New report from Norway: Electronic cigarettes - usage patterns, user groups and user culture

Last Friday (the 12th) the Norwegian Institute for Alcohol and Drug Research (SIRUS) released a report on e-cigarettes with focus on usage patterns, user groups and user culture. I talked to Rikke Tokle, who is responsible for the study, in January when the project was in the start up phase. She said back then that "the background for SIRUS to start this project is the desire for more knowledge and focus on the users and their experience with using e-cigarettes". 

Sirus published an article on their web-page on Friday where Tokle talks a bit about the report. The report and the article is only available in Norwegian at the moment, but I asked Tokle about this and the plan is to release an article in English based on the report later on. The summary of the report is also written in English, and is now available at the last pages.

With Christmas coming up and everything I haven't had the time to read the whole report yet, but I had a brief look at it and it looks like a good read (if you can read Norwegian of course), having a lot of statements from the users that Tokle interviewed in the study. The report is mainly based on interviews with 16 vapers recruited from different channels to avoid selection. In addition to this Tokle has also attended a "vape meet" and observed user controlled websites. So the main objectives of this report is to document how e-cigarettes are used, who uses them, how they got introduced to them and the users perspective on some of the political aspects of vaping. It's not a report that aims to debunk or prove any theories or health consequences of e-cigarette use, but it aims to document the user culture and the users views on things. I think this is quite an interesting angle as I can't recall having seen anything like it before. It's actually not a study of e-cigarettes but a study of e-cigarette users and usage.

As I've said before, I think if you really want to know something about vaping, you need to talk to vapers. A lot of vapers are very updated on vaping politics, the market and maybe most importantly the science and research done on the subject. There is still a lot of so-called experts in the media claiming that "we don't know enough yet" or "there is not much research done on the subject yet". In my opinion, with all the easily accessible research available just a few clicks away, such statements disqualifies anyone from being described as "an expert". SIRUS shows with this report that they have understood this and they have also done so in the media on several occasions as well, with Karl Erik Lund referencing up to date science on the subject (as opposed to certain others that points to out-of-date reports on products long gone from the market).

I'm looking forward to reading the whole report as it is the first report I've seen with this focus on the vapers and their experiences and thoughts on the subject. It is 134 pages long so don't even thing about asking me to translate the whole thing. Hopefully the above mentioned article will be released soon. However, with a lot of help from google, I've translated the article that SIRUS posted on their web-page for those of you who don't read Norwegian (which according to my statistics should be most of you):

A minority of smokers who have switched to e-cigarettes has plans to stop using e-cigarettes. This is shown the first Norwegian study of e-cigarette users.

The use of e-cigarettes is increasing, but there is currently little Norwegian research on the subject. In the report "Electronic cigarettes - usage patterns, user groups and user culture" Rikke Tokle has interviewed users of e-cigarettes, participated in "vape meets" and observed Norwegian vaping web-sites.

The report documents the perceptions and attitudes of users of electronic cigarettes in an early phase dispersion product. The phase is characterized by a lack of clear rules for the application and acquisition, and that the media conveys inconsistent messages about risk.

- E-cigarettes seems to be a successful smoke substitute because the product addresses both the physical addiction to nicotine and the psychological addiction to action and smoke ritual. Vaping is a way to keep the "smoke habit" without smoke, says Tokle.

Many of the interviewees stated that they aim to vape nicotine free [e-juice] and that they actively step down on nicotine strength with the goal of total nicotine freedom.

A harm reduction alternative to tobacco

- For smokers e-cigarettes can be a harm-reducing alternative to tobacco cigarettes because nicotine is delivered without exposing the user to tar and many of the harmful gases released during the combustion of tobacco, says Tokle.

I the report she shows that the motives for using e-cigarettes are closely related to the informants' smoking career and addiction. Quitting smoking emerges as the primary motivation for the use of e-cigarettes. E-cigarettes seems to be crucial for many of the informants' freedom from smok today. The health aspect is the primary reason for wanting smoking cessation.

Used by various groups

The report indicates that the use of e-cigarettes have gained a foothold in different groups of smokers. For daily smokers vaping is an important and integrated part of the day. They vape in situations where they have previously smoked.

Occasional smokers often tell about double use and situation dependent use, where e-cigarette usage is "for fun", as opposition, or are motivated by practical reasons.

"Versatility" also seems to affect patterns of use in that vaping can be done at several and "new" places, such as inside nightclubs, workplaces, dining places, while reading, or in front of the tv. This seems to increase the frequency of use compared to conventional cigarettes.

Smokers are the primary audience for e-cigarettes according the informants in this study, which is supported by the fact that all of them has a smoking career. The informants can be divided into three user groups:

• The first group are those who use e-cigarettes to quit smoking and to maintain smoking cessation. This user group appears to include the majority of vapers today.

• Activists and committed "enthusiasts" can be referred to as a separate group. Vapers that may be linked to this group is characterized by enthusiasm for e-cigarettes. This becomes apparent through participation in forums like the one run by the Norwegian Union of Vapers, wishes to recruit smokers to vaping, and for some, working closely with the authorities to influence regulation. This group also houses the "particularly interested", where vaping also has a hobby aspect.

