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With the onset of COVID-19, governments around the world are frantically trying to put measures in place to deal with the greatest crisis we have faced in a generation. In many countries all but non-essential businesses have been shut, mass gatherings have been banned, countries have closed their borders and strict travel restrictions have been put in place. These measures, together with social distancing, are vital to ensure we ‘flatten the curve’ and slow down the spread of the virus, but they have also presented some challenges and had unintended consequences of their own.

As we have previously reported, restricted access to safer nicotine products is proving to be one of the unintended consequences of the current crisis. This has been highlighted once again since the border between Finland and Sweden closed a number of weeks ago. ETHRA partner, EUforSnus, has reported that there are growing concerns among the 200000 Finnish snus users that they cannot now purchase snus for personal use.  According to Finnish (and EU) law, buying snus for personal use is not prohibited and travellers to Finland are allowed to bring in 1kg of snus. 1 kg of snus corresponds to about 30-40 cans of portion snus.

Now Finnish snus users are demanding that the Finnish government temporarily allows Finns to make online snus purchases. Marko Matilainen, EUforSnus moderator, has made the proposal to the Finnish government to allow the ordering and selling of snus in Finland arguing:  “in the current situation, passenger imports from Sweden for snus are impossible, and there is a high risk that many will resort to cigarettes. It is known that tobacco exacerbates the susceptibility to coronary pneumonia, so the non-smoking option is better, this also significantly supports the Government's "non-smoking Finland" project.”

We would urge all ETHRA partners and supporters of tobacco harm reduction to share this initiative to allow temporary remote ordering of snus in Finland. The petition requires 50000 signatures by Finnish citizens, and can be found here [Link]

Thanks to EUforSnus for bringing this to our attention [Link]

Snus has a proven track record when it comes to harm reduction and Sweden, where snus is widely used as a replacement for combustible tobacco, has the lowest instances of smoking related male cancer and heart disease in the developed world. Snus’ record as a smoking cessation aid is equally impressive, with Sweden having already reached its smoke free target of <5% smoking prevalence. Snus is also the only tobacco product to have been granted a modified risk order by the US FDA.

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Facebook and Vapolitique
One social media platform appears to be doing its utmost to restrict the free flow of information.

Philippe Poirson found himself locked out of Facebook after he shared an article from the newspaper 24 Heures, regarding chloroquine tests on COVID-19 at the Lausanne hospital, on the grounds that he’d breached the policy on “organized violence and apology for crime”.

The crackdown on Vapolitique’s Poirson follows a ban being issued to Dr. Philippe Arvers, an addiction and tobacco specialist at the Armed Forces Medical Center, for sharing a VICE article denigrating studies by Stanton Glantz.

Philippe reports that Facebook is also blocking access to COVID-19 articles from Buzzfeed, Politico, The Atlantic, USA Today, Vice, Business Insider, Axios and The Seattle Times.

Guy Rosen, vice president of Facebook, said in a tweet that this was a, "problem with an automated system which removes links to abusive sites, but which has removed many other posts too.”

  • Covid-19: la censure de Facebook connait un nouvel accès de fièvre, très orientée idéologiquement”, Vapolitique – [link]

France
Thanks to the excellent work of SOVAPE, among others, French vape shops have been allowed to reopen following an instruction to close due to the pandemic.

Vapolitique highlights that keeping vape stores open can help limit the spread of COVID-19: “[It] reduces social interactions by preventing vapers who do not have the possibility of buying at a distance from adding to smokers in the same tobacco shops. This reduces the effects of promiscuity and facilitates social distance, which is currently the most effective means of prevention against the spread of the virus.”

Philippe notes that Fivape, an independent vape federation, and SIIV, the vape trade union, both published recommendations yesterday on the in-store rules to follow for the vape sector:

The Swiss organisation Association of French vaping professionals (ARPV) has also communicated its advice:

  • A distance of two meters between each person
  • Systematic hand washing with an alcoholic product between each customer
  • Disinfect counters, handles and equipment handled between each customer

Philippe reports that a number of vape stores have set up drive-thru systems for orders by phone or email. They will also continue to ship these orders by post – for as long as the service runs - to help people in emergency situations and recent ex-smokers.

