Monday, January 30, 2023

A Netherlands Nicotine Pouch Ban Would Assure That Dutch Smokers Continue to Die






The Dutch government has published a “consultation”, or invitation to comment, on proposed legislation to ban nicotine pouches.  I fear that this process, much like FDA comment periods, is more theater than substance, with agency positions already baked in and heavily influenced by the usual tobacco-prohibition suspects.

Nevertheless, I submitted the following response with a straightforward message: A nicotine pouch ban would assure that Dutch smokers continue to die.

January 12, 2023

Dear Madam/Sir,

I am a professor of medicine and hold an endowed chair in tobacco harm reduction research at the University of Louisville in the United States.  I am responding to the Dutch government’s consultation on legislation to ban nicotine pouches.  I was the senior author of the first medical journal publication about nicotine pouches (1), and I feel qualified to make the following comments.

If the Dutch government bans nicotine pouches, this will inevitably perpetuate high mortality rates among Dutch smokers.  To illustrate my statement, I compared mortality rates for lung cancer, the sentinel disease of smoking, among men and women in The Netherlands and in Sweden, where vastly safer smoke-free options such as snus and nicotine pouches are widely available and consumed.  I derived estimates for the year 2020 from the World Health Organization’s International Agency for Research on Cancer mortality database (2).  The rates for the two countries are completely comparable because IARC provides individual country rates that are calculated using a standardized population age structure (3).  All the rates in the following paragraph are reported as deaths per 100,000 among men or women age 40+ years.   

The lung cancer mortality rate (LCMR) among men in the Netherlands is 92, which is twice as high as the rate for Swedish men (45.1).  Similarly, the LCMR among women in the Netherlands is 72, which is 60% higher than the rate for Swedish women (45). 

In short, a Dutch government ban on nicotine pouches would deny Dutch smokers vastly safer cigarette substitutes, thereby needlessly increasing their risk for premature smoking-attributable diseases and deaths.


Brad Rodu


University of Louisville


  1. Plurphanswat N, Hughes JR, Fagerström K, Rodu B. Initial Information on a Novel Nicotine Product. Am J Addict. 2020 Jul;29(4):279-286. doi: 10.1111/ajad.13020. Epub 2020 Mar 16. PMID: 32176374.   Cancer Today, IARC, WHO
  1. Cancer Today Website.  International Agency for Research on Cancer, World Health Organization.
  1. Cancer Today Website, Help.  International Agency for Research on Cancer, World Health Organization.



Thursday, January 19, 2023

Tobacco Controllers, Denying Harm Reduction Facts, Promote Orwellian Newspeak


Joanna Cohen is the Bloomberg Professor of Disease Prevention and the Director of the Institute for Global Tobacco Control at Johns Hopkins University’s Bloomberg School of Public Health.  Together with other editors of the prohibitionist journal Tobacco Control, she published a screed aiming to change the words people use to talk about tobacco, and particularly reduced risk products. 

Dr. Cohen, in a public email, further claimed that common, accurate terms such as “e-cigarette and heated tobacco products” serve “tobacco industry interests… We should not be doing the tobacco industry’s work for them.”

Dr. Cohen knows something about wording and misperception.  Here are the results and conclusions of a 2022 study for which she served as senior author:

“About 61.2% of smokers believe nicotine causes cancer or don’t know… High perceived threat of tobacco may be overgeneralized to nicotine…The current study supports the need for corrective messaging to address the misperception that nicotine causes cancer. Identifying that nicotine misperceptions are associated with higher harm perceptions about tobacco smoking suggests that there may be unintended consequences of high perceived harm of tobacco smoking that need to be addressed. As nicotine misperceptions are significantly more prevalent among those already at higher risk of tobacco smoking caused diseases, care should be taken to ensure equity in message dissemination.” (Cohen text, Brad Rodu corrections for accuracy)

The point of the above corrections is to underscore that Tobacco Control editors should not be advocating changes in terminology when they are guilty themselves of conflating the tobacco plant with lighting it on fire and inhaling smoke.  This is a topic I have blogged about before (here and here).

Dr. Cohen ought to direct her efforts toward the worst example of improper terminology – “e-cigarette or vaping product use-associated lung injury (EVALI).”  First coined by the CDC, this misleading formulation has been adopted by tobacco harm reduction opponents in order to obfuscate differences between vaping marijuana and vaping nicotine.  Rather than correcting their error, prohibitionists have doubled down, as seen in a recent EVALI endorsement by the American Thoracic Society (ATS).

