Extreme prohibition policies in some countries, while surprisingly progressive decisions in others. This is how the news year for Vejpkollen and harm reduction reporting for smokers, 2023, can be summarized.
Looking ahead to the coming year and the Tobacco Convention meeting, it is becoming increasingly clear that the debate on new nicotine products will continue. And it is likely to be more about politics and less about science.
It is not a genuine concern about injury risks that is behind prohibitions or restrictions of the availability of nicotine pouches or flavors in e-cigarettes. Neither is it compliance with the tobacco industry behind measures such as favors smoke-free alternatives over the deadly cigarettes. The health risks of smokeless nicotine products are significantly less than they are for smoking and cigarettes. But that matters less.
Concerns among scientists
The issue of e-cigs, snus, nicotine and smoking has revealed a conflict that is rooted in everything from economics to ideology. This is also true in the scientific sphere. The issue is so infected that some researchers deliberately exclude important parts of their studies just to "avoid being in the wrong camp" or being perceived as "bought by the tobacco industry". A sticking point for many researchers seems to be the "stigma" that shines through when one's research can be shown to be "beneficial" to the sale of products that can generate revenue for tobacco companies, whether that was the intention or not.
"Do not want to favor the tobacco industry"
I recently asked the Swedish researcher Magnus Lundbäckwho published a high-profile study on e-cigarettes and cardiovascular health in the fall of 2023. In subsequent media reports, he (or perhaps more accurately, the headline writers) warned of the "risks of e-cigarettes". It was a small study that didn't really say much new about how nicotine affects users. The study received criticism in Vejpkollen, mainly because of major flaws in the methodology, but also because the analysis only concludes that nicotine via e-cigarettes CAN be harmful, without comparing this with how harmful the use of nicotine actually IS in connection with smoking. I asked Magnus Lundbäck why his particular studies never compare the risks of vejpning with the well-known risks of smoking. The answer came quickly.
"I've chosen not to get involved in that discussion at all, partly because it takes over too much of what I think is important. But it's also because I don't want to get caught up in something that would favor the launch of new nicotine products, which I fundamentally don't think is a desirable development. Of course, I also read other studies and there are certainly differences between smoking and vejpa. E-cigarettes also seem to have some effect on smoking cessation, which is of course interesting. But in my research, I see no reason to compare risks between e-cigarettes and smoking. That is for others to do." he said diplomatically during an interview for an upcoming article.
Tobacco companies' 'hidden' research
Fortunately, there are now many independent researchers and institutions that make comparisons of injury risks. Among other things, we have seen recurring summaries from British Public Health Agencyfood, American FDA and the Ministry of Health in New Zealand.
But also the tobacco companies productrare research highlighting the differences between smoking and vejpa. They have to do it. Some countries, like the US, require robust research and auditable studies to even allow the launch of new nicotine products on the market. This process is costly and has affected many of the small and independent companies producing vejp products. However, the costs of randomized control trials, thousands of pages of toxicology studies, and so on, are not a major concern for tobacco companies.
A hidden ban - that doesn't work
Not surprisingly, only 23 vejp products (out of millions) have been approved for sale in the US. They are all produced by the tobacco companies and are only launched with so-called tobacco flavor. It is effectively a ban on all vejp products not sold by tobacco companies, according to many. At the same time, the 'ban' does not seem to have much effect.
"Even though the FDA has effectively banned 99 percent of all vejp products, it has no resources to control what is sold. We vejpers can still get what we need, often just by asking for a particular flavor or e-liquid in the stores that remain. Many companies have switched their focus to cannabis, but they usually have a stock of 'unapproved' e-liquids behind the counter." said Alex Clark, CEO for CASA, a consumer association that organizes over 250,000 American vejpers, when we met under E-cigarette summit in Washington in the spring.
WHO makes research "untouchable"
Apart from a quirky implementation, the vejp technology (vaporization of e-liquid) has thus received a thorough review by the US authorities. Flavor is not the focal point when the FDA assesses the relative risks, flavors are more about who is attracted to the products (read: minors). In principle, the vapor does not become more or less harmful because of the taste. However, it is concluded that the products have properties that make them "appropriate for the protection of public health". In other words, the technology has clear harm-reducing effects on the nicotine market. The FDA has done the same in its assessment of the Swedish oral nicotine product - snus - a product that PMI is now allowed to market as a "product that reduces the risks of nicotine use".
Unfortunately, few Western institutions and authorities take focus on this particular research. Not even those who have a positive view of harm reduction in tobacco legislation. The reason is precisely The Tobacco Convention which makes any research coming from the tobacco companies untouchable.
"I just wish more scientists and policymakers would judge our research findings by what they show, not where they come from. Test them, criticize them, disprove them, but don't judge research by anything other than what the results show. Is that too much to ask?" said Ignacio Gonzalez Suarez, Head of Scientific Relations EU at Philip Morris International, when I met him at a of several conferences on harm reduction that is organized annually around the world.
Conflict with public health?
