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
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.
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:
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.
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".
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?
A General Election is being held in Ireland on February 8th and 5 per cent of the electorate is being ignored by the main political parties. Fianna Fail, Fine Gael and the Irish Green Party all promote policies to further marginalise the hundreds of thousands of current vapers in Ireland.
Fianna Fail has suggested banning what they describe as “child focussed flavours” by which they mean all flavours. Most adult vapers consume dessert, fruit and candy flavours to distance themselves from the taste of tobacco so, under this proposal, will be deprived of a significant factor in ensuring they stay away from smoking. The party has also stated they intend to remove vaping entirely as part of their smoke free Ireland targets.
The Green Party boasts about how it intends to introduce “comprehensive e-cigarette legislation covering advertising and flavouring”, while Fine Gael’s manifesto proposes a “licensing system for the retail sale of nicotine-inhaling products” and a “ban on advertising on public transport and in cinemas” while also making it known that they too wish to discourage vaping through targeted taxation.
All these policies are designed to make vaping less accessible to vapers and to smokers who could benefit by switching to safer products for the good of their health. Crucially, these political positions have been formulated in ignorance and without even a cursory consultation with the citizens who will be most affected by them. Vapers are passionate about their choice to improve their health by switching to safer products and well-known to place this high in their priorities when they come to vote.
"Vapers have no party representing them at the General Election this year”, says Damian Sweeney of ETHRA partner NNA Ireland, “we already have sensible regulation of vaping under the EU Tobacco Products Directive, it is irresponsible to damage that by unthinkingly restricting vastly safer products. There are currently between 180,000 to 250,000 vapers in Ireland, making up 5 per cent of the public according to the latest Healthy Ireland Survey, yet no party supports us.
“In advance of the General Election, around 200,000 votes are up for grabs for any enlightened party who would do their research and embrace vaping as a revolutionary innovation which has been responsible for reducing smoking rates all over the world."
"The first and most important thing any future government should do is engage with the people who use these products,”, said Tom Gleeson of NNA Ireland. “They are the ones who will be affected and have the greatest stake in any regulatory outcome. We would advise Irish vapers to question candidates on the doorstep to ask why they are marginalising a significant section of the population without talking to us."
NNA Ireland has today released their General Election Policy which you can read on their website here.
POSTED BY: NIKAN JANUARY 18, 2020
There are now more Norwegians using snus than smoking daily.
New figures from Statistics Norway show that while 14 per cent of the population aged between 16 and 74 used snus daily in 2019, only 9 per cent were daily smokers. Nikan has looked at the figures and asked for comments from researcher Karl Erik Lund at the Institute of Public Health.
In the last 10 years, the proportion of daily smokers has more than halved, from 21 per cent in 2009 to 9 per cent in 2019. Meanwhile, the proportion of daily snus users has increased, from 6 per cent in 2009 to 14 per cent in 2019. Snus has thus taken over as the preferred mode of administrating nicotine - which is gratifying news from a harm reduction perspective.
Percentage of people aged 16-74 who smoke or use snus daily
Source: ssb.no
Karl Erik Lund at the Institute of Public Health comments on developments as follows:
“The change that has taken place in the Norwegian nicotine market is very positive and has received a lot of attention abroad. There has been a rapid shift from life-threatening incineration products such as cigarettes and rolling tobacco to various varieties of snus. The proportion of smokers has halved in 10 years. Twenty years ago, every third Norwegian smoked daily. According to the Directorate of Health, Norway is the country in the world that has had the steepest decline in the number of daily smokers.”
Karl Erik Lund points out that the total volume of tobacco consumed by Norwegians has also reduced. Thus, it is not true that the strong increase in snus consumption has contributed to an increase in overall tobacco use.
“Overall, this will result in a formidable public health benefit. We can expect far fewer new cases of COPD, lung cancer and cardiovascular disease. These diseases together account for 75 per cent of smoker-related deaths. Snus - though not risk-free - does not increase the risk of contracting any of these three diseases.”
The figures from 2019 show a particularly strong decline in smoking from 2018 to 2019 and a corresponding increase in snus use. Lund does not want to pay particular attention to developments from one year to the next but states that he is focusing on the long-term trends. There are annual variations that are often due to chance.
Snus use is most common among young men
There are still many more men than women who use snus daily- 20% and 7% respectively state they use snus daily. Nonetheless, among women, daily use of snus has increased from a low of 1 to 7 per cent over the past 10 years.
Snus use is most common among young people and most commonly used among those between the ages of 25 and 34. In 2019, 24 per cent in this age group used snus daily. In this group, the proportion of daily smokers has decreased from 20 per cent in 2009 to only 4 per cent in 2019. In the youngest age group - 16-24 years - only 2 per cent smoke daily.
The figures below show the development in the group 25-34 years in the last 10 years, among men and women.
Men
Women
Nikan’s View
Nikan is very positive about the development. Although it is not risk-free to use snus, it is far less harmful to health than smoking.
The National Institute of Public Health has estimated that 2 out of 3 smokers will die as a result of smoker-related illnesses. Studies show that many people use snus as a smoking cessation product. There are also some that start using snus without smoking first. The critics claim that the latter is a public health problem. We at Nikan believe that very many in this group would start smoking if snus was not available. It is the countries that allow snus that have had the strongest decline in smoking in recent years. This shows that we need less harmful ways of taking nicotine.
Statistics from Statistics Norway can be found here.
This post originally appeared on Nikan's website, you can read it (in Norwegian) here: Snus erstatter røyking – gir store folkehelsegevinste