated that they
did not know.
39. Perhaps influenced in part by the e-cigarette, or vaping, product use associated lung
injury (EVALI) illnesses in the US, respondents to the 2020 Action on Smoking and
Health Survey viewed e-cigarettes even less favorably compared to cigarettes.16
Particularly striking is that 37% of adults and 34% of smokers regarded e-cigarettes as
more harmful than or as harmful as cigarettes. Reporting on the Survey, ASH states:
‘[t]he proportion of the adult population thinking that e-cigarettes are more or equally
harmful as smoking is five times higher than in 2013, increasing from 7% in 2013 to 37%
in 2020’ and ‘… in 2020 perceptions have shifted markedly with the highest proportion
of people reporting inaccurate misperceptions that e-cigarettes are more harmful than
smoking (37%) and the lowest proportion reporting that e-cigarettes are less or a lot less
harmful (39%).’
16
Action on Smoking and Health (ASH). 2020. “Use of E-Cigarettes (Vapes) among Adults in Great Britain,
October 2020.”
17
E-Cigarette Perceptions in the US
40. The pattern of harm beliefs in the United States also indicates that a substantial part of the
population is not aware of the estimated comparative harm of e-cigarettes and
conventional cigarettes. Richardson, et al. (2014) reported that in a 2011 survey of
current and former smokers, the percentage distribution of comparative beliefs regarding
harms of e-cigarettes was 21% don’t know, 65% less harmful, 10% about the same harm,
and 3% more harmful.17
The less harmful belief percentages were lower for snus (12%),
chewing tobacco, snuff, and dip (10%), and dissolvables (17%).
41. Results reported by Kiviniemi and Kozlowski (2015) using data from the US Health
Information National Trends Survey (HINTS), a population-representative survey of US
adults, for 2012-2013 were that 11% viewed e-cigarettes as much less harmful than
cigarettes, 40% viewed them as less harmful than cigarettes, 46% viewed them as just as
harmful as cigarettes, 1.6% viewed them as more harmful than cigarettes, and 1.2%
viewed them to be much more harmful than cigarettes.18
Combining the as harmful and
more harmful groups, 49% believed that e-cigarettes are as harmful as or more harmful
than cigarettes.
42. Persoskie, et al. (2019) reported trends of declining beliefs that e-cigarettes are less
harmful than cigarettes from 45% in 2012 to 34% in 2017.19
In wave two of the US
National Population Assessment of Tobacco and Health (PATH) Study, 59% of those
17
Amanda Richardson, et al. 2014. “Prevalence, Harm Perceptions, and Reasons for Using Noncombustible
Tobacco Products Among Current and Former Smokers,” Am. J. of Public Health, Vol. 104, No. 8, pp. 1437-1444.
18
Marc T. Kiviniemi and Lynn T. Kozlowski. 2015. “Deficiencies in Public Understanding about Tobacco Harm
Reduction: Results from a United States National Survey,” Harm Reduction Journal, Vol. 12, No. 21, pp. 1-7.
19
Alexander Persoskie, Erin Keely O’Brien, and Karl Poonai. 2019. “Perceived Relative Harm of Using E-
Cigarettes Predicts Future Product Switching among U.S. Adult Cigarette and E-Cigarette Dual Users,” Addiction,
Vol. 114, pp. 2197-2205.
18
who used both e-cigarettes and cigarettes perceive the former as being less harmful, 35%
considered the harms to be about the same, 4% viewed e-cigarettes as more harmful than
cigarettes, and 1% did not know. Compared with those with other perceptions of e‐
cigarette harm, dual users who perceived e-cigarettes as less harmful were more likely to
switch to exclusive e-cigarette use and were less likely to switch to exclusive cigarette
use one year later.
43. Majeed, et al. (2017) considered results in 2012 and 2015 for both non-smokers and an
over-sampled group of smokers.20
The percentage of adults who viewed e-cigarettes as
less harmful than cigarettes was 39% in 2012 and 31% in 2015, and for smokers these
percentages were 45% in 2012 and 36% in 2015. There was a large change in the
percentage of adults who believed the risks to be about the same, from 12% in 2012 up to
36% in 2015. For smokers, that increase was from 11% in 2012 to 31% in 2015. There
was a drop in the “don’t know” percentages from 48% to 30% overall, and from 44% to
29% for smokers. The percentage of those who believed that e-cigarettes cause more
harm than cigarettes remained low at 1% in 2012 and 4% in 2015 for both the full sample
and for smokers.
44. Huang et al. (2019) found that in two nationally representative multiyear cross-sectional
surveys of US adults, the percentage who viewed e-cigarettes as being as harmful as or
more harmful than cigarettes increased from 2012 to 2017.21
In the Tobacco Products
and Risk Perceptions Survey (TPRPS) data, the proportion of adults who perceived e-
20
Ban A. Majeed, et al. 2017. “Changing Perceptions of Harm of E-Cigarettes Among U.S. Adults, 2012-2015,” Am
J. Prev. Med., Vol 52, No. 3, pp. 331-338.
21
Jidong Huang, et al. 2019. “Changing Perceptions of Harm of E-Cigarette vs. Cigarette Use Among Adults in 2
US National Surveys from 2012 to 2017, Tobacco Products and Risk Perceptions Survey and Health Information
National Trends Survey,” JAMA Network Open, Vol. 2, No. 3, pp. 1-12.
19
cigarettes to be as harmful as cigarettes increased from 11.5% in 2012 to 36.4% in 2017
and the percentage of those who perceived e-cigarettes to be more harmful than cigarettes
increased from 1.3% in 2012 to 4.3% in 2017. For the Health Information National
Trends Survey (HINTS) data, the proportion of adults who perceived e-cigarettes to be as
harmful as cigarettes increased from 46.4% in 2012 to 55.6% in 2017; and those who
perceived e-cigarettes to be more harmful than cigarettes increased from 2.8% in 2012 to
9.9% in 2017. One difference in the surveys is that there is a “don’t know” option in
TPRPS but not in HINTS.
45. Nyman (2019) reported harm beliefs in 2017 and 2018 based on the U.S. Tobacco
Products and Risk Perceptions Survey (TPRPS).22
Between 2017 and 2018, the
percentage of adults perceiving e-cigarettes to be as harmful as cigarettes increased from
36.4% to 43.0%. The percentage of adults perceiving e-cigarettes to be more harmful
than cigarettes also increased from 2.4% to 4.4% and the percentage perceiving e-
cigarettes to be much more harmful than cigarettes increased from 1.9% to 3.7%.
46. Malt, et al. (2020) provide a review of the harm beliefs of US adults for e-cigarettes in
three waves of the nationally representative Population Assessment of Tobacco and
Health (PATH) study data.23
In wave 1 from September 2013 to December 2014, 54%
regarded e-cigarettes as being as harmful as or more harmful than cigarettes, and 41%
viewed them as less harmful than cigarettes. In wave 2 from October 2014 to October
2015, 65% regarded e-cigarettes as being as harmful as or more harmful than cigarettes,
22
Amy L. Nyman. 2019. “Perceived Comparative Harm of Cigarettes and Electronic Nicotine Delivery Systems,”
JAMA Network Open, Vol. 2, No. 11, pp. 1-4.
23
Layla Malt, et al. 2020. “Perception of the Relative Harm of Electronic Cigarettes Compared to Cigarettes
Amongst US Adults from 2013 to 2016: Analysis of the Population Assessment of Tobacco and Health (PATH)
Study Data,” Harm Reduction Journal, Vol. 17, No. 65, pp. 1-12.
20
and 32% considered them to be less harmful than cigarettes. The degree of beliefs that e-
cigarettes are less harmful than cigarettes continued to decline to 25% in wave 3 from
October 2015 to October 2016, with the percentage considering e-cigarettes as being as
harmful as or more harmful than cigarettes increasing to 73% in October 2015. The
“don’t know” responses constituted the residual for each of these surveys. The authors
conclude: “in this study, the proportion of US adults who incorrectly perceived e-
cigarettes as equal to, or more, harmful than cigarettes increased steadily regardless of
smoking or vaping status. Current adult smokers appear to be poorly informed about the
relative risks of e-cigarettes yet have potentially the most to gain from transitioning to
these products. The findings of this study emphasize the urgent need to accurately
communicate the reduced relative risk of e-cigarettes compared to continued cigarette
smoking and clearly differentiate absolute and relative harms. Further research is required
to elucidate why the relative harm of e-cigarettes is misunderstood and continues to
deteriorate.”
47. Viscusi (2016, 2020) framed the question in terms of whether e-cigarettes pose lower
risks than conventional cigarettes rather than lower levels of harm.24
The results in both
2014 and 2019 were that 52% viewed e-cigarettes as being somewhat less risky or much
less risky. The fraction who believed that e-cigarettes are more risky rose from 2% in
2014 to 11% in 2019, and the fraction who viewed e-cigarettes as just as risky was 44%
in 2014 and 34% in 2019. In each case there was strong dependence of risk beliefs for e-
cigarettes on respondents’ risk assessment for conventional cigarettes. In particular,
24
W. Kip Viscusi. 2016. “Risk Beliefs and Preferences for E-Cigarettes,” American Journal of Health Economics,
Vol. 2, No. 2, pp. 213-240. W. Kip Viscusi. 2020. “Electronic Cigarette Risk Beliefs and Usage after the Vaping
Illness Outbreak,” Journal of Risk and Uncertainty, Vol. 60, No. 3, pp. 259-279.
21
consumers’ beliefs reflected a weight of about two-thirds on their cigarette risk beliefs
when forming their e-cigarette risk beliefs.
Implications of the UK and US E-Cigarette Perception Studies
48. The percentage of the respondents who perceive e-cigarettes as being less harmful than
cigarettes depends on the time period, the sample group, and the structure of the survey
question. Including a “don’t know” response decreases the percentage of respondents
who commit to making a comparison. Surveys that are restricted to those who are
familiar with e-cigarettes generate higher levels of comparative responses.
49. There are three principal implications of the survey results. First, a substantial segment
of the population view e-cigarettes as posing equivalent risks to conventional cigarettes
or even greater risks, which is inconsistent with the current scientific evidence and the
prevailing public health opinions. Second, both in the UK and in the US, the proportion
of the population who consider e-cigarettes to be as harmful or more harmful than
conventional cigarettes has been increasing over time. Third, there is evidence that these
continued misperceptions of the estimated risk of e-cigarettes are negatively correlated
with e-cigarette use, with respondents who have these views being less likely to use e-
cigarettes.
V. NEW EVIDENCE ON E-CIGARETTE PERCEPTIONS
50. A series of surveys were commissioned by British American Tobacco in 2020 to analyze
the current level of harm beliefs in selected European markets. The principal objectives
of the surveys were to ascertain the harm beliefs regarding e-cigarettes and the
relationship of these beliefs to e-cigarette usage. In addition, the survey also asked
22
respondents’ questions regarding their awareness, use and perceptions of heated tobacco
products and oral nicotine pouches. I assisted in the design of the survey questions. The
samples consisted of adult members of online survey panels. The countries included
were the UK, Belgium, Denmark, the Netherlands, France, Germany, and Italy.
51. To be included in the sample, the respondent had to answer affirmatively to all of the
following: (1) that they had smoked more than 100 cigarettes in their lifetime; (2) that
they had heard of e-cigarettes; and (3) that they were either a current smoker, a current
smoker and vaper, or a former smoker that currently vapes. As noted above, while not
included as part of the screening of the sample (so as to avoid potentially limiting the
sample size, given that these products are newer to the market and generally less used
than e-cigarettes), the survey also asked questions regarding respondents’ awareness, use
and perceptions of heated tobacco products and oral nicotine pouches. After limiting the
multi-country sample to those who passed these sample screens, the sample consisted of
1,073 respondents in Denmark, 1,477 respondents in Germany, and 1,500 respondents in
each of the other five countries. The analysis below focuses on the pooled sample.
Appendix A presents the demographic characteristics of the sample.
52. Table 1 provides overview statistics regarding product use and harm beliefs. Almost
two-thirds of the sample use e-cigarettes currently, and 88% have either tried or currently
use e-cigarettes. This high rate of product usage is a consequence of the sample screen.
The harm perceptions reflect the beliefs of these groups. As also indicated in Figure 1,
57% of the sample view e-cigarettes as less harmful than cigarettes, and 43% consider
them to be the same as or more harmful than cigarettes. For simplicity, all figures below
will have numbers that correspond to the table of results that they are illustrating.
23
Table 1. Product use and relative harm belief percentage
E-Cigarettes
Ever heard of the product * 100
Description of use **
- Never tried the product 11.5
- Tried, but never use now 22.3
- Use the product currently 66.2
- Tried, regardless of current use 88.5
Harm relative to cigarettes ***
- Less harmful than cigarettes 56.8
- About the same as cigarettes 35.5
- More harmful than cigarettes 7.7
- Same or more harmful 43.2
* Knowledge of e-cigarettes was required to participate in the survey.
** Those who have never heard of the product are assumed never to have tried it.
*** Harm beliefs are percentages of the subset of respondents who have heard of
the product.
53. Table 1 indicates that a substantial portion of respondents perceive e-cigarettes to be the
same as or more harmful than cigarettes. Since the sample consists of a disproportionate
share of e-cigarette users, who would be expected to choose this behavior based on
perceived lower levels of harm of the product, these results are likely to understate these
perceptions for the general population.
24
54. The relationship between product use and harm beliefs is examined in Table 2. The first
two columns pertain to the beliefs of cigarette smokers. Half of the smokers in the sample
use e-cigarettes and half of them do not. For cigarette smokers who consider e-cigarettes
to be less harmful than cigarettes, 65% currently use e-cigarettes and 35% do not. In
contrast, for current cigarette smokers who consider the harm levels from e-cigarettes to
be the same or more harmful compared to cigarettes, 37% currently use e-cigarettes and
63% do not. Figure 2 also summarizes these harm belief results. The results for current
non-smokers in the final two columns of Table 2 are less instructive, as all those who are
non-smokers necessarily use e-cigarettes regardless of their harm beliefs or they will not
be included in the sample.
Table 2. Current or former cigarette smokers and their e-cigarette use percentage
Results for
Current cigarette smokers
Results for
Current non-smokers
Does not
use product
Currently
uses product
Does not
use product
Currently
uses product
E-Cigarette users 50.0 50.0 0 100
- Less harmful than cigarettes 35.2 64.8 0 100
- Same or more harmful 63.4 36.6 0 100
56.8%
43.2%
0%
10%
20%
30%
40%
50%
60%
Less harmful than cigarettes About the same or more harmful than
cigarettes
Figure 1. Estimated harm of e-cigarettes
compared to cigarettes
25
55. Table 3 and Figure 3 present the distribution of usage of cigarettes for e-cigarette users
based on their level of harm beliefs. Overall, 51% of e-cigarette users in the sample
currently smoke cigarettes, and 49% do not. For those who use e-cigarettes, having low
levels of comparative harm beliefs is associated with not smoking cigarettes. The largest
harm belief category among e-cigarette users is the less harmful group, for which 54% do
not smoke cigarettes and 46% do. The pattern is strongly reversed for those who
consider the risks to be just as harmful or more harmful, as 63% of this group currently
smoke cigarettes and 37% do not smoke cigarettes.
Table 3. Current or former cigarette smokers percentage, by use and harm perceptions of
e-cigarettes
Observations Currently
smokes cigarettes
Does not
smoke cigarettes
E-Cigarette users 6,650 51.1 48.9
- Less harmful than cigarettes 4,573 45.8 54.2
- About the same as cigarettes 1,634 73.3 26.7
- More harmful than cigarettes 443 24.4 75.6
35.2%
63.4%
64.8%
36.6%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
E-cigarettes are less harmful than
cigarettes
E-cigarettes are the same as or more
harmful than cigarettes
Figure 2. Harm Beliefs of Current Cigarette
Smokers
Does not use e-cigarettes Currently uses e-cigarettes
26
E-Cigarette non-users 3,400 100 0
Distribution for all respondents 10,050 67.6 32.4
56. An alternative perspective on these relationships is the distribution of harm beliefs shown
in Table 4 and Figure 4, conditional on different levels of e-cigarette usage. Those who
currently use e-cigarettes are most likely to perceive that they are less harmful than
cigarettes, with 69% of current e-cigarette users perceiving them to be less harmful than
cigarettes and 31% of current e-cigarette users perceiving e-cigarettes to be just as
harmful or more harmful than cigarettes. The least favorable assessments of the
harmfulness of e-cigarettes are by those who have never tried the product, with only 31%
of this group of those who have never used e-cigarettes considering e-cigarettes to be less
harmful than cigarettes, and 69% considering e-cigarettes to be just as harmful or more
harmful than cigarettes.
45.8%
62.9%
54.2%
37.1%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
E-cigarettes are less harmful than
cigarettes
E-cigarettes are same or more harmful
than cigarettes
Figure 3. Harm beliefs of current and former cigarette
smokers
Currently smokes cigarettes Does not smoke cigarettes
27
Table 4. Harm beliefs relative to cigarettes percentage, by e-cigarette use
Observations Less
harm
Same
harm
More
harm
Same
or More
E-Cigarettes 10,050
- Never tried the product 1,155 31.3 55.8 12.8 68.7
- Tried, but never use now 2,245 34.4 57.5 8.1 65.6
- Use the product currently 6,650 68.8 24.6 6.7 31.2
- Tried, regardless of current use 8,895 60.1 32.9 7.0 39.9
57. The linkage of harm beliefs to more measures of product usage is examined in Table 5
and Figures 5a, 5b, and 5c. Among those who smoke cigarettes but do not use e-
cigarettes, 67% view e-cigarettes as the same as or more harmful than cigarettes.
However, 76% of those who use e-cigarettes but not cigarettes consider e-cigarettes to be
less harmful than cigarettes. By comparison, among those who both smoke cigarettes
and use e-cigarettes, 62% consider e-cigarettes to be less harmful than cigarettes.
31.3% 34.4%
68.8%
68.7% 65.6%
31.2%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Never tried e-cigarettes Tried e-cigarettes but never use now Use e-cigarettes currently
Figure 4. Estimated harm of e-cigarettes compared to cigarettes by use
of product
Less Harm Same or more harm
28
Cigarette smokers who do not use e-cigarettes are more likely to believe that e-cigarettes
are at least as harmful as cigarettes, by a two-to-one margin.
Table 5. Percentage distribution of harm beliefs for different groups of usage of cigarettes
and e-cigarettes
E-Cigarettes are: Less harmful
than cigarettes
Same or
more harmful
than cigarettes
Observations
Product use:
- Smokes cigarettes, not e-cig 33.4 66.6 3,400
- E-Cigarettes, not cigarettes 76.3 23.7 3,252
- Both e-cigarettes and cigarettes 61.6 38.4 3,398
33.4%
61.6%
76.3%
66.6%
38.4%
23.7%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Smokes but does not use e-
cigarettes
Smokes and uses e-cigarettes Uses e-cigarettes but does not
smoke
Figure 5A. Estimated comparative harm beliefs of smokers of
cigarettes and/or e-cigarette users
Less harmful than cigarettes Same or more harmful than cigarettes
29
58. The implication of Tables 1-5 and their figure counterparts is that beliefs that e-cigarettes
are less harmful than cigarettes are correlated with e-cigarette usage, as well as with the
combination of e-cigarette usage and not smoking cigarettes.
59. To better analyze the impact of risk perceptions on current e-cigarette use, Table 6
presents regression results in which the dependent variable is a 0-1 indicator for current
product use, and the explanatory variables consist of harm beliefs, countries, and
76.3%
23.7%
Figure 5B. Harm beliefs of those who use e-cigarettes
but do not smoke cigarettes
E-cigarettes are less harmful than cigarettes
E-cigarettes are the same as or more harmful than cigarettes
33.4%
66.6%
Figure 5C. Harm beliefs of those who smoke
cigarettes and do not use e-cigarettes
E-cigarettes are less harmful than cigarettes
E-cigarettes are the same as or more harmful than cigarettes
30
demographic factors. These regressions in effect analyze factors that affect the
probability that the respondent currently uses e-cigarettes. For some demographic
variables, such as income and gender, a small number of respondents did not answer the
question (Appendix A lists the missing data percentages for each variable). For these
observations for which the respondent did not answer the question, I followed the
standard statistical practice of including these responses in the statistical analysis but
creating a 0-1 indicator variable to address the fact that an observation on this particular
variable is missing for the particular respondent.
60. Controlling for the variables included in the regression in Table 6, those who consider e-
cigarettes to be less harmful than cigarettes are 33% more likely to currently use e-
cigarettes. This relationship is statistically significant with a 95% confidence level, a test
that is noted by at least two asterisks in the regression results in this report (three asterisks
reflect a 99% level). There are no statistically significant country effects. For this and in
subsequent regressions, the UK is the excluded country, which means that any country
effects are measured relative to the UK. Usage of e-cigarettes rises with age, but then
declines for those age 60+.
Table 6. Regressions predicting the probability that respondent CURRENTLY USES e-
cigarettes, based on harm beliefs, country, and demographics
E-Cigarette
yes use
E-cigarette less harmful 0.3260***
(0.0090)
Belgium 0.0066
(0.0170)
Denmark 0.0090
(0.0177)
Netherlands -0.0210
31
(0.0163)
France 0.0213
(0.0161)
Germany 0.0174
(0.0161)
Italy 0.0014
(0.0162)
Age 0.0011**
(0.0005)
Age 60+ -0.0360**
(0.0159)
Income 0.0010***
(0.0002)
Income €150,000+ 0.1087***
(0.0242)
Years education 0.0127***
(0.0020)
Black -0.1276***
(0.0300)
Asian -0.0440
(0.0294)
Other -0.0098
(0.0268)
Female -0.0255***
(0.0091)
Married 0.0114
(0.0128)
Widowed -0.0175
(0.0296)
Divorced -0.0301
(0.0186)
Separated -0.0042
(0.0279)
Partner 0.0217
(0.0147)
Missing income 0.0187
(0.0177)
Missing education 0.2332***
(0.0511)
Missing race 0.0714*
(0.0399)
Missing female -0.1824*
(0.1065)
Missing relationship -0.0283
(0.0438)
Constant 0.1959***
32
(0.0373)
Observations 10,050
R-squared 0.15
Standard errors in parentheses; * significant at 10%; ** significant at 5%; *** significant at 1%
Country effects are relative to the United Kingdom, the excluded country variable.
61. Given the pivotal role of whether the respondent believes that e-cigarettes are less
harmful than cigarettes, the regressions in Table 7 analyze the relationship of the 0-1
variable for whether the respondent perceives e-cigarettes as less harmful than cigarettes.
Also included are the variables for the different countries and demographic groups.
Relative to the UK sample, respondents in Belgium, Denmark, the Netherlands, France,
and Germany are significantly less likely to believe that e-cigarettes are less harmful than
cigarettes. Given the efforts by Public Health England and other public health
organizations in the UK to communicate the relative risk profile of e-cigarettes as
compared to cigarettes, this pattern is consistent with a possible impact of these efforts on
harm beliefs. The greatest disparity is for respondents in Belgium, as they are 25% less
likely to regard e-cigarettes as less harmful. Respondents also are more likely to regard
e-cigarettes as less harmful if they are age 60+ or have high income but are not in the top
income group.
Table 7. Regressions predicting the probability that the respondent believes e-cigarettes
are LESS HARMFUL than cigarettes, based on country and demographics
E-Cigarettes
less harmful
Belgium -0.2596***
(0.0188)
Denmark -0.1356***
(0.0197)
Netherlands -0.0862***
(0.0182)
France -0.0513***
(0.0179)
Germany -0.1216***
33
(0.0179)
Italy -0.0029
(0.0181)
Age -0.0009*
(0.0005)
Age 60+ 0.0813***
(0.0177)
Income 0.0008***
(0.0002)
Income €150,000+ -0.0903***
(0.0269)
Years education -0.0031
(0.0022)
Black -0.0528
(0.0335)
Asian -0.1280***
(0.0327)
Other -0.0394
(0.0299)
Female -0.0723***
(0.0101)
Married -0.0034
(0.0143)
Widowed -0.0228
(0.0330)
Divorced 0.0154
(0.0208)
Separated 0.0072
(0.0311)
Partner 0.0393**
(0.0164)
Missing income 0.0126
(0.0197)
Missing education -0.0386
(0.0570)
Missing race -0.0138
(0.0445)
Missing female -0.3318***
(0.1187)
Missing
relationship
0.0619
(0.0489)
Constant 0.7316***
(0.0409)
Observations 10,050
R-squared 0.04
34
Standard errors in parentheses; * significant at 10%; ** significant at 5%; *** significant at 1%
Country effects are relative to the United Kingdom, the excluded country variable.
62. Whether e-cigarette use is related to smoking status is examined in the regressions in
Table 8, where the dependent variable is the 0-1 indicator variable for whether the
respondent is a current smoker. If the respondent currently uses e-cigarettes, he or she is
48% less likely to also be a current smoker. These results are consistent with e-cigarettes
serving as an alternative for conventional cigarettes given the sample screens that
required all people to be a current or former smoker. Given the cross-sectional nature of
the data, the timing of the transition to use of e-cigarettes cannot be determined.
Table 8. Regressions predicting the probability that the respondent is a CURRENT
CIGARETTE SMOKER, based on e-cigarette USE, country, and demographics
Smoker
E-cigarette yes use -0.4814***
(0.0085)
Belgium 0.0337**
(0.0153)
Denmark 0.0730***
(0.0161)
Netherlands 0.0064
(0.0148)
France 0.0024
(0.0146)
Germany 0.0014
(0.0146)
Italy -0.0217
(0.0147)
Age -0.0054***
(0.0004)
Age 60+ -0.0612***
(0.0144)
Income 0.0000
(0.0002)
Income €150,000+ -0.2013***
(0.0219)
Years education 0.0095***
(0.0018)
Black -0.0229
35
(0.0273)
Asian 0.0611**
(0.0267)
Other 0.0207
(0.0244)
Female -0.0101
(0.0083)
Married 0.0212*
(0.0116)
Widowed 0.0295
(0.0269)
Divorced 0.0021
(0.0169)
Separated -0.0180
(0.0254)
Partner -0.0544***
(0.0133)
Missing income -0.0569***
(0.0160)
Missing education 0.1229***
(0.0465)
Missing race -0.0077
(0.0363)
Missing female 0.0037
(0.0968)
Missing relationship -0.0539
(0.0398)
Constant 1.1053***
(0.0336)
Observations 10,050
R-squared 0.29
Standard errors in parentheses; * significant at 10%; ** significant at 5%; *** significant at 1%
Country effects are relative to the United Kingdom, the excluded country variable.