Clive Bates explains in the following 10 paragraphs the damage caused by adoption of the EVALI fallacy:

“Truly appalling to the point of being cynical and sinister...The most notably absent feature of the [American Thoracic Society] workshop is any real recantation of the massive wave of misinformation about EVALI generated by the anti-vaping tobacco control community from 2019 to the present day, despite the fact that nicotine vaping was not (and could not have been) implicated in the 2019-20 outbreak of lung injuries in the United States (see analysis here).   Instead, there is something far worse: an attempt to redefine EVALI so that the misinformation was right all along.  

‘EVALI: This term will be used to refer to all e-cigarette–related lung injury. This term will be used as an umbrella, as the EVALI epidemic has brought attention to e-cigarette–related health effects and is used broadly to document lung injury/disease attributable to e-cigarettes. It should be noted that the CDC does not limit EVALI diagnosis to those exposed to particular active ingredients, and use of all e-cigarettes were considered under the diagnostic criteria.’

“One wonders if this was a premise or finding of the 2021 ATS workshop or whether it has been added to the write-up retrospectively as an ex-poste justification for the flawed framing of the issue at the workshop. As we've seen on Stanton Glantz's blog and with Laura Crotty Alexander's statements, this definition is a kind of escape from accountability for the misleading attribution of EVALI (the 2019 US lung injury outbreak) to nicotine vaping.  There is nothing on the (now archived) CDC website that suggests CDC intended EVALI to refer to anything but the US lung injury outbreak and the agents and mechanisms that caused it.  

“This formulation allows a single case of an adverse respiratory reaction to nicotine e-cigarettes anywhere in the world to be classed as ‘EVALI’, and for academics/activists to say, ‘nicotine vaping causes EVALI.’ The effect of that, however, is to load the negative perceptions associated with the US outbreak of lung injuries (a large outbreak of 2,800 hospitalisations and 68 deaths) into risk perceptions about nicotine vaping, which did not cause these. It is deeply unethical and misleading to do this. Scientists should be trying to clear up misunderstandings and confusions (many of which they have created or amplified), not adding to them through unwarranted conflations. 

“They could try to justify this on the basis that ‘we are scientists, and we can use whatever terminology we like, as long as we are clear about it.’ However, it would still be unethical because the predictable consequence (whether unintentional or deliberate) will be a conflation of radically different risks and, therefore, the promotion of misunderstanding. Just like saying, ‘all tobacco products are harmful,’ but worse. Scientists behaving ethically would actively take care not to do this and to dismantle the confusions that they had previously worked so hard to promulgate.  There is perfectly good language available to describe effects other than the EVALI caused by THC-VEA for the extremely rare (and usually contested) cases where nicotine vaping may be implicated in adverse pulmonary reactions, for example, in people with allergies or pre-existing conditions.

“The inclusion of this is designed to increase the confusion and inappropriate conflation: 

‘Although most affected individuals reported use of cannabinoid e-cigarettes, approximately 20% reported using only nicotine e-cigarettes [citation removed]. It is unknown whether these patients were unintentionally exposed to VEA through cross-contamination of e-liquids or sharing of e-cigarettes or whether additional ingredients, such as medium-chain triglycerides (MCT), can lead to EVALI  [citation removed].’

“We need to be absolutely clear here. This 20% of cases were not and cannot have been caused by nicotine vaping. That is just inconsistent with the epidemiological evidence (the outbreak was confined in time and place and ended without any changes made to nicotine vaping products. the causal agent VEA cannot be added to nicotine e-liquids and would serve no purpose if it could be).  The reason people deny using THC is that illicit drug use presents problems with law enforcement, parole officers, employers, colleagues, schools and parents. How obvious do things need to be before they are understood by tobacco control academics?  It is also possible that some people were sold fake THC vapes with no active ingredients, just the cutting agent. So the statement above is pure merchant-of-doubt. 

“Personally, I suspect at least some of the authors are doing this deliberately. Firstly to cover their tracks over the massive misinformation sprayed over the public in 2019-20, but more insidiously because they want these products to be seen as harmful to deter use of them.  Further, they need nicotine vaping to be harmful, or they lose the rationale for control (the purpose of tobacco control - it's in the name) and, therefore, their reason to exist.  

“There are two ways to look at this: a disgraceful cynical, defensive fear play or so naive as to be negligent. Sorry, no nice way to put it.”

George Orwell, in his seminal book “1984”, coined the term “newspeak”, defined today by Merriam-Webster as propagandistic language marked by euphemism, circumlocution, and the inversion of customary meanings. George, meet Dr. Cohen and her fellow-travelers.