  • SOVAPE – [link]
  • Suisse, France et Italie: l'ouverture des vapeshops répond d'une double réduction des risques”, Vapolitique – [link]
  • FIVAPE recommendations – [link]

Martin Dockrell Responds
In response to an opinion piece about the role of smoking cessation and COVID-19 [link],  Public Health England’s Martin Dockrell called for vape stores to remain open as part of any action to slow the spread of the virus.

He wrote: “I note that … [France] and [Italy] exempted vape shops from their shut down. Very sensible. Great that food shops are kept going but most sell tobacco. It would be very unfortunate to protect tobacco supplies and block the supplies of the most popular and effective ways to quit.”

Martin Dockrell tweet

Greece
Dr Konstantinos Farsalinos has updated ETHRA on the current situation in Greece. He says that vape stores are regulated as food stores and therefore remain open. Greece instructed all stores other than food shops, vape shops and car repair centres to close.

Vape stores have been told not to allow vaping in-store, which includes the testing of eliquid flavours, and to focus on posting online and phone orders following advice given to the government by Dr Farsalinos.

Italy
Filtermag is reporting that Dr Riccardo Polosa has successfully reversed the nation’s decision to close down vape stores.

Italy’s response to becoming the European nation suffering the most from the COVID-19 pandemic was to ban public gatherings, close schools and shutting down most businesses – including vape brick and mortar shops.

Helen Redmond reports Dr Polosa saying: “I thought it was terribly wrong to keep tobacconists open and vape shops closed for the simple reason that in a situation of high anxiety and stress, people will smoke a lot at home where they are confined and they will expose a lot of bystanders to the risks of tobacco smoke. Particularly young babies, kids.”

For people who have already developed a smoking-related disease, this is good news. They can feel for themselves the beneficial effects of the switch.”

  • A Scientist Persuaded Italy to Exempt Vape Shops From COVID-19 Lockdown”, Filtermag – [link]

Belgium
Belgian smokers and vapers are suffering from the government’s intransigence and blinkered view of tobacco harm reduction.

Frank Baeyens tweeted to ask the Belgium government to allow online sales or to open the vape shops. With no access to juice or vape products, fears are that many ex-smokers will return to using tobacco cigarettes the longer the situation is allowed to persist.

Spain
It has been reported that most shops are closed in Spain, but tobacconists remain open. Some tobacconists carry vape stocks, but this is far from an ideal situation for those seeking to reduce their harm exposure while legally using nicotine.

United Kingdom
The Independent Vape Trade Association (IBVTA) has issued advice to the vape industry on how to conduct business during the COVID outbreak. IBVTA’s advice can be read in the article linked below.

The UK Vaping Industry Association (UKVIA) has written to the UK government to emphasise the importance of keeping vape shops open. UKVIA says: “Our simple ask of you is to ensure that vape shops in towns and rural areas stay open during the crisis. We recognise and support the Government’s intensified containment plan for the virus but would urge you and your colleagues to look at the example of Italy. Dr Riccardo Polosa, a world renowned scientist and researcher on vaping and tobacco harm reduction and founder of the Centre of Excellence for the Acceleration of Harm Reduction, successfully argued that due to the stress caused by the Coronavirus, with the closure of vape shops vapers were highly likely to go back to smoking cigarettes to maintain their nicotine needs. This could be dangerous from a public health perspective and could heighten the risk of exposure of tobacco smoke to bystanders. This could also place a further burden on an already overstretched health system.

  • IBVTA Issues COVID-19 Advice – [link]
  • The UKVIA writes to the Government to urge them to keep vape shops open during and post the coronavirus crisis – [link]
  • The UKVIA writes to the Scottish and Welsh Governments to urge them to keep vape shops open during and post the coronavirus crisis – [link]
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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.  

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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 Researcher
Norwegian Institute of Public Health
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 What follows is an English translation of Vape: la direction de l'OMS pousse pour la défense du tabac indien et l'agenda électoral de Bloomberg contre la science, written by Philippe Poirson and published on Vapolitique, here.