63. Table 9 reports a regression on a closely related matter regarding exclusive e-cigarette
usage. The dependent variable is a 0-1 variable for whether the respondent currently uses
e-cigarettes and also does not smoke cigarettes. The principal variable of interest is
whether the respondent considers e-cigarettes to be less harmful than cigarettes. Those
who have this belief are 9% more likely to be an e-cigarette user and not smoke
conventional cigarettes. The country effects relative to the UK are also interesting. All
36
effects that are statistically significant are negative. The four statistically significant
relationships are for Belgium, the Netherlands, Germany, and Italy, all of which have a
lower likelihood of respondents using e-cigarettes and not also smoking compared to the
UK. Together with the earlier results on risk beliefs, these findings indicate that in the
UK people are more likely to perceive e-cigarettes as less harmful than cigarettes and are
also more likely to use e-cigarettes and not also smoke even after controlling for this
difference in beliefs, compared to these other countries.
Table 9. Regressions predicting the probability that the respondent CURRENTLY USES
e-cigarettes for the subsample that DOES NOT SMOKE CIGARETTES, for exclusive use
of product
E-Cigarette
yes only
E-cig less harmful 0.0935***
(0.0167)
Belgium -0.1904***
(0.0264)
Denmark 0.0200
(0.0259)
Netherlands -0.0758***
(0.0232)
France -0.0268
(0.0215)
Germany -0.1053***
(0.0221)
Italy -0.2933***
(0.0220)
Age -0.0017**
(0.0007)
Age 60+ -0.0018
(0.0206)
Income -0.0029***
(0.0002)
Income €150,000+ -0.2022***
(0.0334)
Years education -0.0078***
(0.0029)
Black 0.0990**
(0.0485)
37
Asian -0.0035
(0.0554)
Other -0.0314
(0.0431)
Female -0.0090
(0.0130)
Married -0.0076
(0.0191)
Widowed -0.0163
(0.0421)
Divorced -0.0304
(0.0261)
Separated -0.0469
(0.0393)
Partner -0.0239
(0.0208)
Missing income -0.0631***
(0.0238)
Missing education -0.0754
(0.0698)
Missing race -0.0323
(0.0527)
Missing female -0.5457
(0.3379)
Missing
relationship
-0.0459
(0.0594)
Constant 1.1903***
(0.0560)
Observations 3,252
R-squared 0.37
Standard errors in parentheses; * significant at 10%; ** significant at 5%; *** significant at 1%
Country effects are relative to the United Kingdom, the excluded country variable.
64. The surveys also elicited respondents’ reasons for never trying e-cigarettes. For the
sample of respondents in Table 10 who have never tried the product, the main reasons
given are that they do not know enough about e-cigarettes or do not think that e-cigarettes
are any less harmful than cigarettes, each of which were mentioned by 27% of the
respondents. Just under 17% of the sample indicate that they do not want to quit
smoking, and 16% believe that e-cigarettes will not help them quit. Cost is a minor
38
concern voiced by 10% of respondents. Figure 10 summarizes the most prominent main
reasons for never trying e-cigarettes.
Table 10. Percentage distribution of the main reason for decision to have NEVER TRIED
e-cigarettes
What is the main reason for you not trying E-Cigarette
I do not know enough about them 27.2
I do not want to quit smoking 16.9
I do not think that they are any less harmful than
cigarettes
27.1
They cost too much 9.7
I do not think that they would help me to quit or
cut down smoking
15.8
Other 3.3
Number of observations 1,155
65. The stated reasons for currently using e-cigarettes shown in Table 11 are consistent with
e-cigarettes serving as an alternative for conventional cigarettes. A combined total of
62% of the current users indicate that they are using e-cigarettes to either help them stop
27.2% 27.1%
I do not know enough about them I do not think they are any less harmful than
cigarettes
Figure 10. Main reason given by respondents for never
having tried e-cigarettes
39
smoking cigarettes (40%) or to cut down on the number of cigarettes smoked (22%).
Figure 11 illustrates these key results. Saving money and the availability of a variety of
flavors rank next in importance. Lower on the list are responses more closely related to
exposure to others and acceptability of using e-cigarettes, as 8% indicate that e-cigarettes
can be used in more places and 6% reference the absence of environmental tobacco
smoke.
Table 11. Percentage distribution of the main reason for decision to CURRENTLY USE e-
cigarettes
What is the main reason for you using E-Cigarette
To help me stop smoking cigarettes 39.8
To cut down on the amount of cigarettes that I
smoke
22.3
[To help me stop or to cut down] 62.0
To save money 11.6
Because they are available in better flavors than
cigarettes
10.2
Convenience, e-cigarettes can be used in more
places
8.1
To not expose people nearby me to cigarette
smoke
5.5
Other 2.6
Number of observations 6,650
40
VI. NEW EVIDENCE ON HARM PERCEPTIONS FOR HEATED TOBACCO
PRODUCTS AND ORAL NICOTINE POUCHES
66. The respondents to the surveys also answered questions regarding heated tobacco
products and oral nicotine pouches. Both because of the sample screens and the lower
overall usage of these products, the results often pertain to a subset of the overall sample.
Table 12. Product use and relative harm belief percentage, for each of two products
Heated tobacco
products
Oral nicotine
pouches
Ever heard of the product* 64.8 47.2
Description of use **
- Never tried the product 61.9 75.3
- Tried, but never use now 21.2 15.7
- Use the product currently 16.9 9.0
- Tried, regardless of current use 38.1 24.7
39.8%
22.3%
To help me stop smoking cigarettes To cut down on the amount of cigarettes
I smoke
Figure 11. Main reason for decisions to currently
use e-cigarettes
41
Harm relative to cigarettes ***
- Less harmful than cigarettes 43.6 48.7
- About the same as cigarettes 48.7 40.3
- More harmful than cigarettes 7.7 11.0
- Same or more harmful 56.4 51.3
* Knowledge of e-cigarettes was required to participate in the survey.
** Those who have never heard of the product are assumed never to have tried it.
*** Harm beliefs are percentages of the subset of respondents who have heard of the product.
67. As indicated in Table 12, 66% of respondents had heard of heated tobacco products, and
only 47% had heard of oral nicotine pouches. The data in Table 12 and Figures 12A and
12B regarding the respondent’s use of the product and harm perceptions only pertain to
the subsample of respondents who indicated that they had heard of each of the products.
Among these groups, 38% had tried heated tobacco products, and 25% had tried oral
nicotine pouches. Beliefs are roughly evenly divided between perceptions that the
product is less harmful than cigarettes and perceptions that the product is just as harmful
or more harmful. For heated tobacco products, 44% view them as less harmful than
cigarettes, and 56% consider them to be the same or more harmful than cigarettes. For
oral nicotine products, 49% consider them to be less harmful than cigarettes, and 51%
consider them to be the same or more harmful than cigarettes.
42
68. The distribution of harm perceptions varies depending on product usage, as indicated in
Table 13 and Figures 13A and 13B. The product usage statistics are at the top of each
43.6%
56.4%
0%
10%
20%
30%
40%
50%
60%
Less harmful than cigarettes About the same or more harmful than
cigarettes
Figure 12A. Estimated harm of heated tobacco
products compared to cigarettes
48.7% 51.3%
0%
10%
20%
30%
40%
50%
60%
Less harmful than cigarettes About the same or more harmful than
cigarettes
Figure 12B. Estimated harm of oral nicotine
pouches compared to cigarettes
43
panel of Table 13. Overall, 14% of current cigarette smokers currently use heated
tobacco products, and 22% of former smokers currently use heated tobacco products.
Among those who believe that heated tobacco products are less harmful than cigarettes,
67% of current smokers currently use heated tobacco products, and 33% do not, while for
former smokers who believe that heated tobacco products are less harmful than
cigarettes, 51% currently use heated tobacco products and 49% do not. Usage among
those who believe that heated tobacco products are the same as or more harmful than
cigarettes is much lower—only 15% among smokers and 16% among former smokers in
this belief group use heated tobacco products. Only 7% of current smokers currently use
oral nicotine pouches and 14% of former smokers currently use oral nicotine pouches.
For those who believe that oral nicotine pouches are less harmful than cigarettes, the rate
of usage is 19% for current smokers and 42% for former smokers. For those who believe
that oral nicotine pouches are the same as or more harmful than cigarettes, the rate of
product usage is 10% among current smokers and 16% among former smokers.
Table 13. Current or former cigarette smokers and their alternative product use
percentage, by product and harm belief for that product
Results for
Current cigarette smokers
Results for
former smokers
Does not
use product
Currently
uses product
Does not
use product
Currently
uses product
Heated tobacco users 85.6 14.4 78.0 22.0
- Less harmful than cigarettes 67.4 32.6 48.7 51.3
- Same or more harmful 84.8 15.2 84.0 16.0
Oral nicotine users 93.2 6.8 86.4 13.6
- Less harmful than cigarettes 80.8 19.2 58.0 42.0
- Same or more harmful 90.1 9.9 84.5 15.5
44
69. To explore the linkage between usage of these products and whether the respondent
currently smokes cigarettes, Table 14 reports these statistics both overall as well as
conditional on harm beliefs. The table and the Figures 14A and 14B illustrate the key
results. Users of heated tobacco products and oral nicotine pouches are more likely to be
former smokers. Among heated tobacco product users 42% do not currently smoke
67.4%
84.8%
32.6%
15.2%
0%
20%
40%
60%
80%
100%
HTPs are less harmful than cigarettes HTPs are the same as or more
harmful than cigarettes
Figure 13A. Harm Beliefs of Current Cigarette
Smokers
Does not use HTPs Currently uses HTPs
80.8%
90.1%
19.2%
9.9%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Oral nicotine pouches are less
harmful than cigarettes
Oral nicotine pouches are the same
as or more harmful than cigarettes
Figure 13B. Harm Beliefs of Current Cigarette
Smokers
Does not use oral nicotine pouches Currently uses oral nicotine pouches
45
cigarettes, as compared to 30% of non-users of heated tobacco products who do not
currently smoke cigarettes; and 49% of oral nicotine pouch users do not currently smoke
cigarettes, as compared to 31% of non-users of oral nicotine pouches who do not smoke
cigarettes. Similarly, users of both heated tobacco and oral nicotine products have a 57%
non-smoking rate.
70. For those who use heated tobacco products and oral nicotine pouches, perceiving these
products as being less harmful than cigarettes is also associated with not smoking
cigarettes. Among heated tobacco product users who believe that heated tobacco is less
harmful than cigarettes, 49% do not currently smoke cigarettes; and 55% of oral nicotine
pouch users who believe that the product is less harmful than cigarettes do not currently
smoke cigarettes. This effect is diminished for those who believe that these products are
the same or more harmful than cigarettes, such that 28% do not currently smoke
cigarettes if they believe this about heated tobacco products and 36% do not currently
smoke cigarettes if they believe this about nicotine pouches, as shown in Figure 14B.
46
Table 14. Current or former cigarette smokers percentage, by use and harm perceptions of
products, including multiple product users
Observations Currently
smokes cigarettes
Does not
smoke cigarettes
Heated tobacco users 1,696 57.9 42.1
- Less harmful than cigarettes 1,130 50.6 49.4
- About the same as cigarettes 438 80.6 19.4
- More harmful than cigarettes 127 44.1 55.9
Heated tobacco non-users 8,354 69.6 30.4
Oral nicotine users 906 51.2 48.8
- Less harmful than cigarettes 629 45.5 54.5
- About the same as cigarettes 172 84.3 15.7
- More harmful than cigarettes 104 30.8 69.2
Oral nicotine non-users 9,144 69.3 30.7
Users of multiple products
- Heated & Pouches 709 43.4 56.6
Distribution for all respondents 10,050 67.6 32.4
50.6%
72.4%
49.4%
27.6%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
HTPs are less harmful than cigarettes HTPs are about the same or more harmful
Figure 14A. Harm beliefs of current and former
cigarette smokers
Currently smokes cigarettes Does not smoke cigarettes
47
71. Table 15 and Figures 15A and 15B show the distribution of harm beliefs conditional on
different levels of heated tobacco and oral nicotine products usage. In the case of heated
tobacco products, 67% of those who use the product perceive that they are less harmful
than cigarettes and 33% perceive that they are the same as or more harmful than
cigarettes. In the case of oral nicotine pouches, 69.5% of those who use the product
perceive that they are less harmful than cigarettes and 30.5% perceive that they are the
same as or more harmful than cigarettes.
Table 15. Harm beliefs relative to cigarettes percentage, by product use for each product
Observations Less
harm
Same
harm
More
harm
Same
or More
Heated tobacco products 6,511
- Never tried the product 2,685 34.7 57.7 7.6 65.3
- Tried, but never use now 2,131 36.6 55.7 7.9 63.4
- Use the product currently 1,695 66.7 25.8 7.5 33.3
- Tried, regardless of current use 3,826 49.9 43.4 7.7 50.1
Oral nicotine pouches 4,739
45.5%
64.1%
54.5%
35.9%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Oral nicotine pouches are less harmful
than cigarettes
Oral nicotine pouches are about the same
or more harmful
Figure 14B. Harm beliefs of current and former
cigarette smokers
Currently smokes cigarettes Does not smoke cigarettes
48
- Never tried the product 2,256 46.9 43.4 9.8 53.1
- Tried, but never use now 1,578 39.4 48.3 12.3 60.6
- Use the product currently 905 69.5 19.0 14.5 30.5
- Tried, regardless of current use 2,483 50.4 37.6 12.0 49.6
34.7% 36.6%
66.7%
65.3% 63.4%
33.3%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Never tried heated
tobacco products
Tried heated tobacco
products but never use
now
Use heated tobacco
products currently
Figure 15A. Estimated harm of heated tobacco
products compared to cigarettes by use of
product
Less harm Same or more harm
46.9%
39.4%
69.5%
53.1%
60.6%
30.5%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Never tried oral
nicotine
pouches
Tried oral
nicotine
pouches but
never use now
Use oral
nicotine
pouches
currently
Figure 15B. Estimated harm of oral nicotine
pouches compared to cigarettes by use of product
Same or more harm
Less harm
49
72. The final set of overall harm belief statistics in Table 16 analyzes the product use groups
in conjunction with the harm beliefs. In the case of heated tobacco products, the
percentage who believe that they are as harmful as or more harmful than cigarettes is
66% for those who smoke cigarettes and do not use heated tobacco products, 22% for
those who use heated tobacco products and do not smoke cigarettes, 42% if they use both
heated tobacco products and cigarettes, and 61% if they use neither heated tobacco
products nor cigarettes. The remainder in each group believe that heated tobacco
products are less harmful than cigarettes. In the case of oral nicotine products, the
percentage who believe that they are as harmful as or more harmful than cigarettes is
57% for those who smoke cigarettes but do not use oral nicotine pouches, 22% for those
who use oral nicotine pouches but do not smoke cigarettes, 38% for those who use both
oral nicotine pouches and smoke cigarettes, and 53% for those who use neither oral
nicotine pouches nor cigarettes.
Table 16. Percentage distribution of harm beliefs for different groups of usage of cigarettes
and other products
Heated products are: Less harmful
than cigarettes
Same or
more harmful
than cigarettes
Observations
Product use:
- Smokes cigarettes, not heated 34.1 65.9 3,467
- Heated, not cigarettes 78.2 21.8 714
- Both heated and cigarettes 58.3 41.7 981
- Neither heated nor cigarettes 39.2 60.8 1,349
Oral nicotine pouches are: Less harmful
than cigarettes
Same or
more harmful
than cigarettes
Observations
Product use:
- Smokes cigarettes, not pouches 42.8 57.2 2,821
- Pouches, not cigarettes 77.6 22.4 442
50
- Both pouches and cigarettes 61.8 38.2 463
- Neither pouches nor cigarettes 46.7 53.3 1,013
73. Given the nature of the sampling screens, usage of heated tobacco products and oral
nicotine pouch products is less common than is e-cigarette usage in this sample.
Nevertheless, the patterns regarding the usage of these products and the relationship of
product usage to perceptions of their degree of harm are instructive. Each of the products
faces substantial barriers with respect to accurate understanding of the estimated risks
that these alternative products pose as compared to the risks posed by conventional
cigarettes that burn tobacco. Just over half of all respondents believe that these products
pose risks of harm that are the same as or greater than those posed by cigarettes. The
perceptions of harm are correlated with product usage in the expected manner, as
respondents who believe that the products are less harmful than cigarettes are more likely
to use them than are respondents who believe that they are just as harmful as cigarettes or
more harmful. People who do not believe that these products pose less harm are less
likely to try these products or to currently use them. This relationship also holds for
cigarette smokers, as the failure to understand the comparative risk reduction that
scientists estimate is provided by these products may deter their usage as an alternative to
smoking cigarettes.
74. Table 17 presents regression results in which the dependent variable is a 0-1 indicator for
current product use, and the explanatory variables consist of harm beliefs, country, and
demographic factors. Those who perceive that heated tobacco products are less harmful
than cigarettes are 15% more likely to be using heated tobacco products, while those who
perceive nicotine pouches as being less harmful than cigarettes are 4% more likely to be
51
using them. There are several differences across countries in the usage of these products.
All statistically significant effects reflect higher levels of usage than in the UK. Higher
income and better educated respondents are also more likely to use each of these
products.
Table 17. Regressions predicting the probability that respondent CURRENTLY USES
each of the products, based on harm beliefs, country, and demographics
Heated
yes use
Pouch
yes use
Heated less harmful 0.1473***
(0.0102)
Pouch less harmful 0.0390***
(0.0098)
Belgium 0.1755*** 0.2034***
(0.0211) (0.0179)
Denmark 0.0132 0.0251
(0.0216) (0.0186)
Netherlands 0.0242 0.0464***
(0.0181) (0.0172)
France 0.0264 0.0339**
(0.0184) (0.0167)
Germany 0.1023*** 0.0322*
(0.0170) (0.0168)
Italy 0.1550*** -0.0138
(0.0167) (0.0174)
Age -0.0002 0.0006
(0.0005) (0.0005)
Age 60+ -0.0328* -0.0295
(0.0191) (0.0198)
Income 0.0017*** 0.0015***
(0.0002) (0.0002)
Income €150,000+ 0.1976*** 0.3044***
(0.0247) (0.0218)
Years education 0.0160*** 0.0122***
(0.0022) (0.0021)
Black -0.0932*** -0.0866***
(0.0309) (0.0260)
Asian -0.0162 0.0566**
(0.0304) (0.0267)
Other 0.0063 0.0202
(0.0291) (0.0243)
Female 0.0080 0.0134
52
(0.0101) (0.0099)
Married 0.0370*** 0.0076
(0.0141) (0.0142)
Widowed -0.0268 -0.0126
(0.0334) (0.0317)
Divorced 0.0144 -0.0350
(0.0221) (0.0223)
Separated 0.0032 0.0825***
(0.0317) (0.0310)
Partner -0.0039 -0.0160
(0.0168) (0.0165)
Missing income 0.0412* 0.0191
(0.0232) (0.0241)
Missing education 0.2838*** 0.1371**
(0.0670) (0.0639)
Missing race -0.0028 -0.0074
(0.0475) (0.0434)
Missing female 0.0782 -0.0535
(0.1170) (0.0825)
Missing relationship -0.0405 -0.0301
(0.0585) (0.0525)
Constant -0.2442*** -0.2289***
(0.0412) (0.0384)
Observations 6,511 4,739
R-squared 0.23 0.36
Standard errors in parentheses; * significant at 10%; ** significant at 5%; *** significant at 1%
Country effects are relative to the United Kingdom, the excluded country variable.
75. The regression results in Table 18 analyze the determinants of whether the respondent
believes that the product is less harmful than cigarettes. The results of greatest interest
are the differences across countries, all of which are relative to the UK. With a few
exceptions, all country effects are negative and statistically significant, meaning that
relative to the UK, the residents of these countries are less likely to perceive these two
products as being less harmful than cigarettes.
53
Table 18. Regressions predicting the probability that the respondent believes the product is
LESS HARMFUL than cigarettes, based on country and demographics
Heated
less harmful
Pouch
less harmful
Belgium -0.0313 -0.0076
(0.0256) (0.0267)
Denmark -0.0470* -0.1190***
(0.0262) (0.0277)
Netherlands -0.1482*** -0.2388***
(0.0219) (0.0253)
France -0.0928*** -0.1621***
(0.0223) (0.0248)
Germany -0.0350* -0.1541***
(0.0206) (0.0249)
Italy 0.1513*** -0.1238***
(0.0202) (0.0258)
Age 0.0023*** 0.0020***
(0.0006) (0.0007)
Age 60+ -0.0409* -0.0763***
(0.0231) (0.0295)
Income 0.0008*** 0.0000
(0.0002) (0.0002)
Income €150,000+ 0.3189*** 0.3249***
(0.0298) (0.0322)
Years education -0.0042 -0.0041
(0.0027) (0.0032)
Black -0.1196*** -0.1056***
(0.0375) (0.0387)
Asian -0.0148 -0.0563
(0.0369) (0.0397)
Other -0.0031 -0.0928**
(0.0353) (0.0362)
Female -0.0736*** -0.0570***
(0.0123) (0.0147)
Married 0.0266 0.0128
(0.0171) (0.0212)
Widowed 0.0432 0.0666
(0.0405) (0.0473)
Divorced -0.0156 0.0142
(0.0268) (0.0332)
Separated -0.0077 -0.0880*
(0.0385) (0.0461)
Partner -0.0478** -0.0252
(0.0204) (0.0246)
Missing income -0.0293 -0.0300
54
(0.0281) (0.0359)
Missing education 0.0243 -0.1074
(0.0813) (0.0951)
Missing race -0.0833 0.0607
(0.0576) (0.0646)
Missing female -0.2186 -0.0328
(0.1419) (0.1230)
Missing
relationship
-0.0226 -0.0066
(0.0710) (0.0783)
Constant 0.3762*** 0.5648***
(0.0498) (0.0567)
Observations 6,511 4,739
R-squared 0.12 0.12
Standard errors in parentheses; * significant at 10%; ** significant at 5%; *** significant at 1%
Country effects are relative to the United Kingdom, the excluded country variable.
76. Whether the respondent is a current smoker is the dependent variable in the regression
results in Table 19. These results for the full sample find that users of both heated
tobacco products and oral nicotine pouches are less likely to be a current smoker, whether
these products are included in the regression results individually or jointly. When both
products are included in the final regression, heated tobacco users are 4% less likely to be
a current smoker and users of oral pouches are 9% less likely to be a current smoker.
Table 19. Regressions predicting the probability that the respondent is a CURRENT
CIGARETTE SMOKER, based on alternative product USE, country, and demographics
Smoker Smoker Smoker
Heat yes use -0.0685*** -0.0438***
(0.0137) (0.0148)
Pouch yes use -0.1162*** -0.0926***
(0.0195) (0.0211)
Belgium 0.0758*** 0.0827*** 0.0833***
(0.0176) (0.0176) (0.0176)
Denmark 0.0893*** 0.0908*** 0.0902***
(0.0184) (0.0184) (0.0184)
Netherlands 0.0296* 0.0304* 0.0300*
55
(0.0170) (0.0170) (0.0170)
France 0.0004 0.0012 0.0012
(0.0167) (0.0167) (0.0167)
Germany 0.0180 0.0120 0.0158
(0.0168) (0.0167) (0.0168)
Italy -0.0094 -0.0236 -0.0152
(0.0171) (0.0169) (0.0171)
Age -0.0058*** -0.0058*** -0.0058***
(0.0005) (0.0005) (0.0005)
Age 60+ -0.0593*** -0.0586*** -0.0599***
(0.0165) (0.0165) (0.0165)
Income -0.0005*** -0.0005*** -0.0004**
(0.0002) (0.0002) (0.0002)
Income €150,000+ -0.2171*** -0.1912*** -0.1867***
(0.0256) (0.0264) (0.0264)
Years education 0.0048** 0.0048** 0.0052**
(0.0021) (0.0021) (0.0021)
Black 0.0420 0.0405 0.0387
(0.0313) (0.0313) (0.0313)
Asian 0.1020*** 0.1073*** 0.1061***
(0.0306) (0.0306) (0.0306)
Other 0.0321 0.0346 0.0343
(0.0280) (0.0279) (0.0279)
Female 0.0125 0.0131 0.0125
(0.0095) (0.0095) (0.0095)
Married 0.0186 0.0184 0.0195
(0.0134) (0.0133) (0.0133)
Widowed 0.0417 0.0431 0.0430
(0.0308) (0.0308) (0.0308)
Divorced 0.0148 0.0134 0.0140
(0.0194) (0.0194) (0.0194)
Separated -0.0164 -0.0118 -0.0125
(0.0291) (0.0291) (0.0291)
Partner -0.0721*** -0.0720*** -0.0726***
(0.0153) (0.0153) (0.0153)
Missing income -0.0664*** -0.0667*** -0.0660***
(0.0184) (0.0184) (0.0184)
Missing education 0.0307 0.0273 0.0341
(0.0533) (0.0533) (0.0533)
Missing race -0.0401 -0.0397 -0.0398
(0.0416) (0.0416) (0.0415)
Missing female 0.1488 0.1466 0.1493
(0.1109) (0.1108) (0.1108)
Missing relationship -0.0517 -0.0515 -0.0523
(0.0457) (0.0456) (0.0456)
Constant 0.8847*** 0.8832*** 0.8785***
56
(0.0383) (0.0383) (0.0383)
Observations 10,050 10,050 10,050
R-squared 0.06 0.06 0.06
Standard errors in parentheses; * significant at 10%; ** significant at 5%; *** significant at 1%
Country effects are relative to the United Kingdom, the excluded country variable.