• A third group that differs from the former are "trendsetters" and the recreational users of e-cigarettes. E-cigarettes appears here more as a selected accessory than as a smoking substitute. The news value and the "future element" of e-cigarettes is positively described. The informants that may be linked to this community seems to be mainly gifted young adults. Some are active in the nightlife.

Dissatisfaction with current regulations

Views on current regulations and the authorities' handling of e-cigarettes are characterized by discontent. The informants appear to be particularly frustrated by the current market situation and the ban on sale of nicotine e-juice from Norwegian retailers, as several of them states that this affects the weakest and most dependent smokers. Several of them also believe that online shopping exclude older people. The planning of orders in relation to shipping and customs can complicate smoking cessation and the transition to vaping for some.

The informants instead calls for regulation and standards for increased product safety. Some of them, especially those very involved informants, also express fear of over-regulation that could lead to narrowed product variety, higher prices and standardized products with little appeal to smokers. There is also scepticism about decisions made in the EU's tobacco products directive that will prohibit threshold values above 20 mg / ml nicotine.

There are differing opinions on how e-cigarettes should be distributed. The proposals range from pharmacy and liquor store to night clubs, kiosks and grocery retailers. There is consensus among the interviewees that there should be 18-year age limit for the purchase of both e-cigarettes and e-juice.

Norwegian Institute for Alcohol and Drug Research (SIRUS) comments on the approval of the TPD

Norwegian Institute for Alcohol and Drug Research
- Sirus supports Norwegian vapers

After the TPD was approved SIRUS and their head of research, Karl Erik Lund, received a lot of requests for comments on this. Not very surprising as SIRUS has been one of the biggest supporters and advocates for e-cigarettes here in Norway. Due to the amount of requests, Karl Erik Lund and SIRUS chose to write a public response on the Norwegian Union of Vapers' (Norsk Dampselskap) Facebook page. We are indeed lucky here in Norway to have SIRUS to support us vapers. Karl Erik Lund is usually the one speaking on their behalf in the media and I've got to say his statements always appears well though out, well formulated and convincing, which is really helping the case here in Norway. (Lund also spoke about the TPD and what it means for us here in Norway in an article on nrk.no on the 28th of February: http://goo.gl/zYdu0e, in Norwagian but google translate might work)

On the before mentioned facebook page Lund writes that it is appropriate to consider two different aspects of the TPD: The procedures that has been followed, and the result. He says that from his point of view the results are much better than the procedures, but that does not necessarily mean the results are good. The procedures have been close to a scandal, he says, with allegations of corruption leading to John Dallis resignation as Commissioner (read more about the "Dalligate" scandal here: http://goo.gl/Hkwnug), absence of consultations with scientific groups, abuse of research results, skullduggery concerning the voting procedures and so on. He refers to Clive Bates' blogg (http://www.clivebates.com) for more information on this. The results are not optimal either, according to SIRUS: The 20mg/ml limit has no scientific foundation, the option for members state to regulate them as medicines creates openings for over-regulation (read my post on the consequences of over-regulating here: http://goo.gl/mrE4bS) leading to less product variety, higher prices and standardized products that have as little appeal to smokers as the nicotine inhalers of the pharmaceutical companies have today, standardized nicotine delivery that requires technology that is not available yet, refill limitations, and so on. So as you can see, SIRUS really gets the point, which is a very good thing for Norwegian vapers.

Now, regarding the situation in Norway, Lund says that the health authorities and the Cancer Society are still clinging to their precautionary principles, but as the scientific results are starting to get to the people in charge, the ban here in Norway is loosing support among them, and the reasoning for keeping the ban is pulverizing. Lund, and a lot of the vapers I know, including myself, is especially disappointed in the Cancer Society. In my opinion their arguments have been based on speculations, not science and they appear to just take everything the EU say as the truth. The smokers could really have benefited from having this organization supporting them in the fight for a harm reducing nicotine alternative and the design of a strategy for increased product safety, Lund says.

"Norsk Dampselskap" (Norwegian Union of vapers)
fights for vaping in Norway

Despite it's many deficiencies, article 18 (editor: now article 20) will have more positive than negative consequences - in Norway, Lund writes. Norway is not part of the EU, but we are part of the EEA, which means we implement most EU directives anyway. So here in Norway, if the TPD is implemented in it's current form, the ban we have today will be repealed and we'll have regulations (although totally over-regulated) to ensure product safety. Now it is still uncertain how the Norwegian health authorities will regulate e-cigarettes but now, with the TPD the debate has changed from being focused on whether or not a ban should be in place to being a debate on how to regulate them. This is progress, says Lund. The demonizing of nicotine (for example in the anti-tobacco movement) is an inappropriate approach to the regulation question, he adds. 