In the WHO Tobacco Convention, the authors emphasize the importance of keeping the interests of the tobacco industry at arm's length from health policy. This particular paragraph are therefore regularly used to exclude a not inconsiderable amount of knowledge about relative risks between different nicotine products. Although e-cigarettes, both technology and e-liquid, have little to do with the tobacco industry from the start (it was small independent entrepreneurs who developed the products and created the market), the fact that tobacco companies now sell some of the products on the market is enough for the more aggressive anti-tobacco activists to be heard when they invoke the Tobacco Convention.
"By definition, the interests of tobacco companies are always in conflict with public health", as the saying goes.
Ignoring 99.7% of research
The United States has never signed the WHO Tobacco Convention, but Sweden has. And that can easily have absurd consequences. When the Swedish government requested a studyrescue that would juxtapose the harms (or estimated risks of harm) of different nicotine products and provide our health policy makers with an evidence-based foundation for a modern ANDTS strategy, the Public Health Agency turned itself inside out to AVOID doing just that. Out of 6000 studies and reviews on the risks of vejpning, the Agency screened out all but 18. In other words, it failed to look at 99.7% of the available research.
Of course, the report states that "we do not know enough about e-cigarettes and vejpning to say anything about the risks". A very small study with 12 participants from Karolinska institute (author Magnus Lundbäck, listen and be amazed) was, however, used as the basis for the Public Health Agency's own statements on the matter.
"E-cigarettes affect blood vessels. All nicotine use is harmful. Everything should be regulated equally," said one pressedsharing from the Public Health Agency of Sweden.
Government activism?
As I said: What could benefit the tobacco industry MUST not affect health policy. In practice, it becomes government activism, where it is considered ok not to tell the whole truth as long as the message is "correct" and fits the narrative of the anti-tobacco movement, and thus the WHO.
"Need to get the full picture"
The report was of course criticized. Not surprisingly, other authorities and institutions around the world do not seem to have had any problems whatsoever in producing evidence that vejping is SIGNIFICANTLY less harmful than smoking. One can also make a fairly clear statement about the absolute health risks of vejpa, even though long-term studies are lacking.
"In all likelihood, the risks are small, although not non-existent", the UK Public Health Agency recently stated in its annual knowledge report on vejpning in England.
The Swedish Public Health Agency did not even manage to show that there are clear differences between snus and smoking. Or rather, you can read it between the lines when you look at the summary. But the agency never says it outright.
"The conclusion for me is that this report from FHM cannot be the sole basis for future decisions, but needs to be seen in a larger context. I would have hoped that more studies included in the report would have focused on relative risk of injury, rather than prevalence. As decision-makers, we must supplement this with other studies in order to obtain an accurate overall picture. For the Moderates, the overall goal is to reduce the habitual smoking of cigarettes, rather than to limit all nicotine use." says Jesper Skalberg Karlsson (m), member of the Social Affairs Committee, in a comment on The FHM report for an article in Vejpkollen.
Monitoring the WHO is important
That said, 2024 will be an exciting year for those interested in the harm reduction debate. Sweden has almost 1.2 million daily users of smokeless nicotine. Almost one million of these are snus users, many of whom also use nicotine pouches and e-cigarettes. Vejpkollen will therefore follow developments closely, not least by monitor COP10, the tenth meeting of the Tobacco Convention, taking place on February 5-10 in Panama. Delegates from around the world will decide whether snus, nicotine pouches and e-cigarettes should be regulated as cigarettes or not. At the moment it looks like WHO wants to cut off access to EVERYTHING related to nicotine. How will Swedish delegates deal with this?
EU elections - a key issue for white snus?
The European Parliament elections will also open up the debate on Swedish nicotine use, or perhaps rather our relationship with nicotine pouches, products which, alongside e-cigarettes, are likely to help reduce the harmful effects of smoking in Sweden. The EU Commission, like the WHO, wants to severely restrict the possibility of using nicotine pouches, at the same time as restricting access to e-cigarettes, through everything from taste bans, high taxes to subsidies for so-called "preventive efforts" (where do you think Non Smoking Generation and Tobaksfakta get their money from?). Vejpkollen is of course monitoring the issue from a user perspective.
Interest is growing
Interest in the political game around nicotine is growing, which is not least reflected in the visitor statistics of Vejpkollen. An average of 5000 people a week visit the magazine. Add to this the enormous activity in the comments sections of social mediahe, where articles on the politics of snus, nicotine pouches and e-cigs attract a lot of interest. Vejpkollen's posts (direct links to articles) have been shared 2000 times in 2023. The posts have been commented on 4148 times and received 29455 reactions.
Why do it this way?
It is of course important that users understand how policies shape the conditions for alternative nicotine products. Many people use e-cig, snuff and nicotine pouches to keep themselves non-smoking and quit nicotine addiction. At the same time, there are just as many people who vejpar and snuff only to they like the flavors, the social aspect, the kick and the feeling of using nicotine.
Hopefully this engagement will continue and also be picked up by politicians who can speak for them in small and large contexts.