77. Table 20 reports a regression on the use of heated tobacco products, the use of oral
nicotine pouches, or the use of both heated tobacco products and oral nicotine pouches,
for those respondents that do not smoke cigarettes. The dependent variable is a 0-1
variable for whether the respondent currently uses a heated tobacco product, an oral
nicotine pouch product, or both heated tobacco products and oral nicotine pouches and
also does not smoke cigarettes. The principal explanatory variable of interest is whether
the respondent considers heated tobacco products or oral nicotine pouches to be less
harmful. Those who believe heated tobacco products are less harmful than cigarettes are
19% more likely to use a heated tobacco product and not smoke conventional cigarettes.
Those who believe oral nicotine pouch products are less harmful than cigarettes are 5%
more likely to use an oral nicotine pouch product and not smoke conventional cigarettes
78. In the third regression in Table 20, beliefs regarding whether the product is less harmful
than cigarettes are included for both products. In this case, respondents are 15% more
likely to be using heated tobacco products or oral nicotine pouches if they perceive
heated tobacco products as being less harmful than cigarettes; while the effect of oral
nicotine pouch beliefs is not statistically significant once the heated tobacco beliefs
variable is included.
57
Table 20. Regressions predicting the probability that the respondent CURRENTLY USES
product for subsample that DOES NOT SMOKE CIGARETTES, for each or any of two
products, based on harm beliefs, country, and demographics
Heated
yes use
Pouch
yes use
Heated or Pouch
yes use
Heated less harmful 0.1905*** 0.1502***
(0.0186) (0.0285)
Pouch less harmful 0.0500*** -0.0390
(0.0182) (0.0290)
Belgium 0.4872*** 0.4440*** 0.5754***
(0.0443) (0.0358) (0.0558)
Denmark 0.0087 -0.0053 0.0499
(0.0434) (0.0379) (0.0604)
Netherlands 0.1335*** 0.1453*** 0.1360***
(0.0342) (0.0329) (0.0482)
France 0.0820** 0.0616** 0.1377***
(0.0348) (0.0303) (0.0488)
Germany 0.1361*** 0.0889*** 0.1645***
(0.0310) (0.0320) (0.0463)
Italy 0.2760*** -0.0004 0.3390***
(0.0301) (0.0326) (0.0462)
Age 0.0010 0.0059*** 0.0033**
(0.0010) (0.0010) (0.0015)
Age 60+ -0.0073 -0.0785** 0.0659
(0.0307) (0.0314) (0.0460)
Income 0.0030*** 0.0029*** 0.0042***
(0.0003) (0.0003) (0.0005)
Income €150,000+ -0.0049 0.0885** -0.1687***
(0.0448) (0.0380) (0.0523)
Years education 0.0040 0.0127*** 0.0097
(0.0043) (0.0042) (0.0064)
Black -0.0604 -0.2043*** -0.0879
(0.0634) (0.0495) (0.0698)
Asian -0.0785 0.1553** 0.0887
(0.0805) (0.0633) (0.0868)
Other 0.0543 -0.0322 0.1181*
(0.0624) (0.0468) (0.0707)
Female 0.1010*** 0.0721*** 0.1886***
(0.0188) (0.0187) (0.0282)
Married 0.0090 -0.0511* -0.0009
(0.0274) (0.0285) (0.0422)
Widowed -0.0378 -0.0098 -0.0531
(0.0586) (0.0578) (0.0808)
Divorced 0.0646* -0.0017 0.0789
(0.0389) (0.0401) (0.0571)
58
Separated 0.0255 0.0858 0.1316
(0.0560) (0.0574) (0.0853)
Partner 0.0484 0.0863*** 0.0551
(0.0304) (0.0308) (0.0467)
Missing income 0.1009*** 0.0528 0.0714
(0.0382) (0.0413) (0.0663)
Missing education -0.0283 0.2184* 0.0381
(0.1199) (0.1217) (0.1930)
Missing race 0.0501 0.0836 0.4845***
(0.0844) (0.0756) (0.1288)
Missing female 0.7447** 0.1060 0.6967*
(0.3717) (0.2917) (0.3692)
Missing
relationship
0.0809 0.0329 0.0873
(0.0971) (0.1004) (0.1705)
Constant -0.3044*** -0.5862*** -0.5370***
(0.0796) (0.0750) (0.1163)
Observations 2,063 1,455 1,195
R-squared 0.40 0.61 0.48
Standard errors in parentheses; * significant at 10%; ** significant at 5%; *** significant at 1%
Country effects are relative to the United Kingdom, the excluded country variable.
79. Table 21 and Figures 21A and 21B summarize the reported reasons for not using heated
tobacco products and oral nicotine pouches. The most important reason given is that they
do not know enough about the products, which is cited by 44% of respondents who had
not tried heated tobacco products and by 46% of respondents who had not tried oral
nicotine pouches. Belief that the products are not less harmful than regular cigarettes or
not believing that the products will be effective in helping the respondent quit smoking
are also common responses.
59
Table 21. Percentage distribution of the main reason for decision to have NEVER TRIED
product for each product
What is the main reason for you not trying Heated Pouch
I do not know enough about them 43.5 45.7
I do not want to quit smoking 8.1 11.8
I do not think that they are any less harmful than
cigarettes
17.8 12.3
They cost too much 11.7 6.3
I do not think that they would help me to quit or
cut down smoking
12.9 16.6
Other 6.0 7.2
Number of observations 2,685 2,256
43.5%
17.8%
I do not know enough about them I do not think they are any less harmful
than cigarettes
Figure 21A. Main reason given by respondents
for never having tried heated tobacco products
60
80. The reasons that respondents gave for currently using heated tobacco products and oral
nicotine pouches are summarized in Table 22 and Figures 22A and 22B. The dominant
response for 58% of heated tobacco users and 70% of pouch users is that the product
would help them stop or cut down on their smoking.
Table 22. Percentage distribution of the main reason for decision to CURRENTLY USE
product for each product
What is the main reason for you using Heated Pouch
To help me stop smoking cigarettes 41.1 59.4
To cut down on the amount of cigarettes that I
smoke
16.5 11.0
[To help me stop or to cut down] 57.5 70.4
To save money 8.4 7.0
Because they are available in better flavors than
cigarettes
12.3 8.2
Convenience, e-cigarettes can be used in more
places
11.9 9.6
To not expose people nearby me to cigarette
smoke
7.8 4.2
Other 2.1 0.7
Number of observations 1,696 906
45.7%
12.3%
I do not know enough about them I do not think they are any less harmful
than cigarettes
Figure 21B. Main reason given by respondents
for never having tried oral nicotine pouches
61
81. The demographic characteristics of the sample used in the analysis of heated tobacco
products and oral pouches are identical to Appendix A, Table Full Sample Characteristics
below, since the sample is the same.
41.1%
16.5%
To help me stop smoking cigarettes To cut down on the amount of cigarettes
I smoke
Figure 22A. Main reason for decisions to
currently use heated tobacco products
59.4%
11.0%
To help me stop smoking cigarettes To cut down on the amount of cigarettes
I smoke
Figure 22B. Main reason for decisions to
currently use oral nicotine pouches
62
VII. COUNTRY-SPECIFIC RESULTS
82. Although a comprehensive discussion of the specific country effects is not included in
this report, there are some results that were particularly striking, in addition to the effects
of the country variables in the regressions above.
83. The data in Table 23 regarding current product usage and those who do not use cigarettes
reflect the influence of the sample screens. The first two columns reflect how
respondents were recruited to participate in the survey, where two-thirds were intended to
be smokers and two-thirds were intended to be e-cigarette users, with an overlap such
that one-third of respondents currently use both cigarettes and e-cigarettes.
84. The last two columns show product usage by country for heated tobacco products and
oral nicotine pouches, which were not part of whether the respondent would be included
for the sample or screened. As a result of the screening process, the usage of all products
in Table 23 is unlikely to be representative of the entire population. Amongst the sample
there are significant differences in the use of these products across the different countries.
Table 23. Percentage who currently use product.
Cigarettes E-Cigarettes Heated
Tobacco
Products
Oral Nicotine
Pouches
Belgium 66.7 66.7 30.0 28.6
Denmark 74.5 62.7 6.3 3.7
Netherlands 66.7 66.7 16.3 12.4
United Kingdom 66.7 66.7 8.7 4.3
France 66.7 66.7 8.1 4.7
Germany 67.6 66.1 18.8 5.1
Italy 66.7 66.7 26.9 2.7
Total 67.6 66.2 16.9 9.0
63
85. The distribution of the percentage of those who currently use the product and do not use
cigarettes appears in Table 24. The first column again reflects how the sample was
recruited, so all respondents who do not currently smoke cigarettes currently use e-
cigarettes. In this sample, Belgium and the Netherlands have higher rates of use for
heated tobacco products and nicotine pouches. Germany and Italy also have
comparatively higher rates of use for heated tobacco products, but this distribution may
be a consequence of the sampling procedure.
Table 24. Percent who currently use product and do not use cigarettes
N E-Cigarettes Heated Tobacco
Products
Oral Nicotine
Pouches
Belgium 500 100 60.6 59.6
Denmark 274 100 3.6 1.1
Netherlands 500 100 23.8 20.2
United Kingdom 500 100 3.6 1.0
France 500 100 5.8 2.8
Germany 478 100 15.5 3.8
Italy 500 100 32.2 0.6
Total 3,252 100 22.0 13.6
86. The pivotal measure of risk beliefs is whether the respondent believes that the product is
less harmful. This variable is summarized for the different countries in Table 25. The
UK and Italy have a comparatively higher proportion of respondents who regard e-
cigarettes to be less harmful than cigarettes. Beliefs vary for the other products, but
across all countries there is a significant proportion of respondents that do not perceive
these products as being less harmful than cigarettes.
64
Table 25. Percent who believe product less harmful than cigarettes
E-Cigarettes
Less Harmful than
Cigarettes
Heated Tobacco
Products
Less Harmful
Oral Nicotine
Pouches
Less Harmful
Belgium 40.0 61.8 73.5
Denmark 52.0 35.5 43.4
Netherlands 58.5 33.0 37.0
United Kingdom 65.7 41.9 56.0
France 60.0 31.8 39.2
Germany 54.5 39.0 40.8
Italy 65.4 56.8 44.3
Total 56.8 43.6 48.7
87. Table 26 reports for each of the three products, the percentage of current cigarette
smokers who believe that the product is the same or more harmful than cigarettes, by
country. The perceptions across countries are relatively consistent, where most often at
least half of current smokers believe the other products to be as harmful or more harmful
compared to cigarettes.
Table 26. Percent who believe product the same or harmful than cigarettes, current
smokers
E-Cigarettes
Same or More
Harmful than
Cigarettes
Heated Tobacco
Products
Same or More
Harmful
Oral Nicotine
Pouches
Same or More
Harmful
Belgium 54.9 60.5 41.0
Denmark 59.3 65.0 59.1
Netherlands 53.2 64.2 52.2
United Kingdom 47.7 59.9 48.3
France 53.6 69.6 63.5
Germany 55.8 62.6 60.1
Italy 44.5 48.4 58.4
Total 52.5 60.5 54.6
88. Table 27 reports, for each of the products, the percentage of those who do not use that
product who believe that the product is just as harmful or more harmful than cigarettes,
by country. A high percentage among non-users of each product regard it as just as
65
harmful or more harmful than conventional cigarettes. The average across all countries is
greater than half for each product. This is the case for each product in every country with
the exception of oral nicotine pouches in the United Kingdom.
Table 27. Percent who believe product same or more harmful than cigarettes, among those
who do not currently use the product
E-Cigarettes
Same or More
Harmful than
Cigarettes
Heated Tobacco
Products
Same or More
Harmful
Oral Nicotine
Pouches
Same or More
Harmful
Belgium 75.6 77.0 53.9
Denmark 74.8 67.3 57.5
Netherlands 66.6 69.4 63.1
United Kingdom 60.8 59.5 43.9
France 65.6 71.7 60.9
Germany 67.4 66.3 60.4
Italy 57.2 51.7 56.8
Total 66.6 64.5 56.2
89. Table 28 summarizes the country differences in the percentage who give as their reason
for not using the product that they do not know enough about the product or they do not
think that the product is less harmful. These perceptions are relatively consistent across
surveyed countries, where lack of information or a belief that the products are at least as
harmful as cigarettes account for between 46% and 71% of respondents’ primary reasons
for not using the product.
Table 28. Percent whose main reasons for not using product is do not know enough about
them or do not think that they are any less harmful than cigarettes
E-Cigarettes Heated
Tobacco
Products
Oral Nicotine
Pouches
Belgium 56.8 59.5 53.7
Denmark 55.7 59.2 45.7
Netherlands 50.6 62.9 68.1
66
United Kingdom 49.3 67.9 55.9
France 48.4 67.3 58.9
Germany 58.1 51.9 54.2
Italy 68.1 57.1 70.7
Total 54.3 61.3 58.1
90. The country analyses in the appendices also yielded regression estimates for several key
relationships of interest. The coefficients summarized in the first column of Table 29
correspond to the effect of harm beliefs on e-cigarette usage. On average, the belief that
e-cigarettes are less harmful than cigarettes increases that the probability of e-cigarette
usage by 33%. For all countries, e-cigarette usage is negatively related to being a current
smoker, as shown in the second column 2. While the linkage between e-cigarettes being
perceived as less harmful than cigarettes and exclusive e-cigarette usage is not
statistically significant for the individual countries, it is for the entire sample.
Table 29. E-cigarettes, comparative country regressions by product use and harm beliefs
Table A6 Table A8 Table A9
E-cigarette
less harmful
E-cigarette
yes use
E-cigarette
less harmful
*Predicting* *Predicting* *Predicting*
Yes
e-cigarette use
Smoker Only
e-cigarette use
Belgium 0.2864*** -0.3803*** 0.0092
Denmark 0.3772*** -0.4181*** -0.0254
Netherlands 0.2955*** -0.4406*** 0.0263
United Kingdom 0.3932*** -0.4891*** 0.0364
France 0.3514*** -0.4946*** 0.0578*
Germany 0.2976*** -0.5034*** 0.0082
Italy 0.3182*** -0.5041*** 0.0317
Total 0.3260*** -0.4814*** 0.0935***
67
VIII. DISCUSSION
91. Understanding of the attributes of products is an essential input to consumers being able
to make efficient decisions with respect to using the product. One such attribute is the
potential health risk that the product poses to users of the product. The number of
alternative nicotine products on the market has grown to include e-cigarettes, heated
tobacco products, and oral nicotine pouches. Available scientific evidence indicates that
each of these products offers potential risk reductions as compared to conventional
cigarettes. As a result, policies that lead consumers to switch from smoking cigarettes to
these products offer potential public health gains.
92. Consumers must make the decision whether to switch from cigarettes to these products.
These are individual consumer choices made on a decentralized basis. Understanding of
the risks of these alternative products as compared to cigarettes is essential for consumers
to make informed decisions with respect to using these alternative products.
Understanding of the risk is not only important from the standpoint of potential health
consequences but also in terms of matching the product choice to the consumer’s
preferences.
93. In recognition of the importance of understanding the comparative risks, Public Health
England in particular has taken a prominent role in communicating its conclusion that e-
cigarettes provide a risk reduction compared to tobacco burning cigarettes of at least
95%.
94. Unfortunately, the available evidence indicates that many consumers have not grasped
the extent of the estimated risk reduction provided by alternatives to conventional
cigarettes.
68
95. This study provides new survey results from respondents in seven European countries.
The current study provides further evidence, consistent with a number of other studies,
that a substantial portion of the public believes that e-cigarettes and other potentially
reduced risk nicotine products, are just as harmful or more harmful than cigarettes. This
gap in consumer knowledge is consequential, as the results in this report and other studies
demonstrate that these risk perceptions are strongly correlated with the non-use of these
products. These findings suggest that more needs to be done to improve consumers
understanding of the comparative risks of these products.
96. Foregoing consumption of a product that the consumer would choose if adequately
informed of the risk of the product, produces a loss for consumers. Consumers would be
better off if they understood the potentially lower risks of the alternative products and
then made product decisions that matched their preferences. Even if informed of the risk
attributes, some consumers may choose to smoke conventional cigarettes than switch to
e-cigarettes. But some smokers may be deterred from switching because they do not
realize the potential risk reductions that such products offer. These consumers will be
worse off than if they had the information to be able to make a more informed choice.
97. The gaps in consumer knowledge, also may lead to a public health loss to the extent that
people who would have switched from conventional cigarettes to e-cigarettes or other
potentially reduced risk nicotine products are discouraged from doing so because of a
misunderstanding of the risks.
98. These misperceptions exist notwithstanding the generally held view by many public
health experts and public health authorities that e-cigarettes and other non-combustible
tobacco and nicotine products are likely to pose substantially reduced risks compared to
69
combustible cigarettes. However, some opponents to these products continue to raise
concerns regarding the absolute risk of e-cigarettes and the absence of long-term
epidemiological evidence regarding these products. A particular example of this
approach is that of the World Health Organization (WHO), which emphasizes that e-
cigarettes are not safe, and continues to advocate in favor of bans on e-cigarettes, or, if
they are not banned, that these products should be regulated in a similar way to traditional
tobacco products.25
The WHO also takes a similar approach to heated tobacco
products.26
However, this approach to communicating the risk of these products, denies
current smokers accurate information on the risk of these products compared to cigarettes
and contributes to existing misperceptions.
99. Risk perceptions can also be heavily influenced by inaccurate media reporting regarding
these products and related research. This misinformation phenomenon was an issue
highlighted in the 2018 PHE report, where the authors noted the problem with inaccurate
reporting and stated:
“The consequences of this inaccurate or inadequate reporting are that the general
public is misled. This could induce smokers to carry on smoking rather than
switching and EC users to relapse to smoking. While such inaccurate reporting is
not confined to the tobacco harm reduction and EC field, the impact is rarely as
large. Smoking is uniquely dangerous and each year in England around 80,000
smokers die because of tobacco use (2) . There are few other scientific areas
where the gains and losses to public health are so high. It is very likely that these
25
See World Health Organization, E-Cigarettes, Q&A, 29 January 2020.
26
See World Health Organization, Heated tobacco products: a brief (2020).
70
reports and headlines are playing a key role in the persistent misperceptions that
the public have about the relative risks of EC and tobacco cigarettes.”27
100. A particular example of this is in the case of the reporting of the EVALI cases in the US.
While most of the cases in the U.S. have been associated with inhalation of vitamin E
acetate, an additive found in some tetrahydrocannabinol (‘THC’) vaping products, news
reports often failed to distinguish THC vaping products from standard nicotine-based e-
cigarettes.28
There is some evidence suggesting that this inaccurate reporting has
contributed to increasing misperceptions regarding the risk of e-cigarettes.29
101. The regulatory regime for these alternative nicotine products is a critical factor for
communicating risk and facilitating awareness and trial of these products. Research
shows that regulation can affect awareness and use of nicotine vaping products. For
example, Gravely, et al (2019) found that:
"[w]ith a few exceptions, awareness and use of nicotine vaping products varied by
the strength of national regulations governing nicotine vaping product
sales/marketing, and by country income" and "[i]n contrast to many of the [less
restrictive policies] and [restrictive policies] countries, rates of use were quite low
in the [most restrictive policies] countries (Australia, Uruguay and Brazil),
indicating that strict regulation and enforcement of [nicotine vaping products]
27
McNeill 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. London: Public Health England, at p173.
28
See Wayne Hall, Billie Bonevski, Coral Gartner, Policy‐based evidence on e‐cigarette, or vaping product, use–
associated lung injury, Drug and Alcohol Review, 10.1111/dar.13072, 39, 4, (426-427), (2020).
29
Tattan-Birch H, Brown J, Shahab L, Jackson SE. Association of the US Outbreak of Vaping-Associated Lung
Injury With Perceived Harm of e-Cigarettes Compared With Cigarettes. JAMA Netw Open. 2020;3(6):e206981.
doi:10.1001/jamanetworkopen.2020.6981.
71
laws in these countries may have limited smokers’ access to these products and/or
discouraged smokers from using them".30
102. Regulating potentially reduced risk alternative tobacco and nicotine products in the same
way as combustible products conveys the message that these products pose the same
potential health risks as combustible tobacco products and undermines the
communication of the comparative risks of products. The anchoring of the presentation
and communication regarding new potentially reduced products with existing more risky
products has more general implications for the performance of consumer markets for
potentially reduced risk products. If new, potentially reduced risk products become
available, these products will encounter the hurdle of overcoming consumers’ prior risk
beliefs associated with the product class to the extent that consumers are reluctant to alter
their high risk beliefs. The dominant market failure may involve overestimation of the
new product’s riskiness. This influence will impede consumers’ response to new,
potentially less risky alternative products introduced in the market.
103. For example, requiring e-cigarettes and other potentially reduced risk products to carry
the same style warnings and look the same as combustible tobacco products (for example
by imposing the same plain or standardized packaging requirements); and applying the
same restrictions on product display, will reinforce current beliefs that the risks of these
products are comparable in character and magnitude to the risks of cigarettes. The
particular challenge for informational policies is to convey the properties of e-cigarettes
or and other smoking non-combustible tobacco and nicotine alternatives like heated
30
Gravely, et al (2019) Prevalence of awareness, ever‐use and current use of nicotine vaping products (NVPs)
among adult current smokers and ex‐smokers in 14 countries with differing regulations on sales and marketing of
NVPs: cross‐sectional findings from the ITC Project, Addiction. doi: https://doi.org/10.1111/add.14558.
72
tobacco products and oral nicotine pouches, which are estimated to pose significantly
lower health risks than conventional cigarettes but are more comparable in terms of the
nicotine levels. Cigarette style warnings and packaging policies are not designed to
foster lower risk beliefs with respect to e-cigarettes or to promote accurate comparative
risk beliefs. Warnings should frame risk information that allows users to make informed
choices.
104. Advertising bans and prohibitions on comparative risk claims prevent manufactures from
communicating the attributes of these products and potential benefits for smokers,
thereby impeding informed consumer decision making. Imposing advertising bans may
also have negative consequences in increasing demand for traditional cigarettes.31
IX. CONCLUSION
105. Analysis of the survey results for seven European countries yields differences across
countries in terms of the public’s perception of alternative nicotine delivery devices.
Four conclusions are most noteworthy. First, the perceptions of a substantial segment of
the population are not in line with the estimated lower levels of harm posed by e-
cigarettes and other non-combustible tobacco and nicotine alternatives like heated
tobacco products and oral nicotine pouches, based on prevailing public health opinions.
Second, the evidence is strongly consistent with e-cigarettes and other non-combustible
tobacco and nicotine products serving as an alternative for conventional cigarettes.
Third, the main reasons given by respondents for not using e-cigarettes and other
potentially reduced risk products are that they do not know enough about them or they do
31
See Tuchman, Anna E. 2017. “Advertising and Demand for Addictive Goods: The Effects of E-Cigarette
Advertising.” Working Paper, Northwestern University Kellogg School of Management
73
not think that they are less harmful than cigarettes. Fourth, the decisions to use e-
cigarettes and other potentially reduced risk products are strongly correlated with
perceptions that these products pose less harm than smoking conventional cigarettes, so
that continued misperceptions of the estimated harms from non-combustible tobacco and
nicotine products have adverse implications for informed consumer decision making.
106. These findings, in combination with the studies reviewed in this report, lead to the
following observations and policy recommendations for governments and regulators:
a. The results of the European surveys discussed in this report and other studies, find
that consumers are misinformed about the estimated reduced harms of non-
combustible tobacco and nicotine products compared to combustible tobacco
products.
b. The policy challenge is to address the shortfall in consumer knowledge so that
current cigarette smokers can make a comparison between cigarettes and these
alternative products that reflects the estimated substantial reduction in the risk of
harm that they are expected to provide. Improving the perceptions of harm for
non-combustible tobacco and nicotine products in line with their estimated
reduced harm compared to conventional cigarettes will likely lead to more
smokers switching to these products as an alternative to smoking.
c. To reduce the continued misperception of the estimated harm posed by non-
combustible tobacco and nicotine products compared to conventional cigarettes,
governments and regulators should treat these products differently than cigarettes
and should undertake sustained efforts to communicate the estimated lower risk
that they pose compared to cigarettes.
74
d. Such policies might include efforts along the following lines:
i. Undertaking risk communication efforts that credibly convey to
consumers accurate information about the estimated lower risk posed by
these non-combustible products.
ii. Adopting warnings for these products that are not patterned on cigarette
warnings but rather are reflective of the lower degree of estimated risk that
they pose and providing information that facilitates informed consumer
decision making. Warnings and other information efforts should not be
policies of persuasion designed to discourage smokers’ usage of non-
combustible tobacco and nicotine products.
iii. Allowing marketing freedoms for companies selling alternative tobacco
and nicotine products so that they can create awareness of these products
and the estimated risk reduction that they offer to smokers who choose
these products instead of cigarettes.
107. The underlying principle of these recommendations, which is that non-combustible
tobacco and nicotine products merit quite different treatment than conventional
cigarettes, should be carried over across all dimensions of government and regulatory
policies. These efforts include, among others, advertising bans and limitations, retail
display bans, and requirements regarding the use of plain or standardized packaging as
well as restrictions on ingredients and the imposition of taxes. Efforts that adopt the same
regulatory approach as is used for tobacco cigarettes will continue to reinforce
consumers’ misperceptions regarding the comparative estimated risk of these products.
There is evidence that consumer beliefs have become more out of line with the estimated
75
risk that these products pose compared to cigarettes. Given the increase in risk beliefs for
e-cigarettes that has been observed in several recent surveys, it is possible that recent
regulatory efforts that treat these alternative products in the same way as combustible
tobacco products may have even increased the degree of misperception regarding non-
combustible tobacco and nicotine products.
