In this hard-hitting post researcher Karl Erik Lund slams Dagens Næringsliv’s (Norway’s largest financial newspaper) biased and erroneous report on e-cigarettes. On 1st February the DN ran a hugely negative fourteen-page article on vaping. Prior to the article, the newspaper had published a dramatic video-trailer on its website. The newspaper received a lot of reaction from vapers, and Nikan wrote to the journalists responsible. However, no corrections were made.
Dr Karl Erik Lund, a senior researcher at the Norwegian Institute of Public Health, has researched tobacco harm reduction and e-cigarettes since they entered the market. Dr Lund wrote to DN to refute five of the claims made in the article. The editor agreed only to print a shortened and edited version so Lund gave Nikan permission to publish the full version.
We hope this will be read by many people, including vapers, smokers who are confused about health risks from vaping and politicians. This is an English translation of Nikan’s post, the original, in Norwegian, is on Nikan’s website, here.
Oversimplifying the vaping phenomenon
Dagens Næringlivs (DN) dramatic report from 1st February must have been targeted at Parliament’s decision to permit the sale of nicotine-containing liquid in e-cigarettes. The article’s drama unfolded in five parts:
1) The emergence of e-cigarettes was attributed to the tobacco industry.
2) A young woman attributed her “f*****” lungs to vaping,
3) E-cigarettes were associated with the deadly lung disease outbreak in the USA.
4) Vaping was alleged to be a global social problem, an epidemic affecting millions of nicotine-addicted youth.
5)It was suggested that while other countries are on alert, the Norwegian health authorities are passive and unprepared.
Wednesday’s edition saw a shocked Kjersti Toppe (MP) demanding intervention from health minister Høie - who on his side is asking, understandably, for thorough research. DN’s article addresses a potential problem but it is biased, alarmist and contains errors.
1. Is the tobacco industry behind vaping?
As a researcher, I have been following the development of the nicotine market for 35 years. I have written about the tobacco industry’s dubious dispositions in scientific articles and reports, in public reports and in numerous opinion posts. In five court cases I have been called upon to act as an expert witness against the tobacco industry. The tobacco industry can be accused of a lot of misconduct, but the development of e-cigarettes is not due to any of their conspiratorial business. The development of e-cigarettes has rather been a consumer-driven phenomenon, driven by smokers who wanted a less risky intake of nicotine - mainly for recreational use but also as a therapeutic method in smoking cessation. With e-cigarettes, the nicotine market received a new entry and both the tobacco and the pharmaceutical industry felt their market shares being threatened by a new group of providers. Until Altria bought into Juul Labs in 2018, independent producers had more than 80% of the market.
However, more recently tobacco companies have developed their own e-cigarettes or have bought into businesses that already had a high market share (eg. Juul). This raised alarm bells. Many who originally had a positive attitude towards e-cigarettes have now turned negative; an understandable emotional reaction. Nevertheless, we must ask; is it better if the tobacco industry just sticks to the production of deadly cigarettes and leaves the e-cigarette market to others? As a financially strong actor, the tobacco industry can be expected to improve product safety and quality, both of which are very varied in the current market. The dilemma for the politicians is whether they should prevent or facilitate the transformation of the tobacco industry, who themselves claim to be replacing the production of cigarettes with e-cigarettes. Will the tobacco industry voluntarily stop the production of cigarettes? Probably not, unless their profits are low. Fewer and fewer smokers and higher taxes on cigarettes could help that happen.
Even if smoking is reduced to a minimum, several things indicate that nicotine in one form or another will continue to be consumed for recreational purposes. Consumers report numerous positive stimuli (a very understudied phenomenon), not unlike what you get from caffeine. However, on the health side, we typically interpret and explain the use of nicotine in a model of dependence where the consumer compulsively takes the substance against his own will. Dependence can explain why some people are nicotine users, but in Norway, almost half of the smokers and snus users are occasional users – less frequent than daily. Their limited intake is generally dependent on the social context, so is apparently under control and must be explained according to the pleasure principle.
In Norway, the sale of nicotine in its most deadly form (cigarettes) is permitted, whilst e-cigarettes and tobacco-free snus are banned from the market. Clearly, this is a paradox. Nicotine is not risk-free, but it is neither carcinogenic nor is it a direct cause of smoking-related deaths. The method for nicotine uptake largely decides the potential for establishing dependence. The cigarette is the worst for establishing this dependence.
The e-cigarettes that will be sold in Norway will have less potential for dependence than both combustible cigarettes and the e-cigarettes that are now sold in the USA, for example, Juul.
Many have a purist aim of an ideal society without the use of nicotine whatsoever and do not want new nicotine products to be released onto the market. A more pragmatic aim is to facilitate the use of low-risk nicotine products while at the same time tightening the market conditions for cigarettes. Does it really matter who is the manufacturer if e-cigarettes are able to out-compete cigarettes? Sometimes hatred of the tobacco industry appears to be stronger than the desire to reduce smoking-related deaths.
In the DN the phenomenon of vaping is kind of pasted on the tobacco industry – The Good Enemy - which everyone can agree to hate. There is currently an outpouring of protest on social media from the organized vaping community to this suggestion. This community has in a short time guided many smokers to switch to e-cigarettes – at no cost to the taxpayer. These switchers are often smokers that we on the health side have a hard time reaching, as they have little use for nicotine replacement therapies, and they see themselves not as patients but as consumers. The vaping community now feels they have been denounced by the DN as an actor in a conspiracy staged by the tobacco industry - which they are not.
The fact that the tobacco industry now has a larger share of the e-cigarette market is because there is a lengthy and expensive application process which is required for the products to get access to the market in the USA. Actors outside the tobacco industry do not have the same ability and competence to go this race, and therefore fall out of the market.