Vaping took centre stage in what turned out to be a concerning briefing at the 146th session of the WHO Executive Board (EB146) in Geneva on 4 February. Put on the agenda by Iraq, a nation where vaping is not a priority, the subject was introduced by the Director-General of the WHO, Dr Tedros Adhanom Ghebreyesu. Although the session had only an informative and non-decision-making status, the direction desired by the Secretariat of WHO left no room for doubt. Tedros has taken up the language of the billionaire candidate for the White House, Michael Bloomberg, by repeating the unsupported belief that vaping is toxic and a threat to young people. "We know enough to have to protect our children from their harmful effects," says Dr Tedros as a policy line for the WHO. This was without discussing harm reduction in the context of smoking, nor relevant scientific work of independent organizations, notably those in the UK.

1

Ranti Fayokun, the collage expert

Attempting to support the predetermined anti-vape rhetoric of the session, Ranti Fayokun was summoned as a scientific expert. In a presentation that contradicted established scientific studies, she exaggerated the already ludicrously false claims about vaping. At one point confusing solid fine particles and liquid droplets, she then assured those listening that vaping gives off more formaldehyde than cigarettes, neglecting to explain that this finding occurred during unrealistic, ‘dry puff’ conditions which would make vaping impossible in a real-world situation. Following this and in a vain attempt to suggest that vaping increases heart attacks and strokes, she then referenced a bogus study that counted people who had heart attacks or strokes before vaping. To illustrate this baseless assertion for the delegates, (not visible on the WHO public broadcast) she used this photomontage, which is worthy of The Sun:

2

In a further bizarre twist, Ranti Fayokun said she’s concerned because some devices are adjustable. The health justification for this concern remains a mystery, the only logical explanation I can come up with is an aversion to freedom of choice on the part of the WHO expert.

Not relying on mockup spoof imagery showing babies vaping, as she did in the Senate of the Philippines, she still maintained that flavours of liquids are primarily intended to attract "children". She then distributed 50ml bottles of vape liquids that were purchased in Geneva but didn’t specify that bottles containing more than 10ml of liquid are sold without nicotine, in compliance with EU regulations.

Scientific denialism

Concerning people who stop smoking with vaping, "what is the harm for these people [ex-smokers] to use vaping. (...) What will you say to a parent who lost his or her child to EVALI?" wonders Ranti Fayokun. This is said in the full knowledge that these lung injuries are linked to adulterated vitamin E products on the THC black market and not to nicotine-containing e-liquid. Compounding the illogical leaps in her presentation, a few minutes later she returned to the subject of smoking cessation to affirm that there is no evidence that vaping helps people to quit smoking. The existence of British studies and the millions of testimonies are simply denied.

Using National Youth Tobacco Survey (NYTS) data on past 30 days use, at least one puff in a month, the fact that this data is not related to frequent use was omitted. Also omitted, despite mentioning knowing beforehand, was the fact that a large part of the vaping data concerned the use of non-nicotine products. Yet she said youth will become addicted to nicotine "and it will affect their health ". Not bothering to take into account the dramatic fall in adolescent smoking correlated with vaping.

3

Rewriting history?

She concluded by sticking to the script of the Bloomberg funded, anti-vape MPOWER report, published last summer.  Also present at the session was Vinayak Prasad, co-author of the report and former senior official in the Indian government, who unsurprisingly supported the call for a crackdown on vaping, along with Tibor Szilagyi, coordinator of the Secretariat of the Framework Convention on Tobacco Control (FCTC).

The WHO has taken an increasing prohibitionist approach to vaping, during COP7 in New Delhi Szilagyi stated that he would have voted to recommend to member countries "to prohibit or restrict vaping"

4

Should the English and the French continue to finance this propaganda?

The willingness of WHO to place this subject at this session of the Executive Board clearly points to the electoral agenda of the financial sponsor of the organization, Michael Bloomberg. For its part, Indian tobacco has already made its interests a priority by relying on the MPOWER report, co-authored by Vinayak Prasad, to prohibit vaping in India. The deep conflicts of the WHO on the subject, as highlighted by Sovape, are very worrying - especially the hijacking of the WHO’s anti-smoking activities by the American billionaire and Indian tobacco interests.

This should raise serious questions about the position of two major donor countries in this area of ​​WHO (up to 6% of the budget each); France and the United Kingdom. Should the taxpayers of these two countries continue to subsidise and be complicit in the political manoeuvring of the American oligarch and the financial interests of the Indian Tobacco Company (ITC Ltd), at the expense of the anti-tobacco campaign, FCTC and the human right to harm reduction?