____________________
W. Kip Viscusi
17 December 2020
76
Appendix A. Sample Characteristics and Survey Text
Appendix Table Full Sample Characteristics. Full sample demographic percentages
Age
18-20 21-29 30-39 40-49 50-59 60+
Age 2.3 138 27.8 21.6 20.7 13.8
Gender
Male Female Other No Answer
Gender 52.7 46.4 0.7 0.2
Race or ethnicity
White Black Asian Multiple Other No Answer
Race 91.4 2.2 2.3 2.1 0.6 1.3
Relationship
Married Widowed Divorced Separated Never
Married
Live-in
Partner
No
Answer
Relationship 48.6 2.6 8.6 2.8 18.9 17.4 1.1
Education
Less than
High
School
High
School
Trade /
Tech /
Vocational
Bachelor Post-
Graduate
No
Answer
Education 7.1 25.3 23.4 23.9 19.1 1.1
Income in Euros*
0-10 10-30 30-49 50-75 75-100 100-
125
125-
150
150+ No
Answer
Income 7.1 25.6 24.3 13.9 10.4 0.7 2.2 7.2 8.6
* United Kingdom and Denmark respondents were adjusted based on their currencies’ exchange
rate relative to the euro on July 22, 2020 which is the date when half of all surveys were
complete. Top income for the United Kingdom is the equivalent of €165,000 or more in pounds.
Top income for Denmark is the equivalent €167,500 or more in kroner.
Country
N Percentage
Belgium 1,500 14.9
Denmark 1,073 10.7
Netherlands 1,500 14.9
United Kingdom 1,500 14.9
France 1,500 14.9
Germany 1,477 14.7
Italy 1,500 14.9
1
Anna Dunø Madsen
Fra: Camilla Friborg Madsen
Sendt: 16. marts 2023 14:00
Til: Anna Dunø Madsen
Emne: VS: Høring: Udkast til forslag til lov om ændring af lov om tobaksvarer m.v., lov om
elektroniske cigaretter m.v., lov om forbud mod salg af tobak og alkohol til
personer under 18 år og lov om røgfri miljøer - intern frist den 24. februar 2023
Vedhæftede filer: Signature-20230207083241.txt
Fra: BOH-FP-Direktion <Direktion.bornholms-hospital@regionh.dk>
Sendt: 7. februar 2023 09:32
Til: Camilla Friborg Madsen <CFMA@SUM.DK>
Emne: VS: Høring: Udkast til forslag til lov om ændring af lov om tobaksvarer m.v., lov om elektroniske cigaretter
m.v., lov om forbud mod salg af tobak og alkohol til personer under 18 år og lov om røgfri miljøer - intern frist den
24. februar 2023
Kære Camilla,
På vegne af Bornholms Hospital.
Vi har ingen bemærkninger til fremsendte materiale.
Med venlig hilsen
Tina Munch-Kure
Direktionssekretær
Bornholms Hospital
Direktionen
Ullasvej 8 · DK-3700 Rønne
Dir. tlf. 3867 0020 / Tlf. 3867 0000
tina.munch-kure@regionh.dk
www.bornholmshospital.dk
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Fra: Camilla Friborg Madsen <CFMA@SUM.DK>
Sendt: 3. februar 2023 09:26
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2
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Til alle høringsparter
Se venligst vedhæftede høring over udkast til forslag til lov om ændring af lov om tobaksvarer m.v., lov om
elektroniske cigaretter m.v., lov om forbud mod salg af tobak og alkohol til personer under 18 år og lov om røgfri
miljøer (Implementering af dele af delegeret direktiv vedrørende opvarmede tobaksvarer samt andre præciseringer
og tekniske justeringer)
Indenrigs- og Sundhedsministeriet skal anmode om at modtage eventuelle bemærkninger til udkastet senest
mandag d. 6. marts 2023 kl. 12.
Bemærkninger bedes sendt til sum@sum.dk og til cfma@sum.dk.
Camilla Friborg Madsen
Fuldmægtig, Kontor for Forebyggelse og Strålebestyttelse
M 21 67 75 18
@ cfma@sum.dk
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Læs ministeriets datapolitik her
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Indenrigs- og Sundhedsministeriet
Sagsnummer 2213653
sum@sum.dk
cfma@sum.dk
Den 6. marts 2023
Høring over udkast til forslag til lov om ændring af lov om tobaksvarer m.v., lov om elektroniske
cigaretter m.v., lov om forbud mod salg af tobak og alkohol til personer under 18 år og lov om røgfri
miljøer
Bryggeriforeningen takker for muligheden for at afgive bemærkninger til lovforslaget.
Bryggeriforeningens bemærkninger vedrører den del af lovforslaget, der præciserer kravene til
alderskontrol.
I høringsbrevet er det oplyst, at der i forbindelse med flere domstolsprøvelser ikke er tilstrækkelig klar
lovhjemmel til at stille krav om, at erhvervsdrivende skal etablere et generelt alderskontrolsystem ved
online salg af varer underlagt salgsaldersgrænse. Det er i tilknytning hertil Bryggeriforeningens vurdering, at
det er essentielt, at lovgivningen virker, hvilket bl.a. betyder, at lovhjemmelen skal være tilstrækkelig ved
domstolsprøvelser.
Det er vigtigt og relevant, at der med det konkrete lovforslag implementeres en effektiv lovhjemmel, der
kan sikre optimale domstolsprøvelser, men den eksisterende udfordring med håndhævelsen af
salgsaldersgrænserne bør også søges løst.
Håndhævelsen af salgsaldersgrænserne har i mange år været en stor udfordring, hvilket afspejles i en
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fysiske handel kan sandsynligvis henføres til, at det alene er den enkelte kassemedarbejder, der er ansvarlig
for at vurdere kundens alder, hvilket resulterer i mange fejl. For så vidt angår online håndhævelse er det
nærliggende, at grunden primært skyldes muligheden for omgåelse. Sådan som løsningen er i dag ved
online salg, kan mindreårige i de fleste situationer indtaste en hvilken som helst alder ved køb af varer (pop
up, afkrydsning eller andet), der er underlagt salgsaldersgrænse.
Som en del af løsningen på den mangeårige håndhævelsesudfordring foreslår Bryggeriforeningen, at
Sundhedsministeriet nedsætter arbejdsgruppe, der skal afsøge hvilke tilgængelige løsninger for
alderskontrol, der i væsentligt og tilfredsstillende omfang kan forbedre håndhævelsen af de nuværende
salgsaldersgrænser. Dette arbejde kan f.eks. ske i forlængelse af de drøftelser som Sundhedsministeriet
igangsatte i foråret 2022 med deltagelse af en række organisationer. Som repræsentant for bryggerierne
deltager Bryggeriforeningen gerne i dette videre arbejde.
Det er Bryggeriforeningens vurdering, at der er behov for at få udviklet et digitalt alderskontrolsystem, der
kan sikre en forbedring af såvel håndhævelsen i den fysiske detailhandel som ved online salg. Et digitalt
alderskontrolsystem skal forhindre, at kunder kan gennemføre køb af produkter, som de ikke er gamle nok
til at købe.
Et digitalt alderskontrolsystem kræver udvikling af en løsning, der ikke er tilgængelig i dag, men som ifølge
flere af de relevante og naturligt involverede parter, herunder også fx MasterCard, er realistisk, da der til
hvert elektroniske betalingsmiddel er knyttet en konkret kontohaver. Ved at indhente samtykke fra
kontohaver med accept til at foretage alderskontrol, er det muligt digitalt at verificere alderen ved køb i
detailhandlen, når forbrugeren gennemfører sin betaling elektronisk, hvad enten det er med kort eller
telefon ved terminalen – såvel fysisk som online.
Giver høringssvaret anledning til spørgsmål, står vi naturligvis til rådighed.
Med venlig hilsen
Lea Kholghi Frederiksen
Erhvervspolitisk chef
Mobil (+45) 29 27 26 23
lkf@bryggeriforeningen.dk
BRYGGERIFORENINGEN
Danish Brewers’ Association
Faxehus, Gamle Carlsberg Vej 16
1799 København V, Denmark
DANSK ERHVERV
Børsen
1217 København K
www.danskerhverv.dk
info@danskerhverv.dk
T. + 45 3374 6000
stsb@danskerhverv.dk
stsb/STSB
Side 1/1
Indenrigs- og Sundhedsministeriet
Att.: Camilla Friborg Madsen
Den 6. marts 2023
Høring: udkast til forslag til lov om ændring af lov om tobaksvarer m.v., lov
om elektroniske cigaretter m.v., lov om forbud mod salg af tobak og alkohol
til personer under 18 år og lov om røgfrie miljøer
Dansk Erhverv har modtaget ovenstående udkast til lovforslag i høring. Lovforslaget gennemfører
dele af delegeret direktiv vedrørende opvarmede tobaksvarer samt en præcisering af lovgivning
vedr. alderskontrol og skiltning, som baserer sig på eksisterende praksis på området og med for-
målet at skabe lovhjemmel for, at erhvervsdrivende kan pålægges straf, såfremt de ikke overhol-
der kravene. Dansk Erhverv har følgende bemærkninger til udkastet:
Generelle bemærkninger
Dansk Erhverv støtter formålet med forslaget og deler ønsket om at sætte ind mod unges rygning.
Dansk Erhverv er medlem af partnerskabet for Røgfri fremtid.
For så vidt angår første del af lovforslaget vedrørende gennemførelse af dele af delegeret direktiv
om opvarmede tobaksvarer, bakker Dansk Erhverv op om forslaget, der vurderes at kunne bi-
drage til at begrænse forbruget af de opvarmede tobaksprodukter.
Ligeledes bakker Dansk Erhverv op om lovforslagets præcisering af lovgivning vedrørende alders-
kontrol og skiltning, da denne præcisering allerede er eksisterende praksis og alene har til formål
at skabe tilstrækkelig lovhjemmel.
Metode til alderskontrol ved online salg
Dansk Erhverv noterer sig, at der i lovforslaget fortsat er lagt op til metodefrihed for alderskontrol
ved online salg (pop up, afkrydsning eller andet). Dette bakker Dansk Erhverv fuldt op om og det
vil også fremadrettet være et opmærksomhedspunkt for Dansk Erhverv, da vi mener, det er vig-
tigt, at de erhvervsdrivende ikke bebyrdes med krav til specifikke metoder til alderskontrol mv.
Med venlig hilsen,
Stine Sjølund Blok
Chefkonsulent
Indenrigs- og Sundhedsministeriet
Fremsendt pr. e-mail til sum@sum.dk og cfma@sum.dk
28. februar 2023
Høringssvar fra Dansk Selskab for Folkesundhed vedr.:
”Lov om ændring af lov om tobaksvarer m.v., lov om elektroniske cigaretter m.v., lov om forbud
mod salg af tobak og alkohol til personer under 18 år og lov om røgfri miljøer”
DSFF hilser det meget velkommen at opvarmede tobaksvarer fremover ikke kan undtages fra
bestemmelserne i artikel 7, stk. 1 og 7. DSFF støtter fuldt ud op om at det skal være forbudt at
markedsføre opvarmede tobaksvarer med en kendetegnende aroma, og at det skal være forbudt at
markedsføre opvarmede tobaksvarer, der indeholder aromastoffer i deres bestanddele såsom filtre,
papir, emballage, kapsler eller enhver teknisk funktion, der gør det muligt at ændre opvarmede
tobaksvarers duft eller smag eller deres røgudviklingsintensitet. DSFF støtter også at opvarmede
tobaksvarer, der består af filtre, papir eller kapsler med indhold af tobak eller nikotin, ikke må
markedsføres her i landet og at opvarmede tobaksvarer skal have samme kombinerede
sundhedsadvarsler som cigaretter.
DSFF finder det meget vigtigt, at smagsstoffer ikke kun forbydes som ”kendetegnende aromaer”,
men som ingredienser, så der ikke er tvivl om, hvor meget smag, der må/ikke må tilsættes et
produkt. DSFF vil dog gerne opponere imod at opvarmet tobak fremover kun vil være omfattet af
bestemmelserne i artikel 7, stk. 1 og 7, i tobaksvaredirektivet for så vidt opvarmet tobak er
røgtobak.
DSFF vil gerne opponere imod at opvarmet tobak både kan defineres som røgtobak og røgfri tobak
jf. følgende definition af opvarmet tobak:
I § 2 indsættes som nr. 31: »31) Opvarmet tobaksvare: En ny kategori af tobaksvarer, der opvarmes
for at frembringe en emission indeholdende nikotin og andre kemikalier,
som derefter inhaleres af brugeren/brugerne, og som afhængigt af deres karakteristika
er røgfrie tobaksvarer eller røgtobak. «
Udtrykket ”som afhængigt af deres karakteristika er røgfrie tobaksvarer eller røgtobak” er yderst
uheldig, da det ikke specificeres hvad der menes med karakteristika. Denne unøjagtige formulering
vil uden tvivl blive udnyttet af tobaksproducenterne, der har en stærk interesse i at markedsføre
opvarmet tobak som et ”uskadeligt alternativ” til almindelige cigaretter. De amerikanske
sundhedsmyndigheder, FDA, har konkluderet “data failed to show consistently lower risks of harm
in humans using IQOS (et opvarmet tobaksprodukt) compared with conventional cigarettes.”
WHO anbefaler at opvarmet tobak lovgives som andre tobaksvarer. Opvarmet tobak er små
cigaretter lavet af tobaksblade, og udover at være stærkt afhængighedsskabende, dannes der
mange stærkt sundhedsskadelige stoffer ved opvarmning. Det bør ikke være til forhandling om
tobak er tobak, uanset om det opvarmes, puttes under læben, brændes eller indtages på anden vis.
DSFF anbefaler derfor at al opvarmet tobak fremover defineres som røgtobak og at al opvarmet
tobak således fremover vil være omfattet af bestemmelserne i artikel 7, stk. 1 og 7 i
tobaksvaredirektivet.
DSFF hilser det meget velkommen at pligten til at drive et alderskontrolsystem fremover
vil påhvile alle detailforhandlere af tobaksvarer, tobakssurrogater og urtebaserede rygeprodukter,
der markedsfører via fjernsalg, og ikke kun dem, der markedsfører via fjernslag over landegrænser.
Ved markedsføring af produkterne online foreslås det, at der skal etableres og drives et generelt
alderskontrolsystem. Dette skal bl.a. gøres via en app-funktion, for at sikre et system, der effektivt
verificerer køberens alder.
Når man læser lovteksten, fremstår den dog ikke så stærk som ønsket.
Stk. 3. Den, der erhvervsmæssigt markedsfører elektroniske cigaretter eller genopfyldnings-
beholdere med eller uden nikotin online, skal kræve, at kunden inden salget gennemføres utvetydigt
tilkendegiver, om kunden er fyldt 18 år.«
Ansvaret lægges altså hos kunden, ikke den erhvervsdrivende. Når en 15-årig ønsker at købe tobak
eller e-cigaretter online skal vedkommende så bare sætte et hak ved ”ja, jeg er over 18 år”? Dette
har i DSFFs øjne intet med alderskontrol at gøre. Det svarer til at man i fysiske butikker bare skal
nikke ja til at man er over 18 år, uden legitimation. Unge, kan med få klik få tilsendt store mængder
tobak/tobakssurrogater via onlinekøb. DSFF opponerer stærkt imod dette. Som udgangspunkt
mener DSFF, ligesom WHO, at online salg af tobak og tobakssurrogater ikke skal være tilladt.
Såfremt denne anbefaling fra WHO ikke følges, vil vi opfordre til at man strammer lovteksten, så
onlinesalg af tobaksprodukter og tobakssurrogater kun kan finde sted ved brug af fx MitID, så der
sikres en reel alderskontrol. DSFF anbefaler at man suspenderer muligheden for at forhandle
tobaksvarer indtil en tilfredsstillende og sikker løsning vedr. alderskontrol er etableret.
DSFF vil til sidst gerne gøre opmærksom på at vi er meget uenige i tobaksvaredirektivets artikel 7,
stk. 12, hvor det fremgår, at andre tobaksvarer end cigaretter og rulletobak er undtaget fra
forbuddene i stk. 1 og 7. Disse undtagelser er allerede blevet udnyttet at tobaksproducenterne. I
USA sælges små cigarer der til forveksling ligner almindelige cigaretter, men har brunt rullepapir. De
sælges med søde smagsstoffer, de sælges i farvestrålende pakninger, der reklameres kraftigt for
dem, og de ligger ved kassen i børns øjenhøjde – fordi de kan omgå tobaksvarelovgivningen. Flere
unge i USA bruger små cigarer end almindelige cigaretter.
På vegne af Dansk Selskab for Folkesundhed
Helle Terkildsen Maindal Nina Krogh Larsen
Forperson Bestyrelsessuppleant
Danske Patienter er paraply for patient- og pårørendeforeninger i Danmark. Danske Patienter har 23 medlemsforeninger, der repræsenterer 104
patientforeninger og 900.000 medlemmer: Alzheimerforeningen, Astma-Allergi Danmark, Bedre Psykiatri, Colitis-Crohn Foreningen, Diabetesforeningen,
Epilepsiforeningen, Fibromyalgi- og Smerteforeningen, Foreningen Spiseforstyrrelser og Selvskade, Gigtforeningen, Hjerneskadeforeningen,
Hjerteforeningen, Kræftens Bekæmpelse, Patientforeningen Fertilitet og Tab, Lungeforeningen, Muskelsvindfonden, Nyreforeningen,
Osteoporoseforeningen, Parkinsonforeningen, Polioforeningen, Scleroseforeningen, Sjældne Diagnoser, UlykkesPatientForeningen og Øjenforeningen.
Høringssvar vedr. udkast til forslag til lov om ændring af lov om
tobaksvarer m.v., lov om elektroniske cigaretter m.v., lov om
forbud mod salg af tobak og alkohol til personer under 18 år og
lov om røgfri miljøer (Implementering af dele af delegeret
direktiv vedrørende opvarmede tobaksvarer samt andre
præciseringer og tekniske justeringer)
Danske Patienter takker for muligheden for at afgive høringssvar til det
fremsendte lovforslag. I Danmark er der mange børn og unge, der
begynder at ryge og bliver afhængige af nikotin – og det sker i takt med,
at der kommer flere og flere tobaks- og nikotinprodukter på markedet. I
Danske Patienter bakker vi derfor op om øget regulering af opvarmede
tobaksvarer.
Danske Patienter mener, at opvarmede tobaksvarer skal reguleres på
linje med cigaretter og anden tobak. Vi er derfor positive over for, at der
lægges op til, at opvarmede tobaksvarer omfattes af samme forbud
mod aromastoffer som cigaretter. Mentol og andre aromaer gør
produkterne mere tiltrækkende for særligt børn og unge og bør derfor
forbydes i opvarmede tobaksvarer. Vi mener desuden, at forbuddet
mod aromastoffer bør udvides til at gælde for alle typer af tobaksvarer.
Vi finder det også positivt, at der indføres lovhjemmel til at stille krav om
alderskontrol ved online salg af tobak, urtebaserede rygeprodukter,
tobakssurrogater og e-cigaretter. Vi frygter dog, at det i sig selv ikke er
tilstrækkeligt, idet forhandlere blot kan vælge at lade forbrugere krydse
af, at de er over 18 år. Vi mener derfor, at det er mere oplagt helt at
forbyde salg af tobak og lignende produkter online, hvilket WHO
ligeledes anbefaler. Det mener vi vil gøre tobak mindre tilgængeligt for
særligt børn og unge.
Med venlig hilsen
Morten Freil
Direktør
Dato:
6. marts 2023
Danske Patienter
Kompagnistræde 22, 1. sal
1208 København K
Tlf.: 33 41 47 60
www.danskepatienter.dk
E-mail:
lk@danskepatienter.dk
Cvr-nr: 31812976
Side 1/1
Indenrigs- og Sundhedsministeriet
Holbergsgade 6
1057 København K
E-mail: sum@sum.dk, cc: cfma@sum.dk
1
21-02-2023
EMN-2023-00263
1610034
Sofie Vennike
NOTAT
Danske Regioners bemærkninger til høring af Udkast til for-
slag til lov om ændring af lov om tobaksvarer m.v., lov om
elektroniske cigaretter m.v., lov om forbud mod salg af to-
bak og alkohol til personer under 18 år og lov om røgfri mil-
jøer
Indenrigs- og Sundhedsministeriet har d. 3. februar 2023 anmodet om Danske
Regioners bemærkninger til lovforslag vedrørende lov om tobaksvarer og alko-
hol.
Med lovforslaget udvides forbuddet mod markedsføring af tobaksvarer nu til
også at omfatte opvarmede tobaksvarer. Lovforslaget skal gøre opvarmede to-
baksvarer mindre attraktive, og gøre forbrugere mere opmærksomme på de
sundhedsrisici, der er forbundet med at anvende opvarmede røgtobaksvarer.
Direktivet forventes således at bidrage til at begrænse forbruget af opvarmede
tobaksvarer, herunder at børn og unge indleder et forbrug. Lovforslaget har til
formål at rette op på, at der ikke er tilstrækkelig klar lovhjemmel til at stille krav
om, at erhvervsdrivende skal etablere et generelt alderskontrolsystem ved on-
line salg af disse produkter.
Danske Regioner går ind for en målrettet og koordineret forebyggende indsats
på tobaks- og alkoholområdet, og på den baggrund bakker Danske Regioner der-
for op om lovforslaget.
På vegne af Danske Regioner
Thomas I. Jensen
1
Indenrigs- og Sundhedsministeriet
E-mail: sum@sum.dk og cfma@sum.dk.
Høringssvar vedr. Udkast til forslag til lov om ændring af lov om tobaksvarer m.v., lov om elektroniske
cigaretter m.v., lov om forbud mod salg af tobak og alkohol til personer under 18 år og lov om røgfri
miljøer
Danske Tandplejere takker for muligheden for at komme med bemærkninger til ovennævnte høring.
Danske Tandplejere støtter generelt op om alle tiltag og lovændringer, som mindsker brugen af
nikotinholdige produkter af alle slags, da nikotin og indtaget heraf har en yderst skadelig effekt på borgerens
generelle sundhed, herunder også borgernes tandsundhed. Der er blandt andet en markant og signifikant
sammenhæng mellem parodontitis og brug af tobaksprodukter. Parodontitis udvikler sig hurtigere hos
rygere, og succesraten ved behandling er langt ringere hos rygere end hos ikke-rygere. Disse
helbredsmæssige konsekvenser er også gældende for børn og unge, der bruger tobaks- og nikotinholdige
produkter, hvor eksempelvis brugen af snusprodukter har fået antallet af skader på tandkød og den
generelle mundsundhed til at udvikle sig negativt for et stort antal børn og unge.
Danske Tandplejere støtter derfor op om de foreslåede lovændringer og står naturligvis til rådighed, hvis
ovenstående ønskes uddybet.
Venlig hilsen,
Elisabeth Gregersen
Formand, Danske Tandplejere
23. februar 2023
Danske Tandplejere
Rosenborggade 1a
1130 København K
T: 8230 3540
E: info@dansktp.dk
www.dansketandplejere.dk
De Samvirkende Købmænd
Islands Brygge 26 | DK-2300 København S |Tlf. +45 39 62 16 16 | dsk@dsk.dk | www.dsk.dk
CVR nr.15232013 | Danske Bank 4180-4110212313
1
Indenrigs- og Sundhedsministeriet
Sagsnummer 2213653
sum@sum.dk
cfma@sum.dk
København, den 21. februar 2023
Høring over udkast til forslag til lov om ændring af lov om tobaksvarer m.v., lov om elektroniske
cigaretter m.v., lov om forbud mod salg af tobak og alkohol til personer under 18 år og lov om
røgfri miljøer
De Samvirkende Købmænd, DSK, har den 3. februar 2023 modtaget ovennævnte forslag i hø-
ring.
Medlemskredsen omfatter godt 1.500 supermarkeder, discountbutikker, nærbutikker og conveni-
ence. DSK har også samtidig et tæt samarbejde med de to grossister i den frie sektor: Dagrofa
og Reitan Distribution. DSK’s medlemmer beskæftiger samlet set ca. 35.000 ansatte.
Vi takker for muligheden for at afgive kommentarer.
DSK har alene bemærkninger til den del af lovforslaget, der omhandler alderskontrol i fysiske bu-
tikker. Alderskontrol i de fysiske butikker er baseret på, at der skal kræves billedlegitimation, hvis
sælgeren er i tvivl om, hvorvidt kunden er fyldt 16 år hhv. 18 år afhængig af den pågældende
vare.
I praksis er det alene den enkelte kassemedarbejder, der vurderer kundens alder og det medfører
for mange fejl, hvor for unge kunder køber varer som de ellers ikke bør.
En undersøgelse fra HK Handel 2022 viser, at hele 80% af de adspurgte butiksansatte har ople-
vet at blive talt grimt eller nedsættende til af kunder. Når kunderne ikke i tilstrækkelig grad re-
spekterer, at de butiksansatte varetager en jobfunktion med at sikre overholdelse af lovgivning,
får de butiksansatte ikke altid bedt om fremvisning af gyldig billedlegitimation.
Det afspejles da også i adskillige undersøgelser – herunder branchens egne - der konkluderer, at
det lykkes for en stor andel unge at købe alkohol og tobak mv., som de ikke er gamle nok til at
købe.
Det skal der rettes op på. De politisk fastsatte aldersgrænser skal naturligvis overholdes.
Hos DSK vil vi gerne opfordre til, at der udarbejdes et alderskontrolsystem, der ikke kun skal be-
nyttes ved fjernsalg, men som også kan benyttes ved fysisk handel.
I Danmark er vi rigtig gode til brug af nye IT-løsninger. Danmark er faktisk blandt de mest digitali-
serede lande i verden. Det bør vi udnytte ved alderskontrollen, så effektiviteten af lovgivningen
ikke alene afhænger af kassemedarbejderens vurdering, når den butiksansatte er face-to-face
med forbrugeren.