2. Do you get “f*****” lungs from e-cigarettes?
The DN presents the story of a 20-year-old who believes that she no longer has the energy to run to the bus because her lungs are “f*****” from e-cigarettes. Does the DN really have confirmation that her problems can be attributed to vaping? In light of the research that reviews respiratory effects from vaping, the presented correlation seems strange. If the DN had strived for a more balanced angle, the paper could refer to research showing respiratory ailments are reduced when switching from smoke to vape. Will the DN be doing a follow-up article, featuring a former smoker who can now run for a bus, thanks to the switch to e-cigarettes?
3. Are e-cigarettes the cause of the outbreak of lung disease in the United States?
It gets even worse when DN, after the true cause has been long been identified, continues to associate the use of e-cigarettes with the outbreak of severe lung disease among adolescents in the United States. The outbreak occurred as a result of e-cigarettes used to inhale cannabis oil purchased on the black market. Vitamin E- acetate was added as a thickener to the liquids to make the product seem more potent to the buyer. The oil caused burns to the lungs. About 50 young people died.
Back in August 2019 epidemiologists were already asserting that ordinary use of e-cigarettes could not possibly be the cause, because of these characteristics:
- The lung disease appeared suddenly – not after long-term exposure.
- The outbreak was mainly limited to the United States – e-cigarettes have users all over the world
- It occurred mainly among young people –e-cigarettes have users in all age groups
- It affected vapers who inhaled cannabis oil
However, the health authorities let it pass for several months before announcing that nicotine-containing e-cigarettes were no longer the main suspect. The delay was partly due to a number of young patients not admitting to the illegal use of cannabis to the health professionals investigating the outbreak. The DN refers to sources that help to maintain this distraction and stimulate continued doubt and uncertainty. In the months of confusion about the cause in the United States, store chains deleted e-cigarettes from their product ranges, the population changed their risk perception, and newspapers reported on smokers now returning to the “safe” cigarettes. Wall Street analysts changed their scenario for e-cigarettes and wrote that the tobacco cigarette market might not be so threatened by e-cigarettes after all. This led to the price of tobacco stocks rising after a long decline.
4. Is vaping amongst the young an epidemic?
If the term “epidemic” is bandied about, the population will be keen to accept urgent and effective countermeasures. DN is referring to the National Youth Tobacco Survey and presents selectively from this survey. What this survey actually shows is that 86% of American youths do not use e-cigarettes and that among the minority who claim to have vaped in the last 30 days, the vast majority are not regular users. The survey also shows that most young people who use e-cigarettes are smokers or former smokers. Many of these young people are involved in other risky behaviours. More than half state that the use of e-cigarettes has occurred in connection with the intake of cannabis.
In Norway, 1.5% of the population use e-cigarettes, of which 95% of vapers are smokers or former smokers. The average age is more than 40 years. Only around 17% of vapers are younger than 24 years old. Our studies show that the youngest most often use nicotine-free e-cigarettes. Among young people who experiment, a very small proportion become regular users. However, you will not get this information by reading DN’s report. DN cites sources which claim that young people will be hooked for life after trying an e-cigarette. If we, as providers of health information conveyed such a message to young people, we would soon be revealed and lose our credibility. At a meeting regarding the new Norwegian drug reform recently, our Minister of Health Bengt Høie stated:
“We have failed in our communication with youth about cannabis. We have been running scare propaganda and saying things that are not right. Youth has revealed us.”
We have to make sure that the same thing does not happen in our communications about e-cigarettes.
5. Are Norwegian health authorities passive?
DN reports sources who believe that the lifting of the ban on nicotine-containing e-cigarettes is irresponsible policy, that the health authorities are passive and unprepared for what this will entail.
This is false. It is the case that under the ban the health authorities have little control over the e-cigarette market. Our figures show that around 90% of vapers import their e-liquid from abroad – often from uncertain sources of supply - for example from China. In 2016, the Parliament decided to replace the current ban with the regulated sale of nicotine-containing e-cigarettes - not a totally ‘free release’ as DN claims. This means that the country’s 100,000 vapers will no longer have to buy nicotine-containing liquid online.
The products that will be allowed to be sold during 2020 will have passed a comprehensive security clearance in advance. Six months before the product goes on sale, the seller, importer or distributor must, in a pre-market notification report, detail the content and obtain approval from the Norwegian Medicines Agency. All sellers will be registered. The upper limit for nicotine content will be 20 mg/ml. Advertising will be prohibited. All of this is contrary to what is the case in the United States. The National Institute of Public Health is monitoring the use of e-cigarettes very closely, and any upward trend among young non-smokers will be uncovered and reported to the politicians responsible.
Under a continuing sales ban, health authorities have less control and consumers have lower product safety. I believe that e-cigarettes should preferably be sold only to people over the age of 20, from specialist stores with expert guidance from customer service providers. Research from England and France shows that specialist shops can serve as a smoking cessation arena for smokers that otherwise do not seek help from health professionals –that is, the vast majority of smokers. I also believe we should consider rules for the use of nicotine salt. The presence of nicotine salts in e-liquids makes it possible to inhale higher nicotine levels without the throat resistance that would have arisen from inhalation of traditional e-juices with the same nicotine level. No resistance (smoothness) and faster absorption rate of nicotine increases the potential for both nicotine dependence and overdose – especially if used in high battery vaporizers. Internally at the National Institute of Public Health, however, there are different opinions on how e-cigarettes should be best regulated, and I only write on behalf of myself.
The DN undoubtedly has good intentions and wants young people to stay away from e-cigarettes. I do too, but believe that publishing unbalanced and exaggerated information does not serve that purpose.Karl Erik Lund (Ph.D)Senior ResearcherNorwegian Institute of Public Health