Der er endnu ikke udviklet en 100% effektiv digital løsning, men det er vigtigt, at ”hullerne i osten”
ikke længere får lov til at skygge for de fremskridt som brugen af teknologi kan medvirke til.
2
Digital alderskontrol kan f.eks. ske automatisk, når forbrugeren gennemfører sin betaling elektro-
nisk, hvad enten det er med kort eller telefon ved terminalen. Stregkoden på varen fortæller, hvis
varen er underlagt en salgsaldersgrænse, og hvis forbrugeren ikke er gammel nok til at købe va-
ren, bliver betalingen automatisk afvist.
Det kræver udvikling af en løsning, der ikke er tilgængelig i dag, men som bør være realistisk, da
hvert eneste elektroniske betalingsmiddel er knyttet til en konkret kontohaver.
En digitaliseret løsning bør godkendes af Datatilsynet inden den lanceres. Der må på ingen som
helst måde skabes tvivl om forbrugerbeskyttelsen og en digitaliseret løsning bør udelukkende for-
holde sig til, hvorvidt kunden er gammel nok. Ja eller nej.
Prissætningen – en elektronisk løsning vil ikke være gratis - bør vurderes af Konkurrence- og For-
brugerstyrelsen på lige fod med f.eks. styrelsens overvågning af prissætningen på Dankortet.
Andre digitaliserede kontrolmuligheder end via betalingsmidlet bør ikke udelukkes på forhånd.
Visionen må være, at der tilvejebringes et effektivt alderskontrolsystem, der ikke kun finder an-
vendelse ved markedsføring via fjernsalg, men ligeledes ved fysisk handel. Løsningen er ikke til-
gængelig i dag, men arbejdet bør igangsættes hurtigst muligt under politisk ledelse.
På den baggrund vil vi opfordre til, at der gøres et helhjertet forsøg på at forene såvel dagligvare-
handlen, de butiksansatte, producenterne af de berørte varer, NGO’ere med naturlig interesse for
børn og unges sundhed samt den finansielle sektor til drøftelser om, hvordan alderskontrollen i
de fysiske butikker kan forbedres mærkbart ved brug af en form for digitaliseret løsning.
Supplerende forslag, der skal medvirke til øget beskyttelse af børn og unge:
- Ved handel online, skal kunden inden salget gennemføres utvetydigt tilkendegive, om
kunden er fyldt 16 år hhv. 18 år. En lignende løsning bør tænkes ind i den fysiske handel.
Her kan man f.eks. forestille sig, at det ikke kun er forbudt at sælge til for unge kunder -
det krav skal naturligvis fortsat gælde – men at det også bliver forbudt at erhverve sig pro-
dukter med salgsaldersgrænse, hvis man som kunde ikke er gammel nok. Købsforbuddet
foreslås markedsført med krav om tydelig skiltning, så unge overtræder købsforbuddet,
hvis salgsstedet efterlever krav om tydelig skiltning efter myndighedernes anvisning.
- Der bør indføres et forbud mod såkaldt proxysalg, så man fremadrettet kan få en bøde,
hvis man for eksempel køber tobak eller alkohol på vegne af en mindreårig, hvor der er
sket en økonomisk transaktion, hvor den myndige tager betaling for at købe tobak eller
alkohol mv på vegne af den mindreårige.
Giver vores høringssvar anledning til yderligere, er vi naturligvis til rådighed.
Med venlig hilsen
Claus Bøgelund Nielsen
Vicedirektør
1
Anna Dunø Madsen
Fra: David Luxhøj-Pedersen <dlp@fanet.dk>
Sendt: 9. februar 2023 12:19
Til: Camilla Friborg Madsen; DEP Sundhedsministeriet
Emne: SV: Høring: Udkast til forslag til lov om ændring af lov om tobaksvarer m.v., lov om
elektroniske cigaretter m.v., lov om forbud mod salg af tobak og alkohol til
personer under 18 år og lov om røgfri miljøer
Vedhæftede filer: Signature-20230209111926.txt
Kære Camilla
Finanssektorens Arbejdsgiverforening (FA) takker for høringsmuligheden og har ingen bemærkninger til
lovforslagene.
Med venlig hilsen
David Luxhøj-Pedersen
Advokatfuldmægtig
E: dlp@fanet.dk
M: +45 33 38 16 23
Amaliegade 7
1256 København K
Fra: Camilla Friborg Madsen <CFMA@SUM.DK>
Sendt: 3. februar 2023 09:26
Til: Advoksamfundet <samfund@advokatsamfundet.dk>; info@alkohologsamfund.dk; ac@ac.dk; ka@ka.dk;
Arbejdstilsynet <arbejdstilsynet@at.dk>; Astma-Allergi Forbundet <info@astma-allergi.dk>;
Bsinfo@baggersorensen.com; formand@becig.dk; bkd@blaakors.dk; post@branchedanmark.dk; info_dk@bat.com;
Danske Læskedrik Fabrikanter (info) <info@bryggeriforeningen.dk>; Børnerådet <brd@brd.dk>; bv@bornsvilkar.dk;
kontakt@cfh.ku.dk; forbrugerservice@forbruger.coop.dk; kontakt@dagrofa.dk; Danmarks Apotekerforening
<apotekerforeningen@apotekerforeningen.dk>; farmaceutiske-selskab@pharmadanmark.dk; info@lunge.dk;
Danmarks Restauranter og Cafeer <drc@thehost.dk>; da@da.dk; formand@dadafo.dk; Dansk Erhverv (info)
<info@danskerhverv.dk>; Emballageindustrien <hoering@di.dk>; dls.dlsoffice@gmail.com;
Helen.gerdrup.nielsen@regionh.dk; dsam@dsam.dk; psykiatri@regionh.dk; administration@dsff.dk;
info@patientsikkerhed.dk; support@bilka.dk; dsr@dsr.dk; Dansk Transport og Logistik (DTL) <dtl@dtl.eu>;
fysio@fysio.dk; kontakt@dgsnet.dk; dh@handicap.dk; info@danskepatienter.dk; Danske Regioner
<regioner@regioner.dk>; info@danske-seniorer.dk; dse@skoleelever.dk; info@dansktp.dk; info@danske-
aeldreraad.dk; Post@dataetiskraad.dk; Datatilsynet <dt@datatilsynet.dk>; dsk@dsk.dk;
dommerforeningen@gmail.com; Det Etiske Råd kontakt <kontakt@etiskraad.dk>; Diabetesforeningen
<info@diabetes.dk>; sales@efuma.com; kontakt@eeo.dk; foa@foa.dk; fh@fho.dk; hero@fho.dk; bla@fho.dk;
EUI@fho.dk; Faglig Fælles Forbund 3F <3f@3f.dk>; ff@farmakonom.dk; Finanssektorens Arbejdsgiverforening
<fa@fanet.dk>; 1 - KFST Forbrugerombudsmanden (KFST) <FO@Forbrugerombudsmanden.dk>; 1 - KFST
Forbrugerombudsmanden (KFST) <FO@Forbrugerombudsmanden.dk>; Forbrugerrådet <hoeringer@fbr.dk>;
hf@fadl.dk; fas@dadl.dk; kontakt@fdih.dk; info@fpmdk.dk; hs@fpmdk.dk; fp@fogp.dk; mal@fogp.dk;
himr@himr.fo; Gigtforeningen <info@gigtforeningen.dk>; Hjerteforeningen <post@hjerteforeningen.dk>;
2
horesta@horesta.dk; info@oliver-twist.dk; oliver-twist@oliver-twist.dk; info@igldk.dk; info.dk@jti.com;
sek@jordemoderforeningen.dk; national@kfum-kfuk.dk; kk@kirkenskorshaer.dk; kfs@sundkom.dk; Kommunernes
Landsforening <KL@KL.DK>; Kræftens Bekæmpelse <info@cancer.dk>; los@los.dk; lh@handelselever.dk; lo@lo.dk;
Lægeforeningen <dadl@dadl.dk>; Brancheforeningen for Lægemiddelvirksomheder i Danmark (LIF) <info@lif.dk>;
medico@medicoindustrien.dk; ungdom@danskmetal.dk; cach@danskmetal.dk;
moedrehjaelpen@moedrehjaelpen.dk; govsec@nanoq.gl; NVK Kontakt <kontakt@nvk.dk>; DKetik
Institutionspostkasse <DKetik@DKetik.dk>; isf@nikotinbranchen.dk; Nærbutikkernes Landsforening <info@nbl-
landsforening.dk>; nnf@nnf.dk; Offentligt Ansattea Organisationer <oao@oao.dk>; info@pfldk.dk;
medlem@patientforeningen.dk; njl@patientforeningen.dk; info@patientforeningen-danmark.dk;
pd@pharmadanmark.dk; info@pharmakon.dk; christoffer.arzrouni@pmi.com; Pmaps@pmi.com; plo@dadl.dk;
pto@pto.dk; info@rigsrevisionen.dk; kontakt@roegfrifremtid.dk; Rådet for Socialt Udsatte <post@udsatte.dk>;
post@skole-foraeldre.dk; Jeanett@SMOKE-IT.dk; Jens@SMOKE-IT.dk; support@gejser.dk;
info@smokesolution.com; benny.husted@ssp-samraadet.dk; post@sundbynetvaerket.dk;
info@sundheddanmark.nu; shk@sundhedskartellet.dk; silkeborg@swedishmatch.com; info@sygeforsikring.dk;
info@tandlaegeforeningen.dk; jh@tobaksindustrien.dk; info@tobaksproducenterne.dk; info@vinordic.org;
aeldresagen@aeldresagen.dk; yl@dadl.dk
Emne: Høring: Udkast til forslag til lov om ændring af lov om tobaksvarer m.v., lov om elektroniske cigaretter m.v.,
lov om forbud mod salg af tobak og alkohol til personer under 18 år og lov om røgfri miljøer
Til alle høringsparter
Se venligst vedhæftede høring over udkast til forslag til lov om ændring af lov om tobaksvarer m.v., lov om
elektroniske cigaretter m.v., lov om forbud mod salg af tobak og alkohol til personer under 18 år og lov om røgfri
miljøer (Implementering af dele af delegeret direktiv vedrørende opvarmede tobaksvarer samt andre præciseringer
og tekniske justeringer)
Indenrigs- og Sundhedsministeriet skal anmode om at modtage eventuelle bemærkninger til udkastet senest
mandag d. 6. marts 2023 kl. 12.
Bemærkninger bedes sendt til sum@sum.dk og til cfma@sum.dk.
Camilla Friborg Madsen
Fuldmægtig, Kontor for Forebyggelse og Strålebestyttelse
M 21 67 75 18
@ cfma@sum.dk
Indenrigs- og Sundhedsministeriet
Tlf. 7226 9000
Læs ministeriets datapolitik her
www.sum.dk
______________________________________________________________________________________
Galten, d. 1. marts 2023
GEjSER ApS - Erhvervsparken Klank 3 - 8464 Galten | Tlf. 26220707 | www.gejser.dk | CVR 32337260
Til Indenrigs- og Sundhedsministeriet
Høringssvar vedr.: Udkast til forslag til lov om ændring af lov om tobaksvarer m.v., lov om elektroniske
cigaretter m.v., lov om forbud mod salg af tobak og alkohol til personer under 18 år og lov om røgfri miljøer
(Implementering af dele af delegeret direktiv vedrørende opvarmede tobaksvarer samt andre
præciseringer og tekniske justeringer)
Først og fremmest ønsker GEjSER at takke for muligheden for at kommentere på fremsendte lovforslag.
Det glæder os, at Indenrigs- og Sundhedsministeriets har et ønske om at tydeliggøre hvilke krav der skal
stilles til alderskontrol, henholdsvis på fysiske salgssteder og ved salg online i forbindelse med salg af
elektroniske cigaretter og tilbehør. Vi mener dog, at der bør foretages ensrettede og mere konkrete
ændringer, som tydeliggør hvilke specifikke krav der stilles i forbindelse med aldersverificering, og særligt
for online-salgssteder.
I GEjSER bakker vi op om De Samvirkende Købmænds forslag om elektronisk aldersverificering via.
betalingskort1
, og vi er overbeviste om, at denne løsning især vil kunne forhindre salg af nikotinprodukter til
børn og unge via. online-salgssteder. Derfor har vi naturligvis et håb om, at Indenrigs- og
Sundhedsministeriet vil have løsningen med i overvejelserne, så ensretning for samtlige online-salgskanaler
opnås. Vi mener der er behov for konkrete løsninger og yderligere præcisering på området, og her er
elektronisk aldersverificering via. betalingskort et godt bud.
Vi anerkender, at der kan opstå tvivl i forbindelse med kontant-betalinger i forbindelse med salg på fysiske
salgssteder, og derfor er det også glædeligt, at præciseringen vedr. krav om anmodning om fremvisning af
gyldig billedlegitimation, hvis en ekspedient er i tvivl om en kundes alder, fremgår i lovforslaget.
Vi håber at Indenrigs- og Sundhedsministeriet vil tage GEjSER’s forslag og betragtninger med i
viderebehandlingen af lovforslaget, og vi takker endnu engang for muligheden for at få lov til at dele dem
med jer.
1
https://www.berlingske.dk/danmark/koebmaend-alderstjek-via-kreditkort-kan-hindre-salg-af-nikotinprodukter
Med venlig hilsen
Jeanett Andersen
Kommunikationsansvarlig
GEjSER ApS
Erhvervsparken Klank 3, DK-8464 Galten
CVR / VAT DK32337260
+45 25 63 14 14
jeanett@gejser.dk
www.gejser.dk
Dato:
01. 03. 2023
Direkte tlf.: 51 28 22 43
E-mail:tcmoerch@hjerteforeningen.dk
Indenrigs- og Sundhedsministeriet har den 3. februar 2023 fremsendt udkast til:
Forslag til lov om ændring af lov om tobaksvarer m.v., lov om elektroniske cigaretter m.v., lov om
forbud mod salg af tobak og alkohol til personer under 18 år og lov om røgfri miljøer (Implementering
af dele af delegeret direktiv vedrørende opvarmede tobaksvarer samt andre præciseringer og tekniske
justeringer)
Hjerteforeningen takker for muligheden for at kommentere forslaget om tilbagetrækning af undtagelser vedr.
forbud mod smagsstoffer for opvarmet tobak samt andre præciseringer herunder lovhjemmel til aldersgrænser
ved onlinesalg af tobak og alkohol.
Smagsstoffer til opvarmet tobak
Hos Hjerteforeningen er vi positivt indstillede over for, at der ikke må tilsættes smagsstoffer til opvarmet
tobak. Tobak udgør den største enkeltstående risikofaktor for udviklingen af hjertesygdomme. Vidensråd for
Forebyggelse konkluderer i en rapport fra 2022 om nikotinbrug blandt børn og unge, at der er stærk evidens
for nikotins skadelige virkning på hjerte og kar, samt at der er større risiko for død ved eksisterende
hjertesygdom/blodprop ved brug af nikotinholdige produkter. I litteraturen finder Vidensråd for Forebyggelse
at en sammenhæng mellem tidlig udsættelse for nikotin og senere hjerte-kar-sygdom er sandsynlig. Det
konkrete niveau for den øgede risiko for udvikling af hjerte-kar-sygdom kan ikke angives. Udviklingen af nye
tobaks- og nikotinprodukter går hurtigt, og derfor er det nødvendigt at lovgivningen bliver tilpasset den
udvikling, vi ser på markedet.
Ifølge WHO er der ikke evidens for, at opvarmet tobak er mindre skadeligt end andre former for tobak. Derfor
er anbefalingerne, i henhold til WHO’s rammekonvention om tobakskontrol, som Danmark og EU har
ratificeret, at opvarmet tobak reguleres på samme måder som cigaretter.
Vi mener, at forbuddet mod smagsstoffer skal udvides, så det dækker alle typer af tobaksprodukter. Dertil er
det også vigtigt, at smagsstofferne bliver forbudt som ingredienser, og ikke som ”kendetegnende aromaer”, så
der ikke opstår usikkerhed om, hvor meget smag der må indgå i produktet.
Indenrigs- og Sundhedsministeriet
Slotsholmsgade 10-12 – 1216 København K
E-mail: sum@sum.dk
Side 2 af 2
Hjerteforeningen støtter, at opvarmet tobak fremover omfattes af samme forbud mod smagsstoffer, som gør
sig gældende for cigaretter, og det er særligt vigtigt, da smagsstofferne gør produkterne mere tiltrækkende for
børn og unge.
Onlinesalg af tobak og lignende produkter skal ikke være lovligt
Ved online salg af tobak, urtebaserede rygeprodukter, tobakssurogater og e-cigaretter, vil der med lovforslaget
blive indført lovhjemmel til at stille krav om alderskontrol. Det er vi positivt indstillede overfor, men det er
ikke tilstrækkeligt. Det er alt for nemt for forhandlere at indføre et skema, hvor forbrugeren siger ja til, at
vedkommende er over 18. Som det fremgår af lovforslaget, bliver der først stillet krav til forhandlerne om at
sikre et system, der effektivt verificerer køberens alder, når det kan sikres, ”at den rette tilgængelige løsning
til et effektivt alderskontrolsystem kan implementeres hos forhandlerne”.
Vi mener, at det ikke skal være tilladt at sælge tobak og lignende produkter online, da vi den vej igennem kan
mindske tilgængeligheden og markedsføring af de skadelige produkter for børn og unge.
Effektiv alderskontrol ved onlinesalg af alkohol
Det er en god udvikling, at der med lovforslaget bliver rettet op på den manglende lovhjemmel ift.
aldersgrænser for onlinesalg af alkohol. Men da der heller ikke her stilles krav om, at kontrolsystemet for alder
skal være effektivt, godkender lovgivningen på en måde den nuværende fremgangsmåde, hvor forbrugeren
kan afkrydse, om vedkommende er fyldt hhv. 16 eller 18 år. Det nuværende alderskontrolsystem er derfor ikke
tilstrækkeligt, da det stadig muliggør onlinesalg af alkohol til børn og unge.
Hjerteforeningen mener desuden, at der bør indføres en aldersgrænse på 18 år for køb af alle typer af alkohol.
Det er også i overensstemmelse med Sundhedsstyrelsens anbefalinger, hvori børn og unge under 18 år frarådes
at drikke alkohol.
Med venlig hilsen
Anne Kaltoft
Adm. direktør
Side 2
Strandboulevarden 49, B-8 : DK-2100 København Ø : T +45 38 74 55 44 : info@lunge.dk : www.lunge.dk :
www.facebook.com/lungeforeningen
Indenrigs- og Sundhedsministeriet
Holbergsgade 6
1057 København K
Høringssvar vedr. implementering af direktiv vedr. opvarmede tobaksvarer samt andre præciseringer,
herunder alderskrav ved online salg af tobak og alkohol
Lungeforeningen takker for muligheden for at kommentere på lovforslaget.
Opvarmet tobak skal reguleres på linje med cigaretter og anden tobak
Vi er i Lungeforeningen positive over for, at der lægges op til, at opvarmet tobak omfattes af samme forbud
mod smagsstoffer som cigaretter. Mentol og andre aromaer gør produkterne mere tiltrækkende for særligt
børn og unge og bør derfor forbydes. Vi mener også, at smagsstofferne fremover bør udvides til at gælde
for alle typer af tobaksprodukter.
Tobak er hvert år årsag til mere end 13.600 dødsfald i Danmark, og for flere lungesygdomme er rygning
årsagen til hovedparten af tilfældene, herunder lungesygdommen KOL, hvor ca. 9 ud af 10 tilfælde skyldes
rygning. Der kommer hele tiden nye tobaks- og nikotinprodukter på markedet, og derfor er det vigtigt, at
lovgivningen hele tiden tilpasses. WHO anbefaler, at opvarmet tobak reguleres på samme måde som
cigaretter og anden tobak og derfor er det godt, at loven tilpasses i overensstemmelse hermed.
Onlinesalg bør helt forbydes
Med lovforslaget indføres lovhjemmel til at stille krav om alderskontrol ved onlinesalg af tobak,
urtebaserede rygeprodukter, tobakssurrogater og e-cigaretter.
Vi finder det positivt, at der indføres lovhjemmel, men vi kan godt frygte om det er nok, da forhandlerne
blot kan vælge at lade forbrugere krydse af, at de er over 18 år. Langt mere oplagt ville det være at forbyde
onlinesalg af tobak og lignende produkter, som WHO anbefaler. Det vil gøre tobak mindre tilgængeligt for
især børn og unge.
Vi bidrager gerne yderligere
Skulle vores høringssvar medføre spørgsmål eller ønske om yderligere drøftelse, står vi naturligvis til
rådighed.
Med venlig hilsen
Anne Brandt
Direktør i Lungeforeningen
● ●
Indenrigs- og Sundhedsministeriet
Sagsnr.: 2213653
Dok. nr.: 2523532
sum@sum.dk
cfma@sum.dk
marts 2023
Udkast til forslag til lov om ændring af lov om tobaksvarer (Implementering af dele
af delegeret direktiv vedrørende opvarmede tobaksvarer m.m.)
Nikotinbranchen kvitterer for muligheden for at kommentere "Udkast til forslag til lov om ændring
af lov om tobaksvarer m.v., lov om elektroniske cigaretter m.v., lov om forbud mod salg af tobak og
alkohol til personer under 18 år og lov om røgfri miljøer (Implementering af dele af delegeret
direktiv vedrørende opvarmede tobaksvarer samt andre præciseringer og tekniske justeringer)” –
herefter benævnt ”forslaget”.
Nikotinbranchens medlemmer producerer ikke opvarmet tobak – herefter benævnt ”THP”
(tobacco heating products), men vi finder det aktuelt at kommentere på forslaget, da det
overordnet vedrører regulering af røgfrie nikotinprodukter per se og i sammenligning med
reguleringen for cigaretter/røgtobak.
Forslagets indhold
Dette delegerede direktiv rummer disse for Nikotinbranchen relevante elementer:
Der lægges op til, at sælgere af tobak og alkohol skal kunne kræve forevisning af billedlegitimation,
hvis der er tvivl om købers alder. Denne del af forslaget er relevant for Nikotinbranchen, fordi salg
af røgfrie nikotinprodukter til mindreårige er et problem.
Det vil fjerne den hidtil gældende undtagelse for THP i forhold til forbuddet om brug af
”kendetegnende aromaer” i produkterne.
Kommenterede delelementer
ID-kontrol
Det er positivt, at man med forslaget sikrer en tilstrækkelig tydelig hjemmel for krav om
alderskontrolsystem ved salg fra hjemmesider, men det er efter Nikotinbranchens opfattelse
bekymrende at der endnu ikke er taget konkrete skridt for indførsel af krav om ID-kontrol både ved
salg fra fysiske butikker og hjemmesider.
Dels ved vi, at alt for mange børn og unge har adgang til at købe nikotinprodukter i butikker trods
eksisterende aldersgrænse og skiltning herom, dels bliver det i for stort omfang alene den
● ●
individuelle ekspedients ansvar at bede om og kontrollere ID, og det er ikke en rimelig opgave at
pålægge personalet i detailhandlen.
En del nikotinprodukter forhandles via nettet, og vi finder det derfor oplagt, at man har
symmetriske regler online såvel som i fysiske butikker. Det kunne f.eks. ske ved, at man ved online
køb ikke alene skal klikke af, at man er over 18 år, men også mødes af tofaktorgodkendelse i form af
krav om aldersverifikation med digital ID.
I fysiske butikker kunne løsningen bestå af automatisk data i elektronisk betalingssammenhæng.
Nikotinbranchen foreslår, at man fra myndighedernes side etablerer en samlet plan for at
nedbringe salget af nikotinprodukter til personer under 18 år såvel i fysiske butikker som på
internettet. Nikotinbranchen bidrager gerne med input og viden om det illegale salg fra
medlemmernes complianceindsats.
Kendetegnende aromaer og manglende differentiering mellem produktkategorier
Nikotinbranchen betragter forslaget om forbud mod kendetegnende aromaer i THP som
problematisk i sin principielle tilgang, da det sidestiller THP og cigaretter for så vidt angår kravet
om, at kendetegnende aromaer ikke må findes i såvel THP som cigaretter/røgtobak.
Det er grundlæggende problematisk at regulere cigaretter og traditionelle tobaksvarer på samme
vis som røgfrie nikotinprodukter – herunder THP – idet produkterne er væsensforskellige for så
vidt angår skadesvirkninger for den enkelte, gener og potentielle sundhedsrisici for omgivelserne
og samfundsomkostningerne i forlængelse af brugen af produkterne.
Kendetegnende aromaer og smag er en for mange brugere afgørende forskel og incitament til at
skifte fra cigaretter til røgfrie produkter som THP, e-cigaretter og nikotinposer.
Skadesreduktion
Rygning koster hvert år 13.600 danske liv. Antallet af rygere ligger stabilt med en let opadgående
tendens trods års indsats i form af oplysning, forbud og stigende afgifter.
Med nikotinposers entré på det danske marked i 2019 faldt antallet af rygere, og det understøtter
opfattelsen af røgfrie nikotinprodukters rolle som en realistisk vej væk fra cigaretterne for mange
rygere.
I Sverige har man kendt til snus som røgfrit nikotinprodukt i årtier, og her er man tæt på at nå den
fælles europæiske målsætning om maks. 5 pct. daglige rygere. Det er på tide i Danmark at tage ved
lære af Sverige, men også lande som Storbritannien og New Zealand, hvor man regulerer røgtobak
hårdt, men går på to ben og anerkender røgfrie nikotinprodukters skadesreducerende potentiale.
Reguleringen af cigaretter/røgtobak og røgfrie nikotinprodukter bør afspejle væsensforskellene
mellem kategorierne og give incitament for rygere til at skifte fra røg til røgfri. Det kan bl.a. ske ved
at fastholde, at forbuddet mod kendetegnende aromaer gælder for cigaretter men ikke for røgfrie
alternativer.
Indstilling
● ●
Nikotinbranchen forstår Danmarks forpligtelse til at implementere EU-lovgivningen i dansk ret,
men vil alligevel opfordre til, at Danmark i EU-regi fordrer en evidensbaseret tilgang til
skadesreduktion og de folkesundhedsmæssige gevinster, der er at hente i anerkendelsen heraf.
Nikotinbranchen står til rådighed for drøftelser med myndigheder og lovgivere.
Med venlig hilsen
Inger Schroll-Fleischer, direktør
Nikotinbranchen
Udkast til forslag til lov om ændring af lov om tobaksvarer (Implementering af dele af delegeret
direktiv vedrørende opvarmede tobaksvarer m.m.)
Vi skal hermed afgive høringssvar om ændring af lov om tobaksvarer med henblik på at implementere det
delegerede direktiv vedrørende opvarmede tobaksvarer.
Vi synes det et en dårlig ide at forbyde smage i opvarmede tobaksvarer. Smagene er vigtige elementer i at
få rygere til at kvitte cigaretter og vælge et mindre skadeligt produkt, såsom opvarmet tobak. Dermed
mener vi, at det nye forbud vil få skadelige konsekvenser for folkesundheden, idet færre rygere vil have
incitament til at forlade cigaretterne til fordel for røgfri tobaksprodukter.
Vi konstaterer dog, at implementeringen af det delegerede direktiv holder sig inden for de rammerne af
vedtagelserne på EU-niveau. Og vi lægger vægt på, at man sondrer mellem tobaksvarer, der er
røgprodukter (med forbrænding) og tobaksvarer, der er røgfri (uden forbrænding).
Med venlig hilsen
Jesper Lundberg
formand
Orøvej 8
3400 Holbæk
Mobil: + 45 2889 1017
E-mail: jl@nbl-landsforening.dk
Website: www.nbl-landsforening.dk
Følg os på Facebook og LinkedIn
1
Anna Dunø Madsen
Fra: Niels Jørgen Langkilde - Patientforeningen <njl@patientforeningen.dk>
Sendt: 15. februar 2023 20:48
Til: Camilla Friborg Madsen; DEP Sundhedsministeriet
Emne: SV: Høring: Udkast til forslag til lov om ændring af lov om tobaksvarer m.v., lov om
elektroniske cigaretter m.v., lov om forbud mod salg af tobak og alkohol til
personer under 18 år og lov om røgfri miljøer
Til Indenrigs- og Sundhedsministeriet
Att: Camilla Friborg Madsen
Alene sendt på sum@sum.dk og cfma@sum.dk
Patientforeningen takker for muligheden for at kommentere på lovforslaget om ændring af Lov om tobaksvarer
mmm.
Patientforeningen har ingen kommentarer til lovforslaget, og Patientforeningen kan anbefale, at det fremsættelse.
De bedste hilsener
Mag. art. Niels Jørgen Langkilde, fhv. MF,
Formand,
Patientforeningen,
Rishøjvej 2, 2. sal th
5672 Broby
For at beskytte dine personlige oplysninger har Microsoft Office forhindret automatisk hentning af dette billede fra internettet.
Tlf. +45 20 96 70 00
www.patientforeningen.dk
CVR.nr.: 30011538
For et frit læge- og sygehusvalg
Fra: Camilla Friborg Madsen <CFMA@SUM.DK>
Sendt: 3. februar 2023 09:26
2
Til: Advoksamfundet <samfund@advokatsamfundet.dk>; info@alkohologsamfund.dk; ac@ac.dk; ka@ka.dk;
Arbejdstilsynet <arbejdstilsynet@at.dk>; Astma-Allergi Forbundet <info@astma-allergi.dk>;
Bsinfo@baggersorensen.com; formand@becig.dk; bkd@blaakors.dk; post@branchedanmark.dk; info_dk@bat.com;
Danske Læskedrik Fabrikanter (info) <info@bryggeriforeningen.dk>; Børnerådet <brd@brd.dk>; bv@bornsvilkar.dk;
kontakt@cfh.ku.dk; forbrugerservice@forbruger.coop.dk; kontakt@dagrofa.dk; Danmarks Apotekerforening
<apotekerforeningen@apotekerforeningen.dk>; farmaceutiske-selskab@pharmadanmark.dk; info@lunge.dk;
Danmarks Restauranter og Cafeer <drc@thehost.dk>; da@da.dk; formand@dadafo.dk; Dansk Erhverv (info)
<info@danskerhverv.dk>; Emballageindustrien <hoering@di.dk>; dls.dlsoffice@gmail.com;
Helen.gerdrup.nielsen@regionh.dk; dsam@dsam.dk; psykiatri@regionh.dk; administration@dsff.dk;
info@patientsikkerhed.dk; support@bilka.dk; dsr@dsr.dk; Dansk Transport og Logistik (DTL) <dtl@dtl.eu>;
fysio@fysio.dk; kontakt@dgsnet.dk; dh@handicap.dk; info@danskepatienter.dk; Danske Regioner
<regioner@regioner.dk>; info@danske-seniorer.dk; dse@skoleelever.dk; info@dansktp.dk; info@danske-
aeldreraad.dk; Post@dataetiskraad.dk; Datatilsynet <dt@datatilsynet.dk>; dsk@dsk.dk;
dommerforeningen@gmail.com; Det Etiske Råd kontakt <kontakt@etiskraad.dk>; Diabetesforeningen
<info@diabetes.dk>; sales@efuma.com; kontakt@eeo.dk; foa@foa.dk; fh@fho.dk; hero@fho.dk; bla@fho.dk;
EUI@fho.dk; Faglig Fælles Forbund 3F <3f@3f.dk>; ff@farmakonom.dk; fa@fanet.dk; 1 - KFST
Forbrugerombudsmanden (KFST) <FO@Forbrugerombudsmanden.dk>; 1 - KFST Forbrugerombudsmanden (KFST)
<FO@Forbrugerombudsmanden.dk>; Forbrugerrådet <hoeringer@fbr.dk>; hf@fadl.dk; fas@dadl.dk;
kontakt@fdih.dk; info@fpmdk.dk; hs@fpmdk.dk; fp@fogp.dk; mal@fogp.dk; himr@himr.fo; Gigtforeningen
<info@gigtforeningen.dk>; Hjerteforeningen <post@hjerteforeningen.dk>; horesta@horesta.dk; info@oliver-
twist.dk; oliver-twist@oliver-twist.dk; info@igldk.dk; info.dk@jti.com; sek@jordemoderforeningen.dk;
national@kfum-kfuk.dk; kk@kirkenskorshaer.dk; kfs@sundkom.dk; Kommunernes Landsforening <KL@KL.DK>;
Kræftens Bekæmpelse <info@cancer.dk>; los@los.dk; lh@handelselever.dk; lo@lo.dk; Lægeforeningen
<dadl@dadl.dk>; Brancheforeningen for Lægemiddelvirksomheder i Danmark (LIF) <info@lif.dk>;
medico@medicoindustrien.dk; ungdom@danskmetal.dk; cach@danskmetal.dk;
moedrehjaelpen@moedrehjaelpen.dk; govsec@nanoq.gl; NVK Kontakt <kontakt@nvk.dk>; DKetik
Institutionspostkasse <DKetik@DKetik.dk>; isf@nikotinbranchen.dk; Nærbutikkernes Landsforening <info@nbl-
landsforening.dk>; nnf@nnf.dk; Offentligt Ansattea Organisationer <oao@oao.dk>; info@pfldk.dk; Medlem -
Patientforeningen <medlem@patientforeningen.dk>; Niels Jørgen Langkilde - Patientforeningen
<njl@patientforeningen.dk>; info@patientforeningen-danmark.dk; pd@pharmadanmark.dk; info@pharmakon.dk;
christoffer.arzrouni@pmi.com; Pmaps@pmi.com; plo@dadl.dk; pto@pto.dk; info@rigsrevisionen.dk;
kontakt@roegfrifremtid.dk; Rådet for Socialt Udsatte <post@udsatte.dk>; post@skole-foraeldre.dk;
Jeanett@SMOKE-IT.dk; Jens@SMOKE-IT.dk; support@gejser.dk; info@smokesolution.com; benny.husted@ssp-
samraadet.dk; post@sundbynetvaerket.dk; info@sundheddanmark.nu; shk@sundhedskartellet.dk;
silkeborg@swedishmatch.com; info@sygeforsikring.dk; info@tandlaegeforeningen.dk; jh@tobaksindustrien.dk;
info@tobaksproducenterne.dk; info@vinordic.org; aeldresagen@aeldresagen.dk; yl@dadl.dk
Emne: Høring: Udkast til forslag til lov om ændring af lov om tobaksvarer m.v., lov om elektroniske cigaretter m.v.,
lov om forbud mod salg af tobak og alkohol til personer under 18 år og lov om røgfri miljøer
Til alle høringsparter
Se venligst vedhæftede høring over udkast til forslag til lov om ændring af lov om tobaksvarer m.v., lov om
elektroniske cigaretter m.v., lov om forbud mod salg af tobak og alkohol til personer under 18 år og lov om røgfri
miljøer (Implementering af dele af delegeret direktiv vedrørende opvarmede tobaksvarer samt andre præciseringer
og tekniske justeringer)
Indenrigs- og Sundhedsministeriet skal anmode om at modtage eventuelle bemærkninger til udkastet senest
mandag d. 6. marts 2023 kl. 12.
Bemærkninger bedes sendt til sum@sum.dk og til cfma@sum.dk.
Camilla Friborg Madsen
Fuldmægtig, Kontor for Forebyggelse og Strålebestyttelse
M 21 67 75 18
3
@ cfma@sum.dk
Indenrigs- og Sundhedsministeriet
Tlf. 7226 9000
Læs ministeriets datapolitik her
www.sum.dk
Indenrigs- og Sundhedsministeriet
Sagsnr.: 2213653
Dok. nr.: 2523532
sum@sum.dk
cfma@sum.dk
København den 21. februar 2023
Udkast til forslag til lov om ændring af lov om tobaksvarer (Implementering af dele af delegeret direktiv
vedrørende opvarmede tobaksvarer m.m.)
Vi takker for muligheden for at kommentere "Udkast til forslag til lov om ændring af lov om tobaksvarer
m.v., lov om elektroniske cigaretter m.v., lov om forbud mod salg af tobak og alkohol til personer under 18
år og lov om røgfri miljøer (Implementering af dele af delegeret direktiv vedrørende opvarmede
tobaksvarer samt andre præciseringer og tekniske justeringer)” – herefter omtalt som “Forslaget”.
Med dette forslag gennemfører Danmark Kommissionens delegerede direktiv (EU) 2022/2100 af 29. juni
2022 om ændring af Europa-Parlamentets og Rådets direktiv 2014/40/EU (TPD) med hensyn til
tilbagetrækning af visse undtagelser for opvarmede tobaksvarer (det delegerede direktiv).
Lovens indhold
Gennemførelsen af dette delegerede direktiv vil fjerne den undtagelse, som har været gældende for
opvarmede tobaksvarer, i forhold til forbuddet mod at bruge kendetegnede aromaer.
Desuden vil det påbyde brugen af kombinerede sundhedsadvarsler og den generelle
informationsmeddelelse i henhold til art. 9 og 10 i TPD for de opvarmede tobaksprodukter, der er blevet
klassificeret som tobaksvarer til rygning i overensstemmelse med art. 2(5) TPD.
Vigtige juridiske hensyn
Gennemførelse af det delegerede direktiv skal ske i overensstemmelse med art. 114 TEUF og må ikke
resultere i en forvridning af det indre marked eller en krænkelse af Acquis Communautaire generelt. Dette
indebærer, at den nationale lovgivning klart skal skelne mellem mærkningsreglerne for opvarmede
tobaksprodukter, der ikke involverer en forbrændingsproces, og dem, der er klassificeret som tobak til
rygning. Førstnævnte vil skulle anvende sundhedsadvarsler i henhold til art. 12 TPD, mens sidstnævnte skal
overholde art. 9 og 10 i TPD i denne henseende.
Vi noterer os Danmarks hensigt om at gennemføre det delegerede direktiv inden for de retlige rammer for
Acquis Communautaire og derfor alene kræve kombinerede sundhedsadvarsler for de opvarmede
tobaksprodukter, der er klassificeret som rygetobak og involverer en forbrændingsproces:
”Endvidere medfører det delegerede direktiv en ændring af artikel 11, stk. 1, i tobaksvaredirektivet, således
opvarmede tobaksvarer, for så vidt de er røgtobak, fremover ikke kan undtages fra bestemmelserne om
påføring af den informationsmeddelelse, der er fastsat i artikel 9, stk. 2, i tobaksvaredirektivet og de
kombinerede sundhedsadvarsler, der er fastsat i artikel 10 i tobaksvaredirektivet (Forslagets side 7)
Forslaget fremmer desværre ikke folkesundheden
Med hensyn til tilsætningsstoffer vil gennemførelsen af det delegerede direktiv føre til en sidestilling af
reguleringen for opvarmede tobaksprodukter med brændbare tobaksprodukter såsom cigaretter og
finskårne tobaksprodukter.
Selvom denne regulering er resultatet af et krav i TPD efter en "væsentlig ændring i forholdene" i
betydningen af art. 2 (28) TPD, er det imidlertid en udvikling, der ikke vil gavne folkesundheden.
Sundhedsministeriet giver udtryk for, at det delegerede direktivs gennemførelse vil gøre "opvarmede
tobaksvarer mindre attraktive og, for så vidt de opvarmede tobaksvarer er røgtobak, at gøre forbrugere
mere opmærksomme på de sundhedsrisici, der er forbundet med at anvende opvarmede tobaksvarer. Det
vurderes, at direktivet således vil bidrage til at begrænse forbruget af opvarmede tobaksvarer, herunder at
børn og unge indleder et forbrug.” (Forslagets side 7)
I den forbindelse vil vi gerne påpege, at der ifølge Eurobarometer-data stort set ingen, der påbegynder et
nikotinforbrug via opvarmede tobaksvarer – ligesom kun få påbegynder nikotinforbrug via e-cigaretter1
.
Nationale undersøgelser i EU bekræfter dette resultat2
.
Vi henviser i øvrigt til præsentationen af ”Vidensråd for Forebyggelse” i Folketingets sundhedsudvalg den
10. juni 2021, hvor det blev oplyst, at kun 0,7 pct. af unge rygere er blevet introduceret til nikotin gennem
opvarmet tobak3
.
For opvarmede tobaksvarer understøttes denne vurdering af den seneste rapport fra Europa-
Kommissionen om en væsentlig ændring i forholdene for opvarmede tobaksvarer. Rapporten: "did not
identify an increase of the level of prevalence of use in the under 25 years of age consumer group by at least
five percentage points in at least five Member States for heated tobacco products”4
.
1
Eurobarometer Special Report 506, p. 97.
2
I Tyskland er andelen af unge, der bruger opvarmede tobaksprodukter 0,3 %, ifølge tal fra det tyske føderale center
for sundhedsuddannelse (BZgA), se:
https://www.bzga.de/fileadmin/user_upload/PDF/pressemitteilungen/daten_und_fakten/Info-
Blatt_01._Juli_2020.pdf
For e-cigaretter er denne andel 0,5 % i Tyskland, ifølge de seneste tal fra DEBRA-undersøgelsen fra Kölns Universitet,
se: https://www.debra-study.info/wp-content/uploads/2022/02/Factsheet-07-v5.pdf
3
(https://www.ft.dk/samling/20201/almdel/SUU/bilag/475/2415957.pdf
4
COM(2022) 279 final: Report from the Commission on the establishment of a substantial change of circumstances for
heated tobacco products in line with Directive 2014/40/EU – se:
Dette viser, at alternativer til cigaretter for det meste anvendes af voksne rygere og ikke af mindreårige
eller ikke-rygere. Desværre vil forbuddet mod kendetegnende aromaer i opvarmede tobaksvarer
sandsynligvis gøre det mindre oplagt for voksne rygere at skifte til disse produkter, hvilket vi vil uddybe
yderligere nedenfor.
Brug for tobaksskadereduktion og differentieret regulering
Den bedste måde at undgå skaderne ved rygning er, at man aldrig begynder, eller at eksisterende rygere
holder op. Men virkeligheden er, at mange ikke opfører sig sådan.
Det er vores opfattelse, at de mennesker, som ellers ville fortsætte med at ryge, fortjener en pragmatisk
tilgang og en fornuftig løsning, der flytter dem væk fra brugen af cigaretter, som er den mest skadelige
måde at forbruge nikotin på ifølge videnskaben.
Europa-Kommissionen påpeger, at 700.000 europæere dør for tidligt af rygning årligt5
. I Danmark er dette
tal 13.600.
Den eneste måde at nedbringe dette tal er at gennemføre regulering, der fremskynder ophøret af rygning.
Der er stærke uafhængige internationale beviser for skadesreduktion indenfor tobak. Derfor bør rygestop
fremskyndes ved at gøre brug af de positive erfaringer med skadesreduktion.
Tilskyndelser til rygestop fremmes bedst ved hjælp af en differentieret regulering baseret på
skadevirkningerne forårsaget af tobaks- og nikotinholdige produkter i forhold til deres toksicitet.
Her må det være tilsynsmyndighedernes primære mål at reducere cigaretternes tiltrækningskraft (ved at
fremme ikke-initiering og tilskynde til ophør), idet cigaretterne er den mest skadelige måde at levere
nikotin på.
Samtidig bør voksne rygere, som ellers ville fortsætte med at ryge , have mulighed for at vælge bedre,
røgfri alternativer såsom opvarmede tobaksvarer.
Sådanne politikker bør indebære differentierede regler, både med hensyn til kommunikation og med
hensyn til emballage, mærkning og ingredienser. Det vil sikre, at bedre alternativer skal være korrekt
mærkede i overensstemmelse med deres egenskaber. Desuden skal de være kendte og accepterede i
forhold til voksne rygere.
Smagenes rolle for tobaksskadereduktion
Forbuddet mod kendetegnende aromaer i opvarmede tobaksvarer indebærer desværre, at disse produkter
nu reguleringsmæssigt de facto bliver ligestillet med de langt mere skadelige produkter såsom cigaretter og
rulletobak.
Forskellige smagsvarianter spiller en væsentlig rolle for voksne rygere i forhold til at få dem til at skifte væk
fra cigaretter. Et forbud mod kendetegnende aromaer reducerer dermed rygeres incitamenter til at skifte
til skadesreducerende produkter. Det vil tilmed kunne få brugere, som anvender mindre skadelige
opvarmede tobaksprodukter til at skifte tilbage til cigaretter.
5
Background document on the Call For Evidence to Evaluate the Tobacco Control Framework Ref. Ares(2022)3824008,
- se: https://ec.europa.eu/info/law/better-regulation/have-your-say/initiatives/13481-Evaluation-of-the-legislative-
framework-for-tobacco-control_en
Det er kendt fra rygestop, at andre smage end tobak i røgfri alternativer til cigaretter støtter rygere i at
holde op6
.
Empiriske data tyder på, at et forbud mod smag i røgfri alternativer endda kan have den utilsigtede
konsekvens at øge rygefrekvensen ved at modvirke skift: En undersøgelse udført i San Francisco viste, at
rygestop for voksne og skift til røgfri produkter var mere effektivt for de voksne, der brugte e-cigaretter
uden tobakssmag. Undersøgelsen konkluderer:
“Critically, this study’s findings suggest that efforts to ban flavored e-cigarettes could increase smoking:
nontobacco flavors were no more strongly associated with youth smoking initiation than tobacco flavors but
were more strongly associated with adult cessation. Given limited sample sizes, further work is needed”7
Anbefaling
Selvom PMI forstår, at Danmark er nødt til at gennemføre EU-lovgivningen, anbefaler vi kraftigt, at
Danmark arbejder konstruktivt for at modernisere EU's tobakskontrolramme og forholde sig positivt til den
evidensbaserede tilgang til tobaksskadereduktion. På den måde kunne Danmark demonstrere sit lederskab
globalt med henblik på at bidrage til at skabe en røgfri verden. En sådan tilgang vil også fremme
transformationen af tobaksindustrien, som har en afgørende rolle at spille i at fremskynde denne overgang
til en røgfri fremtid. Det skyldes industriens evne til at udvikle bedre røgfri alternativer, der kan erstatte
rygning.
Vi står til rådighed for en åben og gennemsigtig dialog om fremtidens tobaksregulering i Danmark.
Med venlig hilsen
Christopher Arzrouni
Philip Morris ApS
Copenhagen Towers
Ørestads Boulevard 108, 3. sal
2300 København S
6
Romijnders et al (2019): E-Liquid Flavor Preferences and Individual Factors Related to Vaping: A Survey among Dutch
Never-Users, Smokers, Dual Users, and Exclusive Vapers, in Int J Environ Res Public Health, 4661
7
Friedman 2020 Associations of Flavored e-Cigarette Uptake With Subsequent Smoking Initiation and Cessation
Indenrigs- og Sundhedsministeriet
Att. Camilla Friborg Madsen
Høring: Udkast til forslag til lov om ændring af lov om
tobaksvarer m.v., lov om elektroniske cigaretter m.v., lov om
forbud mod salg af tobak og alkohol til personer under 18 år og
lov om røgfri miljøer (Implementering af dele af delegeret
direktiv vedrørende opvarmede tobaksvarer samt andre præciseringer og tekni-
ske justeringer)
SSP-Samrådet takker for muligheden for at kommentere ”Udkast til forslag til lov om
ændring af lov om tobaksvarer m.v., lov om elektroniske cigaretter m.v., lov om
forbud mod salg af tobak og alkohol til personer under 18 år og lov om røgfri miljøer
(Implementering af dele af delegeret direktiv vedrørende opvarmede tobaksvarer
samt andre præciseringer og tekniske justeringer)”.
SSP-Samrådet har følgende bemærkninger til det fremsatte lovforslag:
 Det er positivt, at opvarmede tobaksvarer omfattes af de eksisterende regler
om forbud mod markedsføring af produkter med kendetegnende aroma eller
aromastoffer.
 Det er ligeledes positivt, at lovgivningen omkring alderskontrol præciseres,
særligt i forhold til online-salg. Det er dog en svaghed, at man ikke pt. har et
tilgængeligt system, der entydigt kan identificere køber som værende over 18
år.
SSP-Samrådet har ikke tiltro til at et alderskontrolsystem, der er baseret på en
tilkendegivelse af alder, vil have den ønskede effekt. Der bør fortsat arbejdes
på et alderskontrolsystem der er baseret på en teknisk hindring af muligheden
for at gennemføre et online køb, såfremt man ikke kan dokumentere, at man er
over 18 år.
På vegne af SSP-Samrådet
Benny Husted Pernille Ødegaard Skovsted
Formand Næstformand
SSP-Samrådet
Benny Husted
Formand
Tlf.: 2325 8547
Benny.husted@skanderborg.dk
Pernille Ødegaard Skovsted
Næstformand
Tlf.: 4053 3006
pede@gentofte.dk
www.ssp-samraadet.dk
Skanderborg den 06.03.2023
Sund By Netværket
c/o KL-huset
Weidekampsgade 10
2300 København S
3370 3580
post@sundbynetvaerket.dk
www.sund-by-net.dk
6. marts 2023
Høringssvar fra Sund By Netværket
Vedr. høring til Udkast til forslag til lov om ændring af lov om tobaksvarer m.v., lov
om elektroniske cigaretter m.v., lov om forbud mod salg af tobak og alkohol til
personer under 18 år og lov om røgfri miljøer.
Sund By Netværket har gennem sin temagruppe med fokus på forebyggelse af brugen
af tobak, damp, snus og nikotinprodukter, kigget på lovforslaget. Temagruppens
medlemmer, der repræsenterer 52 danske kommuner, har følgende bemærkninger:
Generel kommentar om strukturelle rammer
Tobak- og nikotinprodukter finder desværre vej til vores børn og unge, i mange af de
miljøer de befinder sig i, i hverdagen – fx i skolen og foreningslivet. I kommunerne i
Danmark arbejdes der hver dag med forebyggelse af udfordringerne, men både
Sygdomsbyrderapporten (Sundhedsstyrelsen, 2023) og rapporten Nikotinbrug blandt
børn og unge (Vidensråd for Forebyggelse, 2022), viser behovet for at vi har et
yderligere fokus her. Og her har de strukturelle greb en afgørende betydning. Med
afsæt i viden om de kendte skadevirkninger, og udfordringen med særligt børn og
unges stigende forbrug af nikotinprodukter, kunne vi således ønske, at det blev langt
sværere for børn og unge at begynde på produkterne, hvorfor vi som fagligt netværk
savner et langt større fokus på:
 Håndhævelse af allerede eksisterende lovgivning – 18års grænsen skal
overholdes (nikotinens skadelige virkning for unge helt op til 25-30års
alderen kunne endda tale for at grænsen skulle hæves yderligere)
Der skal afsættes tilstrækkelige økonomiske ressourcer og kapacitet til at
fastholde eller ligefrem øge kontrollen på tobaks- og nikotinområdet, så
nærværende lovgivning som minimum håndhæves. Det er desuden ikke
lykkes med håndhævelse af nikotinfrie miljøer i fx skoletiden (på trods af –
men muligvis pga. ikke tydelig – lovgivning på området)
 Der skal være flere røgfrie- og nikotinfrie miljøer hvor børn og unge færdes
Gerne i foreningslivet, i biografen, på diskoteker og i byens rum. Alt sammen
med det formål at indskrænke de rum og miljøer i hverdagslivet, hvor børn
og unge disponeres for produkterne
 Priserne på tobak- og nikotinprodukter skal sættes op
Endelig vil vi gerne appellere til højere prissætning på tobaks- og
nikotinprodukter i tillæg til det strukturelle greb med røg- og nikotinfrie
miljøer. En flerstrenget lovgivning, som skruer på alle knapperne til gavn for
folkesundheden nu og her, såvel som for kommende generationer.
Ønske om ulovliggørelse
Det ultimative ønske til gavn for folkesundheden er et egentlig forbud mod tobaks-
og nikotinprodukter. Den netop offentliggjorte sygdomsbyrde rapport bakker i høj
grad op om dette – i tillæg til nyeste viden om nikotinprodukternes skadelig virkning
på børn og unge.
Strukturelle greb som lovgivning og forbud understøtter forebyggelsesarbejdet i
kommunerne hvorfor vi hilser forslag om lovændringer på dette område velkommen,
med følgende bemærkninger til lovteksten:
Skildring mellem medicinsk nikotin og nydelses nikotin
Det er et stærkt ønske om at produkter der går under betegnelsen
’nikotinprodukter’ (bortset fra nikotinprodukter der er godkendt til medicinsk
forbrug, herunder rygestopmedicin eller behandlingsnikotin) gennem lovteksten
underlægges samme lovgivning, som tobaksprodukter (i teksten omtalt som
tobaksvarer, tobakssurrogater eller urtebaserede rygeprodukter). Det betyder, at vi
meget gerne ser produkterne omtalt, så det er tydeligt, at disse produkter er
omfattet af loven som et ’nydelses nikotinprodukt’.
Med den nuværende betegnelse ’røgfri tobak’, der bruges i nærværende lovtekst
åbnes en mulighed for producenterne om at omgå lovgivningen så blandt andet
produkter som nikotinposer, der ikke indeholder tobak, kommer på markedet uden
yderligere kontrol.
Der ønskes desuden en grænseværdi for nikotinindholdet i
’nydelsesnikotinprodukterne, hvor vi ligeledes gerne ser en tydelig
produktinformation på produkterne.
Det undrer os, at vi som sundhedsfaglige (kommunalt) ansatte, er underlagt
delegeret ansvar fra Lægemiddelstyrelsen når vi vejleder borgere, der skal købe
hjælpemidler til rygestop – når borgere kan gå i enhver kiosk eller supermarked og
købe et nikotinprodukt (hvor vi ikke altid kender indholdet af nikotin), som pga.
manglende lovgivning på området, findes i utrolig mange afskygninger.
På vegne af Sund By Netværket
Lene Bruun og Ditte Kirkegaard Madsen
Formandskabet for Sund By Netværkets bestyrelse
Side 1
Indenrigs- og Sundhedsministeriet
Sagsnr.: 2213653
Dok. nr.: 2523532
sum@sum.dk
cfma@sum.dk København, den 6. marts, 2023
Høringssvar fra Swedish Match Danmark vedr. Udkast til forslag til lov om ændring af lov
om tobaksvarer m.v., lov om elektroniske cigaretter m.v., lov om forbud mod salg af
tobak og alkohol til personer under 18 år og lov om røgfri miljøer (Implementering af dele
af delegeret direktiv vedrørende opvarmede tobaksvarer samt andre præciseringer og
tekniske justeringer)
Swedish Match Danmark takker for muligheden for at indgive kommentarer vedr. udkast til
forslag til lov om ændring af lov om tobaksvarer m.v. Swedish Match Danmark producerer og
sælger nikotinposer og spundne røgfri tobakspastiller fra vores fabrik i Silkeborg og vores
datterselskab House of Oliver Twist i Odense.
Vi fremsender hermed vores bemærkninger til alderskontrol i forbindelse med online salg af
nikotinprodukter.
De nuværende regler er, efter vores mening, desværre ikke tilstrækkelige, da der ses et udbredt
salg af røgfri nikotinprodukter til personer under 18 år. Jf. en nylig publiceret rapport fra
Sundhedsstyrelsen om brug af røgfri nikotinprodukter blandt unge mellem 15-29 år fremgår det,
at de 15-17-årige er den aldersgruppe, der i størst omfang køber de røgfri nikotinprodukter
online fra danske og udenlandske hjemmesider.
Udkastet til lovforslaget adresserer problemet med manglende lovhjemmel, mens det fortsat er
lige uvist, hvordan alderskontrolsystemerne ved onlinesalg skal udformes for at være
fyldestgørende og sikre, at kundens aldersoplysning bliver effektivt verificeret.
På hjemmesider, hvor der sælges røgfri nikotinprodukter, er det allerede standard med en aktiv
tilkendegivelse af, at den besøgende er fyldt 18 år. I praksis handler det derfor kun om indførsel
af en funktion, der effektivt verificerer oplysningen om alder for at efterleve bestemmelsen og
dens formål.
Swedish Match foreslår derfor, at man, ved registrering som sælger af tobaksvarer ved
fjernsalg, skal præsentere et alderskontrolsystem der, udover aktiv tilkendegivelse af alder,
samtidig indeholder en funktion, som verificerer den angivne alder ved at indhente supplerende
oplysninger om kunden.
Det kunne være et krav om at registre sig som kunde med indgivelse af oplysninger, der
understøtter den angivne alder, for at få adgang til at handle fra den pågældende website. Det
Side 2
vil ikke eliminere risikoen for falsk profil, men det vil gøre det mere omstændigt og besværligt for
den mindreårige at handle online.
Det udbredte onlinesalg til mindreårige betyder, efter vores bedste overbevisning, at man ikke
bør afvente udviklingen af et officielt alderskontrolsystem, der helt eliminerer risikoen for
mindreåriges adgang til køb af nikotinprodukter fra hjemmesider. Vi mener, at der snarest, efter
nærværende lovforslags vedtagelse, bør indføres krav til sælgere af tobaksvarer ved fjernsalg
om at anvende alderskontrolsystemer med en dobbelt foranstaltning, der indeholder både en
aktiv tilkendegivelse af alder og en konkret funktion for verifikation af den oplyste alder.
Med venlig hilsen
Rune Siglev
Public Affairs Director
Sund mund - Sund krop #SundmundSundkrop
Indenrigs- og Sundhedsministeriet
Kontor for Forebyggelse og Strålebeskyttelse
Att.: Fuldmægtig Camilla Friborg Madsen
Slotsholmsgade 10-12
1216 København K
Tandlægeforeningen
Amaliegade 17
1256 København K
GAN
Høring 003_2023
Dato: 6. marts 2023
Vedr.: Høring om forslag til lov om ændring af lov om tobaks-va-
rer m.v., lov om elektroniske cigaretter m.v., lov om forbud mod
salg af tobak og alkohol til personer under 18 år og lov om røgfri
miljøer
Tandlægeforeningen takker for det modtagne udkast til høring og har følgende
generelle bemærkninger til de regulatoriske ændringer, der lægges op til i det
fremsendte materiale:
Tandlægeforeningen noterer sig, at opvarmede tobaksvarer som følge af det de-
legerede direktiv (Europa-Parlamentets og Rådets direktiv 2014/40/EU) omfattes
af artikel 7, stk. 1 og 7, i tobaksvaredirektivet.
Implementering af direktivet i dansk ret betyder, at forbuddet mod markedsfø-
ring af tobaksvarer med en kendetegnende aroma eller med aromastoffer i deres
bestanddele såsom filtre, papir, emballage, kapsler eller enhver teknisk funktion,
der gør det muligt at ændre de pågældende tobaksvarers duft eller smag eller
deres røgudviklingsintensitet, som allerede findes for cigaretter og rulletobak,
udvides til også̊ at omfatte opvarmede tobaksvarer. Dette finder Tandlægefor-
eningen af sundhedsfaglige grunde hensigtsmæssigt.
Tobak er langt den væsentligste årsag til mundhulekræft og andre alvorlige syg-
domme i mundhulen som fx parodontitis – en sygdom, der har sammenhæng
med diabetes og hjertekarsygdomme, ligesom parodontitis kædes sammen med
psoriasis, leddegigt, osteoporose, Alzheimers sygdom og Parkinsons sygdom.
Forskning viser, at opvarmede tobaksvarer skader cellerne i munden på samme
niveau, som var man udsat for tobaksrygning, og vi ved også, at det øger risi-
koen for parodontitis og tandtab. På den baggrund vurderer Tandlægeforenin-
gen, at en udvidelse af forbuddet mod markedsføring af opvarmede tobaksvarer
kan gavne folkesundheden.
I forlængelse af ovenfornævnte påskønner Tandlægeforeningen det planlagte
lovforslag, der indeholder en præcisering af kravene til alderskontrol og Sund-
hedsstyrelsens skilte. Tandlægeforeningen noterer sig videre, at der i lovforsla-
get lægges op til at styrke alderskontrollen online, når den rette løsning er til-
gængelig. I den sammenhæng mener Tandlægeforeningen, at det er afgørende,
at der ligeledes tages initiativ til et effektivt alderskontrolsystem på fysiske
salgssteder, fx ved brug af aldersverificering på betalingskort.
Tandlægeforeningen har ikke yderligere bemærkninger.


KOMMENTERET HØRINGSNOTAT
vedrørende forslag til
Lov om ændring af lov om tobaksvarer m.v. og forskellige andre love
(Implementering af dele af delegeret direktiv vedrørende opvarmede tobaksvarer m.v.)
I det følgende gennemgås de væsentligste bemærkninger til lovforslaget, som ministeriet
har modtaget i forbindelse med den offentlige høring.
1. Hørte myndigheder og organisationer m.v.
Et udkast til lovforslag om Lov om ændring af lov om tobaksvarer m.v. og forskellige andre
love (Implementering af dele af delegeret direktiv vedrørende opvarmede tobaksvarer
m.v.) har i perioden fra den 3. februar 2023 til den 6. marts 2023 været sendt i offentlig
høring hos følgende myndigheder og organisationer m.v.:
Advokatrådet, Alkohol & Samfund, Akademikernes Centralorganisation (AC),
Arbejdsgiverforeningen KA, Arbejdstilsynet, Astma-Allergi Forbund, Becig, Blå kors,
BrancheDanmark, British American Tobacco, Bryggeriforeningen, Børnerådet, Børns vilkår,
Center for Hjerneskade, Coop Danmark, Dagrofa, Danmarks Apotekerforening, Danmarks
Farmaceutiske Selskab, Danmarks Lungeforening, Danmarks, Restauranter og Cafeer
(DRC), Dansk Arbejdsgiverforening (DA), Dansk e-Damper Forening (DADAFO), Dansk
Erhverv, Dansk Industri, Dansk Lungemedicinsk Selskab, Dansk Psykiatrisk Selskab, Dansk
Selskab for Almen Medicin, Dansk Selskab for Distriktpsykiatri, Dansk Selskab for
Folkesundhed, Dansk Selskab for Patientsikkerhed, Dansk Supermarked
Dansk Sygeplejeråd, Dansk Transport og Logistik (DTL), Danske Fysioterapeuter, Danske
Gymnasieelevers Sammenslutning, Danske Handicaporganisationer (DH), Danske
Patienter, Danske Regioner, Danske seniorer, Danske Skoleelever, Danske Tandplejere,
Danske Ældreråd, Dataetisk råd, Datatilsynet, De Samvirkende Købmænd, Den Danske
Dommerforening, Det Etiske Råd, Diabetesforeningen, Efuma , Erhvervsskolernes
Elevorganisation, Fag og Arbejde (FOA), Fagbevægelsens Hovedorganisation, Fagligt
Fællesforbund – 3F, Farmakonomforeningen, Finanssektorens Arbejdsgiverforening,
Forbrugerombudsmanden, Forbrugerrådet, Foreningen af Danske Lægestuderende
(FADL), Foreningen af Speciallæger, Foreningen for Dansk Internet Handel, Foreningen for
Parallelimportører af Medicin , Forsikring og Pension, Færøernes landsstyre, Gejser,
Gigtforeningen, Hjerteforeningen, HK - Handel, Hotel-, Restaurant - & Turisterhvervet
(HORESTA), House of Oliver Twist A/S, Industriforeningen for generiske og biosemilære
lægemidler, Japan International Tobacco, Jordemoderforeningen, KFUM’ s Sociale
Arbejde, Kirkens Korshær, Komiteen for Sundhedsoplysning, Kommunernes Landsforening
(KL), Kræftens Bekæmpelse, Landsorganisationen for sociale tilbud,
Landssammenslutningen af Handelsskoleelever, LO – Landsorganisationen i Danmark,
Lægeforeningen, Lægemiddelindustriforeningen, Medicoindustrien , Metal Ungdom,
Mødrehjælpen, Naalakkersuisut, National Videnskabsetisk Komité, Nationalt Center for
Dato: <Vælg dato>
Enhed: FOST
Sagsbeh.: DEPCFMA
Sagsnr.: 2213653
Dok. nr.: 2562214
Offentligt
L 123 - Bilag 1
Sundhedsudvalget 2022-23 (2. samling)
Side 2
Etik, Nikotinbranchen, Nærbutikkernes Landsforening, Nærings- og
Nydelsesmiddelarbejder Forbundet (NNF), Offentligt Ansattes Organisationer (OAO),
Parallelimportørforeningen af lægemidler, Patientforeningen, Pharmadanmark,
Pharmakon, Philip Morris, Praktiserende Lægers Organisation, Praktiserende Tandlægers
Organisation, Rigsrevisionen , Røgfri Fremtid, Rådet for Socialt Udsatte, Skole og Forældre,
Smoke Solution, SSP-Samrådet, Sund By Netværket, Sundhed Danmark - Foreningen af
danske sundhedsvirksomheder, Sundhedskartellet, Swedish Match, Sygeforsikringen
”Danmark”, Tandlægeforeningen, Tobaksindustrien, Tobaksproducenterne,
Veterinærmedicinsk Industriforening (VIF), Ældresagen og Yngre læger.
Lovforslaget har desuden været offentliggjort på www.borger.dk under Høringsportalen.
Indenrigs- og Sundhedsministeriet har modtaget høringssvar uden bemærkninger fra:
Bornholms Hospital og Finanssektorens Arbejdsgiverforening.
Indenrigs- og Sundhedsministeriet har modtaget høringssvar med bemærkninger fra:
Alkohol & Samfund, British American Tobacco Denmark, Bryggeriforeningen, Dansk
Erhverv, Dansk Selskab for Folkesundhed, Danske Patienter, Danske Regioner, Danske
Tandplejere, De Samvirkende Købmænd, GEjSER, Hjerteforeningen, Kræftens Bekæmpelse,
Lungeforeningen, Lægeforeningen, Nikotinbranchen, Nærbutikkernes Landsforening,
Patientforeningen, Philip Morris, Region Hovedstaden, SSP-Samrådet, Sund By Netværket,
Swedish Match, Tandlægeforeningen og Tobaksindustrien.
Ministeriet modtog i alt 26 høringssvar.
I det følgende foretages en gennemgang af de væsentligste bemærkninger i
høringssvarene til de enkelte elementer i lovforslaget og dets bemærkninger. Ministeriets
bemærkninger hertil er kursiverede.
2. Generelle bemærkninger
2.1. Overordnede tilbagemeldinger på implementering af dele af det delegerede
direktiv vedrørende opvarmede tobaksvarer
Dansk Erhverv, Dansk Selskab for Folkesundhed (med tilslutning fra Region Hovedstaden),
Danske Patienter, Danske Regioner Danske Tandplejere, Hjerteforeningen, Kræftens
Bekæmpelse, Lungeforeningen, Lægeforeningen, Patientforeningen, SSP-Samrådet og
Tandlægeforeningen anfører, at de bakker op om, at lovforslaget implementerer det
delegerede direktiv således, at opvarmede tobaksvarer omfattes af forbuddet mod
smagsstoffer. Der henvises i den forbindelse bl.a. til, at smagsstoffer gør produkter mere
tiltrækkende overfor børn og unge samt at tobak er årsag til en lang række sygdomme.
Endvidere anfører Hjerteforeningen, Kræftens Bekæmpelse og Lungeforeningen
vigtigheden af, at lovgivningen løbende tilpasses markedet, hvor der hele tiden kommer
nye tobaks- og nikotinprodukter.
British American Tobacco, Nikotinbranchen, Nærbutikkernes Landsforening, og Philip
Morris er generelt kritiske over for implementeringen af det delegerede direktiv, der
indfører et forbud mod smagsstoffer i opvarmede tobaksvarer. Parterne anfører bl.a., at
den nye regulering sidestiller opvarmede tobaksvarer med cigaretter, hvilket de finder
Side 3
uhensigtsmæssigt, samt anfører at lovforslaget vil have en negativ indflydelse på
folkesundheden, jf. de specifikke bemærkninger nedenfor.
2.2. Overordnede tilbagemeldinger på krav til alderskontrol
Alkohol & Samfund, British American Tobacco, Bryggeriforeningen, Dansk Selskab for
Folkesundhed (med tilslutning fra Region Hovedstaden), Dansk Erhverv, Danske Patienter,
Danske Regioner, Danske Tandplejere, GEjSER, Hjerteforeningen, Kræftens Bekæmpelse,
Lungeforeningen, Lægeforeningen, Nikotinbranchen, Patientforeningen, SSP-Samrådet,
Tandlægeforeningen og Tobaksindustrien anfører, at det overordnet er positivt, at der
med lovforslaget sikres den tilstrækkelige lovhjemmel til alderskontrol ved salg online af
alkoholholdige drikkevarer, tobaks- og nikotinprodukter samt urtebaserede
rygeprodukter.
Alkohol & Samfund, British American Tobacco, Bryggeriforeningen, Dansk Selskab for
Folkesundhed (med tilslutning fra Region Hovedstaden), Danske Patienter, De
Samvirkende Købmænd, GEjSER, Hjerteforeningen, Kræftens Bekæmpelse,
Lungeforeningen, Nikotinbranchen, SSP-Samrådet og Swedish Match anfører dog, at den i
lovforslaget foreslåede alderskontrol er utilstrækkelig. I den forbindelse anfører flere af
høringsparterne bl.a., at der er behov for at indføre digitale løsninger eller andet, der
sikrer en mere effektiv alderskontrol i fysiske butikker og ved salg online jf. specifikke de
specifikke bemærkninger nedenfor.
Alkohol & Samfund, British American Tobacco, Bryggeriforeningen og Sund By Netværket
anfører endvidere, at der er problemer med håndhævelsen af den eksisterende lovgivning,
og at de generelt ønsker en bedre håndhævelse af reglerne omkring aldersverificering.
2.3. Forhold der går ud over lovforslagets genstandsområde
Sund By Netværket anfører, at de ønsker et større fokus på øget håndhævelse af
aldersgrænser, flere røg- og nikotinfrie miljøer, højere priser på tobak samt et forbud mod
tobaks- og nikotinprodukter. Sund By Netværket efterspørger desuden en grænseværdi
for nikotinindholdet i nikotinprodukter samt tydelig produktinformation for
nikotinprodukter.
Sund By Netværket anfører videre, at der skal skelnes mellem medicinsk nikotin og
nydelsesnikotin, og hvor nydelsesnikotin skal underlægges samme lovgivning som
tobaksprodukter.
Sund By Netværket anfører desuden undren over, at der på den ene side er sundhedsfag-
lige (kommunalt) ansatte, der er underlagt et delegeret ansvar fra Lægemiddelstyrelsen i
forbindelse med vejledning af borgere, der skal købe rygestophjælpemidler, mens der på
den anden side er borgere, som kan gå i enhver kiosk eller supermarked og købe diverse
nikotinprodukter.
Alkohol & Samfund, Hjerteforeningen, Kræftens Bekæmpelse og Lægeforeningen anfører,
at der bør indføres en ensartet aldersgrænse på 18 år for køb af alle typer af alkohol, idet
der bl.a. henvises til Sundhedsstyrelsens anbefalinger om, at børn og unge under 18 år
frarådes at drikke alkohol.
Side 4
Ministeriet bemærker, at de anførte forhold går ud over rammerne for nærværende
lovforslag, som har til hensigt at implementere dele af et delegeret direktiv fra Europa-
Kommissionen vedrørende opvarmede tobaksvarer i dansk ret. I forbindelse med
implementeringen foretages også justeringer vedrørende krav til alderskontrol og
Sundhedsstyrelsens skilte samt øvrige tekniske justeringer.
Ministeriet kan i øvrigt bemærke, at det fremgår af regeringsgrundlaget, at regeringen vil
løfte sundheden og trivslen blandt børn og unge og på tværs af bl.a. sundheds-, kultur- og
børne- og skoleområdet tage initiativ til en forebyggelsesplan målrettet børn og unge.
3. Specifikke bemærkninger angående implementering af dele af det
delegerede direktiv fra EU vedrørende opvarmede tobaksvarer
3.1. Udvidelse af forbuddet mod smagsstoffer
Dansk Selskab for Folkesundhed (med tilslutning fra Region Hovedstaden), Danske
Patienter, Hjerteforeningen, Kræftens Bekæmpelse, Lungeforeningen og Lægeforeningen
anfører, at forbuddet mod smagsstoffer bør udvides til at gælde for alle typer af
tobaksprodukter. Kræftens Bekæmpelse anfører i den forbindelse, at forbuddet bør
udvides i forbindelse med den kommende revision af EU’s tobaksvaredirektiv. Danske
Patienter, Kræftens Bekæmpelse, Lungeforeningen og Lægeforeningen anfører, at mentol
og andre aromaer gør produkterne mere tiltrækkende for særligt børn og unge.
Dansk Selskab for Folkesundhed (med tilslutning fra Region Hovedstaden),
Hjerteforeningen og Kræftens Bekæmpelse anfører derudover, at smagsstofferne ikke kun
skal forbydes som kendetegnende aromaer, men som ingredienser, så der ikke er
usikkerhed om, hvor meget smag, der må eller ikke må tilsættes et produkt.
Ministeriet bemærker, at lovforslaget ikke har til hensigt at gå videre end
minimumskravene i det delegerede direktiv. Således er de fem principper for
implementering af erhvervsrettet EU-regulering også overholdt. Lovforslaget er endvidere
som udkast blevet notificeret til EU-Kommissionen.
Ministeriet bemærker videre, at det delegerede direktiv understøtter aftalen om den
nationale handleplan mod børn og unges rygning fra 2019. Med handleplanen blev det
bl.a. besluttet at det eksisterende forbud mod kendetegnende aromaer i cigaretter og
rulletobak skulle udvides, således der indføres et forbud mod anden kendetegnende aroma
end tobak og mentol i øvrige tobaksvarer (med undtagelse af pibetobak og cigarer) samt i
urtebaserede rygeprodukter. Denne regulering vil imidlertid først kunne sættes i kraft, når
og såfremt EU-retten tillader det. Med det delegerede direktiv bliver opvarmede
tobaksvarer nu omfattet af forbuddet mod kendetegnende aromaer.
Ministeriet bemærker afslutningsvist, at der med lovforslaget også lægges op til, at
opvarmede tobaksvarer inkluderes i § 14, stk. 2, i lov om tobaksvarer m.v., hvorved
Sundhedsstyrelsen kan fastsætte nærmere regler om forbuddet mod markedsføring af
cigaretter, rulletobak og fremover opvarmet tobak med kendetegnende aromaer, og om
grænseværdier for indholdet i cigaretter, rulletobak og fremover opvarmet tobak af
tilsætningsstoffer eller kombinationer af tilsætningsstoffer, der giver en kendetegnende
aroma.
Side 5
3.2. EU-lovgivning og implementering af det delegerede direktiv i dansk ret
British American Tobacco anfører, at det delegerede direktiv ikke er gyldigt og anfører i
den forbindelse en række argumenter for, hvorfor Kommissionen har overskredet omfan-
get af de delegerede beføjelser, som den er blevet tillagt. Kommissionen har ifølge British
American Tobacco overskredet omfanget af de delegerede beføjelser dels ved at regulere
nye produkter frem for etablerede produktkategorier, dels ved at introducere den nye ka-
tegori ”opvarmede tobaksvarer”, dels fordi den nye kategori af opvarmede tobaksvarer,
der introduceres, er uforenelig med tobaksvaredirektivets system og dels ved at Kommis-
sionens tilgang i vurderingen af en ”væsentlig ændring i forholdene” er behæftet med fejl.
British American Tobacco anfører på den baggrund, at det delegerede direktiv ikke bør im-
plementeres i dansk lovgivning og at omsætningen til dansk ret også vil være ugyldigt. Bri-
tish American Tobacco henviser ligeledes til igangværende retssager vedrørende gyldighe-
den af det delegerede direktiv ved EU-Domstolen og de irske domstole. Endelig anfører
British American Tobacco, at såfremt det delegerede direktiv implementeres i dansk lov-
givning skal det gøres på den senest mulige dato, dvs. d. 23. juli 2023, således at der mu-
ligvis først kan blive afsagt en EU-dom om det delegerede direktivs gyldighed.
Nærbutikkernes Landsforening anfører, at implementeringen af det delegerede direktiv
holder sig inden for rammerne af vedtagelserne på EU-niveau.
Ministeriet bemærker, at det delegerede direktiv er vedtaget af Europa-Kommissionen.
Lovforslaget har til formål at implementere direktivet i overensstemmelse med de rammer,
herunder datoer for gennemførelse, som er udstukket af Europa-Kommissionen.
Lovforslaget har ikke til hensigt at gå videre end minimumskravene i det delegerede
direktiv. Lovforslaget er som udkast blevet notificeret til EU-Kommissionen.
Ministeriet kan i øvrigt bemærke, at ministeriet er opmærksomme på, at der er verserende
retssager om det delegerede direktiv.
3.3. Kategorisering og definition af opvarmet tobak
Sund By Netværket anfører, at betegnelsen ”røgfri tobak” kan være problematisk, da det
bl.a. giver producenter mulighed for at udnytte formuleringen og omgå lovgivningen.
Dansk Selskab for Folkesundhed anfører, at de opponerer imod, at opvarmede tobaksva-
rer kun vil være omfattet af reguleringen vedrørende smagsstoffer for så vidt de er røgto-
bak. De opponerer videre imod, at opvarmet tobak både kan defineres som røgtobak og
røgfri tobak, jf. definitionen for opvarmede tobaksvarer, der indgår i lovforslaget. Dansk
Selskab for Folkesundhed anfører, at definitionen ikke specificerer, hvad der menes med
karakteristika, og at dette vil blive udnyttet af tobaksproducenterne til at markedsføre op-
varmet tobak som et ”uskadeligt alternativ” til almindelige cigaretter. Dansk Selskab for
Folkesundhed anfører, at de anbefaler, at alt opvarmet tobak defineres som røgtobak, og
at al opvarmet tobak omfattes af den nye regulering om forbud mod smagsstoffer. Region
Hovedstaden tilslutter sig høringssvaret fra Dansk Selskab for Folkesundhed.
British American Tobacco anfører, at det foreslåede sprog i lovforslaget er egnet til at
definere opvarmede tobaksvarer, da der skelnes mellem røgfri tobaksvarer og røgtobak.
Nærbutikkernes Landsforening anfører, at de lægger vægt på, at man sondrer mellem
tobaksvarer, der er røgprodukter og tobaksvarer, der er røgfri.
Side 6
Ministeriet bemærker, at definitionen af opvarmet tobak, som introduceres med
lovforslaget, følger af det delegerede direktiv fra Europa-Kommissionen. Opvarmet tobak
hører i øvrigt under definitionen ny kategori af tobaksvarer. Som det fremgår af § 27 i lov
om tobaksvarer m.v. kan Sundhedsstyrelsen fastsætte regler om, hvilke bestemmelser i lov
om tobaksvarer m.v., der gælder for nye kategorier af tobaksvarer, afhængigt af om der er
tale om røgfrie tobaksvarer eller røgtobak. Der pågår et arbejde med at fastlægge, om
forskellige opvarmede tobaksvarer er røgtobak eller røgfri tobak.
Ministeriet bemærker videre, at reguleringen af opvarmede tobaksvarer for så vidt angår
smagsstoffer, der introduceres med lovforslaget som følge af det delegerede direktiv,
gælder for alle opvarmede tobaksprodukter, uanset om de er røgtobak eller røgfri tobak.
De nye mærkningskrav, der følger af det delegerede direktiv og som implementeres på
bekendtgørelsesniveau, vil derimod kun gælde for opvarmede tobaksvarer, der er
røgtobak.
Ministeriet bemærker, at lovforslaget ikke har til hensigt at gå videre end
minimumskravene i det delegerede direktiv. Således er de fem principper for
implementering af erhvervsrettet EU-regulering også overholdt. Lovforslaget er endvidere
som udkast blevet notificeret til EU-Kommissionen.
3.5. Skadereduktion
Dansk Selskab for Folkesundhed (med tilslutning fra Region Hovedstaden)
Hjerteforeningen, Kræftens Bekæmpelse og Lungeforeningen henviser til, at WHO
anbefaler, at opvarmet tobak reguleres på samme måde som cigaretter og anden tobak i
henhold til WHO’s rammekonvention om tobakskontrol. Hjerteforeningen og Kræftens
Bekæmpelse anfører videre, at WHO ikke finder evidens for, at opvarmet tobak er mindre
skadeligt end andre tobaksformer.
British American Tobacco, Nærbutikkernes Landsforening og Philip Morris anfører, at det
nye forbud mod smage i opvarmede tobaksvarer vil påvirke folkesundheden negativt, da
det vil gøre det mindre oplagt for rygere at skifte til opvarmede tobaksvarer, der af
høringsparterne betragtes som et skadesreducerende produkt.
Philip Morris anfører i forlængelse heraf, at der stort set ikke er nogen, der påbegynder et
nikotinforbrug via opvarmede tobaksvarer – ligesom kun få påbegynder nikotinforbrug via
e-cigaretter. Philip Morris anfører videre, at alternativer til cigaretter for det meste
anvendes af voksne rygere og ikke af mindreårige eller ikke-rygere.
Philip Morris anfører desuden, at der skal gennemføres regulering, der fremskynder
ophøret af rygning og henviser til, at rygestop bør fremskyndes ved brug af de positive
erfaringer fra skadesreduktion. Philip Morris anfører, at tilskyndelser til rygestop fremmes
bedst ved hjælp af en differentieret regulering baseret på skadevirkningerne forårsaget af
tobaks- og nikotinholdige produkter.
Philip Morris anfører, at implementeringen af det delegerede direktiv, med hensyn til
smagsstoffer, vil sidestille reguleringen for opvarmede tobaksprodukter med mere
skadelige produkter såsom cigaretter og rulletobak. Philip Morris anfører i forlængelse
heraf, at forskellige smagsvarianter spiller en væsentlig rolle for voksne rygere i forhold til
at få dem til at skifte væk fra cigaretter til skadesreducerende produkter. Et forbud mod
Side 7
smage reducerer dermed rygeres incitamenter til at skifte til skadesreducerende
produkter og kan få brugere til at skifte tilbage til cigaretter.
Philip Morris anfører endeligt, at Danmark bør arbejde konstruktivt for at modernisere
EU’s tobakskontrolramme, og at Danmark i EU-regi bør fordre en evidensbaseret tilgang til
skadesreduktion, hvilket også anføres af Nikotinbranchen.
Nikotinbranchen anfører, at røgfri nikotinprodukter, herunder opvarmede tobaksvarer,
ikke skal reguleres som cigaretter og traditionelle tobaksvarer, da produkterne er
forskellige i forhold til deres skadevirkninger for den enkelte, gener og potentielle
sundhedsrisici for omgivelserne og samfundsomkostningerne i forlængelse af brugen af
produkterne. Reguleringen bør give incitament for rygere til at skrifte fra røg til røgfri.
Nikotinbranchen anfører videre, at kendetegnende aromaer og smag er en afgørende
forskel for mange brugere og et incitament til at skifte fra cigaretter til røgfri produkter
som opvarmet tobak, e-cigaretter og nikotinposer. Nikotinbranchen anfører desuden, at
med nikotinposers entre på det danske marked i 2019 fald antallet af rygere og det
understøtter opfattelsen af røgfrie nikotinprodukters rolle som en realistisk vej væk fra
cigaretter for mange rygere.
British American Tobacco anfører, at opvarmede tobaksvarer har en reduceret risikoprofil
sammenlignet med brændbare cigaretter. British American Tobacco anfører ligeledes, at
de tilgængelige beviser viser, at der ikke er sket nogen betydelig stigning i unge, der
begynder at bruge opvarmede tobaksvarer og dermed er der ikke dokumentet grund til
bekymring over, at opvarmede tobaksvarer kan fungere som gateway til øget brug af
brændbar tobak eller øget påbegyndelse af rygning. British American Tobacco anfører
videre, at smagsbegrænsningerne vil have en negativ indvirkning på voksne rygere og
sandsynligvis medføre utilsigtede konsekvenser for den offentlige sundhed. British
American Tobacco anfører desuden, at når opvarmede tobaksvarer reguleres som
brændbare tobaksvarer, formidler det også et budskab om, at risiciene ved produkter er
de samme, hvorved rygere ikke vil skifte til mindre skadelige produkter.
Ministeriet bemærker, at det delegerede direktiv understøtter aftalen om den nationale
handleplan mod børn og unges rygning fra 2019. Med handleplanen blev det bl.a.
besluttet at det eksisterende forbud mod kendetegnende aromaer i cigaretter og
rulletobak skulle udvides, således der indføres et forbud mod anden kendetegnende aroma
end tobak og mentol i øvrige tobaksvarer (med undtagelse af pibetobak og cigarer) samt i
urtebaserede rygeprodukter. Denne regulering vil imidlertid først kunne sættes i kraft, når
og såfremt EU-retten tillader det. Med det delegerede direktiv bliver opvarmede
tobaksvarer nu omfattet af forbuddet mod kendetegnende aromaer.
Ministeriet kan i øvrigt henvise til, at det fremgår af rapporten ”Nikotinbrug blandt børn
og unge. Konsekvenser og forebyggelse” fra Vidensråd for Forebyggelse i 2022, at nikotin
er afhængighedsskabende samt at brug af nikotin i ungdommen kan have en negativ
indflydelse på hjernens udvikling på flere områder. Brug af nikotinprodukter er således
skadeligt i sig selv. Det fremgår bl.a. også af rapporten, at nikotin ser ud til at øge
sandsynligheden for at blive afhængig af både cigaretter og af rusmidler i almindelighed.
Nikotin ser således ud til at have en såkaldt ‘gateway’ effekt.
Side 8
Ministeriet kan herudover bemærke, at Sundhedsstyrelsen udelukkende anbefaler brug af
nikotin til borgere, der er i behandling for nikotinafhængighed, og kun i en kortere
afgrænset periode. Borgere, der ønsker et varigt rygestop, anbefales at benytte en
kombination af professionel hjælp og godkendt rygestopmedicin, idet der er evidens for, at
der ved denne kombination er den største sandsynlighed for varig røgfrihed.
3.6. Nye mærkningskrav som følge af det delegerede direktiv vedrørende
opvarmede tobaksvarer
Philip Morris anfører, at implementeringen af det delegerede direktiv skal ske i
overensstemmelse med art. 114 TEUF og må ikke resultere i en forvridning af det indre
marked eller en krænkelse af Acquis Communautaire generelt. Det betyder, at der skal
skelnes mellem mærkningsreglerne for opvarmede tobaksprodukter, der ikke involverer
en forbrændingsproces, og dem, der er klassificeret som tobak til rygning. Philip Morris
noterer sig, at hensigten med lovforslaget er at gennemføre det delegerede direktiv inden
for de retlige rammer for Acquis Communautaire og derfor alene kræve kombinerede
sundhedsadvarsler for de opvarmede tobaksprodukter, der er klassificeret som rygetobak
og involverer en forbrændingsproces.
British American Tobacco anfører, at lovforslaget – i overensstemmelse med det
delegerede direktiv - kun ændrer mærkningskravene for opvarmede tobaksvarer, for så
vidt de er røgtobak. British American Tobacco anfører videre, at deres opvarmede
tobaksprodukter er røgfri, da de ikke indebærer en forbrændingsproces.
Tobaksindustrien anfører, at lovforslaget bl.a. implementerer de nye EU-regler for
opvarmet tobak, der skal træde i kraft d. 23. oktober 2023. I den forbindelse anfører
Tobaksindustrien, at der i god tid inden skal udstedes en bekendtgørelse, som nærmere
beskriver, hvilken type advarsel de pågældende produkter skal være påført.
Ministeriet bemærker, at de ændrede mærkningskrav for opvarmede tobaksvarer, der er
røgtobak, og som følger af det delegerede direktiv, implementeres på
bekendtgørelsesniveau og ikke i nærværende lovforslag.
Bekendtgørelsen, som implementerer de nye mærkningskrav har været i høring i perioden
d. 24. februar 2023 til d. 27. marts 2023. Bekendtgørelsen er endvidere som udkast blevet
notificeret til EU-Kommissionen d. 24. februar 2023 med en status quo periode, der i
udgangspunktet afsluttes d. 25. maj 2023. Bekendtgørelsen kan ikke vedtages før status
quo perioden er udløbet.
Ministeriet bemærker i den forbindelse, at det følger af det delegerede direktiv, at love og
bestemmelser, der implementerer det delegerede direktiv skal være vedtaget og
offentliggjort senest d. 23. juli 2023 og skal træde i kraft d. 23. oktober 2023. Ministeriet
har til hensigt at overholde disse rammer.
Ministeriet bemærker videre, at lovforslaget og bekendtgørelsen ikke har til hensigt at gå
videre end minimumskravene i det delegerede direktiv. Således er de fem principper for
implementering af erhvervsrettet EU-regulering også overholdt.
Ministeriet bemærker afslutningsvist, at der pågår et arbejde med at fastlægge, om
forskellige opvarmede tobaksvarer er røgtobak eller røgfri tobak.
Side 9
4. Specifikke bemærkninger om alderskontrol og Sundhedsstyrelsens skilte
4.1. Alderskontrol på fysiske salgssteder
British American Tobacco, Bryggeriforeningen, De Samvirkende Købmænd og Nikotinbran-
chen anfører, at det er problematisk, at det er den enkelte kassemedarbejders ansvar at
kontrollere ID, da det ikke er et rimeligt ansvar at pålægge personalet, og da det kan med-
føre fejl, hvor unge køber varer, som de ellers ikke bør.
Bryggeriforeningen, De Samvirkende Købmænd og Nikotinbranchen anfører, at der er be-
hov for et digitalt alderskontrolsystem og foreslår i den forbindelse en løsning, hvor kun-
dens alder automatisk verificeres gennem elektronisk betaling, hvad enten det er med
kort eller telefon ved terminalen. Flere af parterne anfører, at det vil kræve udvikling af en
løsning, der ikke er tilgængelig i dag, men som bør være realistisk, da hvert elektronisk be-
talingsmiddel er knyttet til en konkret kontohaver. GEjSER anfører, at de bakker op om De
Samvirkende Købmænds forslag om elektronisk aldersverificering via betalingskort, og er
overbeviste om, at denne løsning især vil kunne forhindre salg af nikotinprodukter til børn
og unge via online-salgssteder jf. høringsnotatets afsnit 4.2. Tandlægeforeningen foreslår
ligeledes aldersverificering via betalingskort som et muligt effektivt alderskontrolsystem
på fysiske salgssteder.
GEjSER anfører, at der kan opstå tvivl i forbindelse med kontantbetalinger, og er derfor
positive over for lovforslagets præciseringen af kravet om anmodning om fremvisning af
gyldig billedlegitimation, hvis en ekspedient er i tvivl om kundens alder.
De Samvirkende Købmænd anfører, at der som supplerende forslag til aldersverificering
gennem elektronisk betaling skal være et forbud mod proxysalg samt et købsforbud, såle-
des at det også bliver forbudt som kunde at erhverve sig produkter med en salgsalders-
grænse, hvis man ikke er gammel nok.
British American Tobacco anfører, at en konkret model for aldersverificering i fysiske bu-
tikker f.eks. kunne bestå af krav om et elektronisk system med to-faktorgodkendelse,
mens køb foretaget med kontantbetaling skal forudsætte aldersverificering ved forevis-
ning af gyldig billedlegitimation.
Bryggeriforeningen anfører, at det er relevant, at der med det konkrete lovforslag imple-
menteres en lovhjemmel, der imødegår domstolsprøvelserne, men at udfordringen med
håndhævelsen af salgsaldersgrænserne også bør løses – både i fysisk handel og ved salg
online. Bryggeriforeningen foreslår at Indenrigs- og Sundhedsministeriet nedsætter en ar-
bejdsgruppe, der skal afsøge hvilke tilgængelige løsninger for alderskontrol, der i væsent-
ligt og tilfredsstillende omfang kan forbedre håndhævelsen af de nuværende salgsalders-
grænser.
Nikotinbranchen anfører ligeledes, at man fra myndighedernes side etablerer en samlet
plan for at nedbringe salget af nikotinprodukter til personer under 18 år såvel i fysiske bu-
tikker som på internettet, hvor Nikotinbranchen gerne bidrager med input og viden om
det illegale salg.
Alkohol & Samfund anfører, at der er behov for en yderligere skærpelse for at sikre loven
bliver håndhævet for salg af alkohol både online og i fysiske butikker. De anfører, at
fysiske salgssteder bør pålægges altid at spørge kunder, der er eller ser ud til at være
under 25 år om gyldig legitimation ved slag af produkter, der har en aldersbegrænsning.
Alkohol & Samfund anfører desuden, at Sikkerhedsstyrelsens kontroller ikke er effektive til
Side 10
at sikre fysiske salgssteders håndhævelse af aldersgrænserne, og at Sikkerhedsstyrelsen
bør gives hjemmel til at udføre mystery shopping. Alkohol & Samfund anfører, at mystery
shopping har dokumenterede effekter i andre europæiske lande til øget håndhævelse af
loven for salg af alkohol.
Dansk Selskab for Folkesundhed (med tilslutning fra Region Hovedstaden) anfører, at de er
positive over, at pligten til at drive et alderskontrolsystem fremover påhviler alle
detailforhandlere af tobaksvarer, tobakssurrogater, urtebaserede rygeprodukter, der
markedsfører via fjernsalg, og ikke kun dem, der markedsfører via fjernslag over
landegrænser.
Ministeriet bemærker, at hensigten med lovforslaget er at indføre en klar hjemmel, der
fastsætter, hvilke krav der stilles til alderskontrol henholdsvis på fysiske salgssteder og ved
salg online og således tager højde for forskellene mellem fysiske salgssteder og salg online.
De foreslåede ændringer i lovforslaget bygger på den eksisterende praksis på området.
Ministeriet påpeger, at detailhandlen i dag har ansvaret for at håndhæve
aldersgrænserne. I den forbindelse kan også henvises til aftalen om den nationale
handleplan mod børn og unges rygning fra 2019 hvor det fremgår, at ”Aftalepartierne
bakker op om alle initiativer, der kan være med til at sikre en effektiv håndhævelse af
gældende aldersgrænse for salg af tobaksvarer og e-cigaretter m.v. Derfor er
aftalepartierne også enige om at opfordre detailhandlen evt. i samarbejde med andre til at
afsøge mulighederne for ibrugtagen af nye metoder, herunder digitale, til at understøtte
alderskontrollen i butikkerne. Aftalepartierne indskærper samtidig butikkernes ansvar for
at sikre, at der ikke sælges til mindreårige. Butikkerne skal tjekke ID, hvis der er den
mindste tvivl om, hvorvidt kunden er over 18 år. Og vil man købe tobak m.v., må man være
indstillet på at vise ID – også længe efter sin 18-års fødselsdag. Aftalepartierne er enige
om at holde øje med udviklingen og følge op på, om der er behov for yderligere tiltag for at
sikre, at børn og unge under 18 år ikke har adgang til at købe tobaksvarer m.v.”
Ministeriet kan i øvrigt bemærke, at det fremgår af regeringsgrundlaget, at regeringen vil
løfte sundheden og trivslen blandt børn og unge og på tværs af bl.a. sundheds-, kultur- og
børne- og skoleområdet tage initiativ til en forebyggelsesplan målrettet børn og unge.
4.2. Alderskontrol ved salg online
Alkohol & Samfund, Bryggeriforeningen, Dansk Selskab for Folkesundhed (med tilslutning
fra Region Hovedstaden), Danske Patienter, GEjSER, Hjerteforeningen, Kræftens
Bekæmpelse, Lungeforeningen, Nikotinbranchen, SSP-Samrådet og Swedish Match
anfører, at lovforslaget ikke medfører et effektivt alderskontrolsystem ved salg online af
alkoholholdige drikkevarer, tobaks- og nikotinprodukter samt urtebaserede
rygeprodukter. Flere af parterne anfører bl.a., at en løsning, hvor forbrugerne selv kan
krydse af, at de er over 18 år, stadig muliggør salg online af ovenstående varer til børn og
unge.
Hjerteforeningen og Kræftens Bekæmpelse anfører desuden, at lovforslaget – i fraværet af
en effektiv aldersverificering - godkender den nuværende utilstrækkelige fremgangsmåde,
hvor forbrugeren kan afkrydse, om vedkommende er fyldt hhv. 16 eller 18 år.
Side 11
Dansk Selskab for Folkesundhed (med tilslutning fra Region Hovedstaden), anfører
endvidere, at lovforslaget pålægger ansvaret for alderskontrol hos kunden og ikke den
erhvervsdrivende.
Alkohol & Samfund, British American Tobacco, Dansk Selskab for Folkesundhed (med
tilslutning fra Region Hovedstaden), og Nikotinbranchen anfører, krav om
aldersverificering gennem en to-faktor godkendelse eller nævner f.eks. MitID som en
løsning for at forhindre salg online til mindreårige. SSP-Samrådet anfører i forlængelse
heraf, at der bør arbejdes på et alderskontrolsystem, der udgør en teknisk hindring af
muligheden for at gennemføre et online køb, såfremt man ikke kan dokumentere, at man
er over aldersgrænsen.
British American Tobacco og Nikotinbranchen anfører endvidere, at onlinehandel bør
sidestilles med salg i fysiske butikker, så der opnås symmetri i reglerne.
Swedish Match anfører, at lovforslaget adresserer problemet med manglende
lovhjemmel, men at det fortsat er uvist, hvordan alderskontrolsystemerne ved salg online
skal udformes for at være fyldestgørende og sikre, at kundens aldersoplysning bliver
effektivt verificeret. Swedish Match anfører, at man ikke bør afvente udviklingen af et
officielt alderskontrolsystem, der helt eliminerer risikoen for mindreåriges adgang til køb
af nikotinprodukter fra hjemmesider. I den forbindelse foreslår Swedish Match at man ved
registrering som sælger af tobaksvarer ved fjernsalg, skal præsentere et
alderskontrolsystem der, udover aktiv tilkendegivelse af alder, samtidig indeholder en
funktion, som verificerer den angivne alder ved at indhente supplerende oplysninger om
kunden. Swedish Match anfører ligeledes, at der kunne være krav om at registrere sig som
kunde ved indgivelse af oplysninger, der understøtter den angive alder, for at få adgang til
at handle fra den pågældende webside. Swedish Match påpeger, at dette ikke vil
eliminere risikoen for falske profiler, men at det vil gøre det mere omstændigt og
besværligt for den mindreårige at handle online.
Bryggeriforeningen og GEjSER anfører – i forlængelse af deres bemærkninger til
alderskontrol i fysiske butikker – at aldersverificering ved elektronisk betaling også kan
være en løsning ved salg online.
Tandlægeforeningen anfører, at de noterer sig, at der med lovforslaget lægges op til at
styrke alderskontrollen online, når den rette løsning er tilgængelig.
Dansk Erhverv anfører, at de bakker op om, at der i lovforslaget fortsat er lagt op til
metodefrihed for alderskontrol ved online salg (pop up, afkrydsning eller andet), således
erhvervsdrivende ikke bebyrdes med krav til specifikke metoder til alderskontrol.
Alkohol & Samfund anfører, at det skal være tydeligt, at tredjeparter, fx
udbringningsvirksomheder, også er ansvarlige for at verificere alder i forbindelse med
markedsføring online. De anfører, at dette gerne skal ske elektronisk, da køb foregår
online via app eller hjemmeside. Alkohol & Samfund opfordrer endeligt til, at
Sikkerhedsstyrelsen fører tilsyn med disse typer af virksomheder.
Side 12
Ministeriet bemærker, at aftalepartierne bag den nationale handleplan mod børn og
unges rygning fra 2019 var enige om, at der skulle stilles krav til internetforhandlere om at
sikre et system, der effektivt verificerer købers alder.
Det er således allerede besluttet, at der skal stilles krav om effektiv aldersverificering
online. Aftalepartierne var dog enige om, at det skal sikres, at forhandlerne har
tilgængelige løsninger, før kravet sættes i kraft.
De foreslåede ændringer i lovforslaget bygger på den eksisterende praksis på området og
skal indføre en klar hjemmel for alderskontrollen online, som kan anvendes frem til, at
indenrigs- og sundhedsministeren kan sætte bestemmelserne om et mere effektivt
alderskontrolsystem i kraft. Det bemærkes, at der pågår et arbejde i ministeriet i forhold til
dette.
Ministeriet kan påpege, at det i bemærkningerne til lovforslagets § 2, nr. 3, og § 3, nr. 2, 4
og 6, fremgår at det påhviler den person eller virksomhed m.v. der erhvervsmæssigt
markedsfører produkterne på hjemmesider, profiler, apps, webshops m.v. at sikre, at der
ikke sælges til mindreårige i strid med reglerne. Denne personkreds vil således også
fremover kunne pålægges straf for manglende etablering og drift af et sådant generelt
alderskontrolsystem. Ministeriet kan hertil tilføje, at såfremt, der er flere parter involveret i
et salg, vil ansvaret for alderskontrol påhvile den umiddelbare aftalepart – det vil sige den
part, som forbrugeren indgår salget ved. Dette vil blive præciseret i de specielle
bemærkninger i lovforslaget.
Ministeriet bemærker endvidere, at Sikkerhedsstyrelsen fører kontrol med lov om forbud
mod salg af tobak og alkohol til personer under 18 år samt fører kontrol med
aldersgrænsen i lov om elektroniske cigaretter m.v.
Ministeriet kan i øvrigt bemærke, at det fremgår af regeringsgrundlaget, at regeringen vil
løfte sundheden og trivslen blandt børn og unge og på tværs af bl.a. sundheds-, kultur- og
børne- og skoleområdet tage initiativ til en forebyggelsesplan målrettet børn og unge.
4.2.1. Forbud mod online salg
Dansk Selskab for Folkesundhed (med tilslutning fra Region Hovedstaden), Danske
Patienter, Hjerteforeningen, Kræftens Bekæmpelse og Lungeforeningen anfører, at
onlinesalg af tobaksvarer og lignende produkter ikke bør være tilladt. Flere af parterne
henviser til, at et forbud mod online salg af tobaksprodukter anbefales af WHO, og at det
vil gøre tobak mindre tilgængeligt for især børn og unge.
Ministeriet bemærker, at elementerne i lovforslaget vedrørende alderskontrol bygger på
den eksisterende praksis på området og har til hensigt at indføre en klar hjemmel for
alderskontrollen online, som kan anvendes frem til, at indenrigs- og sundhedsministeren
kan sætte bestemmelserne vedrørende krav til at drive et mere effektivt
alderskontrolsystem i kraft.
Ministeriet kan i øvrigt bemærke, at det fremgår af regeringsgrundlaget, at regeringen vil
løfte sundheden og trivslen blandt børn og unge og på tværs af bl.a. sundheds-, kultur- og
børne- og skoleområdet tage initiativ til en forebyggelsesplan målrettet børn og unge.


Til Folketingets Sundhedsudvalgs orientering fremsendes hermed høringsnotat og
høringssvar til L 123 – Forslag til lov om ændring af lov om tobaksvarer m.v. og
forskellige andre love (Implementering af dele af delegeret direktiv vedrørende
opvarmede tobaksvarer m.v.).
Lovforslaget har været i offentlig høring i perioden fra den 3. februar 2023 til den 6.
marts 2023.
Med venlig hilsen
Sophie Løhde
Folketingets Sundhedsudvalg
Slotsholmsgade 10-12
DK-1216 København K
T +45 7226 9000
F +45 7226 9001
M sum@sum.dk
W sum.dk
Dato: 27-04-2023
Enhed: FOST
Sagsbeh.: DEPADMA
Sagsnr.: 2213653
Dok. nr.: 2589288
. / .
Offentligt
L 123 - Bilag 1
Sundhedsudvalget 2022-23 (2. samling)