I've seen some positive feedback on the TPD among Norwegian vapers lately, stating that it will actually better situation for vapers in Norway. And they are right about that, as SIRUS also points out here. But I'd like to stress, again, that we are not fighting this fight only for our own sake, but for all the smokers whose lives could be saved, not only in Norway but all over the world. And I think it's important for Norwegian vapers to be aware that even though this means a step in the right direction for Norway, it's a long step backwards for the countries where we buy our vaping equipment and e-liquid today. And thus it is very important that we continue the fight here in Norway as well, and try to get our politicians to take science and facts into consideration when the laws regarding e-cigarettes in this country is written, and not just adopt the EU directive directly. As I said yesterday: Vapers should write the law on vaping. If we do win that fight we would be a good example for the EU on how it should be done as well and might be able to help others.

Upcoming report on e-cigarettes and user culture by SIRUS

As Karl Erik Lund mentioned in the interview I published earlier this week, SIRUS is soon to launch a new study on e-cigarettes. This project is lead by researcher Rikke Tokle and she introduced the case in the Norsk Dampselskap (the Norwegian union of vapers) facebook group earlier this week. I sent Rikke an email offering to be a participant in the study and asked her a little about what it was all about.

This is what she says about the project:
The project is still in the start-up phase, which means the research questions to be investigated is still relatively open. I operate with a preliminary working title which is "E-cigarettes and user culture", but this will probably be changed as the research questions will be changed or added when the data collection starts. The background for SIRUS to start this project is the desire for more knowledge and focus on the users and their experience with using e-cigarettes. It is also interesting to catch up on new words and expressions that occur around "new" phenomenons - for example "vaping" (editor: "damping" in Norwegian). There is a lot of good information to be gathered from Dampselskapets (editor: the Norwegian union of vapers) web-pages and blogs like yours (editor: Thank you). This information will be supplemented by individual interviews with users of e-cigarettes in and outside the forum.

I think this looks very interesting and I'm looking forward to following the study as it progresses. Any Norwegian readers who wants to participate in the study can contact Rikke Tokle at rt(at)sirus.no. Let's give her a proper kick-start on the project. I'll keep you guys updated :)

Interview with Karl Erik Lund, Research Director for the SIRUS tobacco unit, Part 2

I hope you all found yesterdays reading interesting. It was at least an all time high pageview count on the blog. I for one am waiting eagerly to see the results of the upcoming study of the culture of vaping that Karl Erik talks about. Here is part 2 of the interview. 

Vaping Giraffe: Let's think of a scenario where all smokers switch to e-cigarettes. This would of course lead to a massive change in public health and economy. One would think a lot of money could be saved since treatment of smoking related diseases would be massively reduced. On the other hand it might lead to people living longer (which would be a cost) and reduced tax income from cigarettes. Do you know of any calculations done on such or similar scenarios?

Karl Erik Lund: I do not approve of such an approach. In the Check Republic, spokesmen for the tobacco industry stated that tobacco gained the economy because smokers tend to die before they became a burden on the social security budgets. This is absurd! Any such calculation that somehow makes an early death profitable for the state economy has an unethical sentiment.  The ultimate goal for a reasonable health policy should be to help people live healthier and longer lives, unaffected of any economic cost-benefit analysis. In Norway where the tobacco-specific tax are very high, smokers probably ‘pay their way’. They have higher sickness rates and charge the public health system more heavily, but the accumulated amount already paid to the state through taxation will probably cover for this. In other economies where tobacco taxation is low and health care costs is covered by the individual and not the public, the situation might not be the same. Non-smokers tend utilize the health care system somewhat less, but live longer and receive pensions for a longer time. Again, I think such kind of calculation is a ‘red herring’, and that promoters of e-cigarettes should abstain from this approach.            

Vaping Giraffe: What do you think is the health authorities main reason for keeping the ban on e-cigarettes with nicotine?

Karl Erik Lund: Spokesmen for the Directorate of Health have repeatedly used the precautionary principle to justify the ban on e-cigarettes. Some also fear that e-cigarettes will renormalize smoking, and other keep using the gateway-argument – even though there is no empirical evidence for either. The precautionary principle opens up for a really interesting discussion. The human costs of a continued ban are very high, smokers are buying lousy and potential risky e-cigarettes over the internet and the ban is an obstacle for smokers to move down the risk continuum of nicotine products. You have to weight these costs against the gains from a precautionary principle. Applying a rational decision model approach, one will find limited support for the precautionary principle.    

Vaping Giraffe: I've read that around 70% of the worlds tobacco consumption is done in developing countries. Still I can find very little about e-cigarettes in these countries on the web. What is your thoughts on that? Are you familiar with any projects in developing countries?

Karl Erik Lund: Even if e-cigarettes have originated from China and much of the production takes place in China, the popularity of e-cigarettes have occurred  in typical developed nations. Following a diffusion-of-innovation model, e-cigarettes will eventually become popular in developing countries as well. Most tobacco-related deaths take place in countries like China, India and Indonesia, which means that e-cigarettes potentially can have an enormous impact on public health. I am not familiar with any projects going on in that part of the world at the moment.  
 
Vaping Giraffe: The tobacco industry and the pharmaceutical industry are two of the largest industries in the world, both now looking at a new competitor that will take a lot of customers from them. What do you think their strategy for keeping the customers are?

Karl Erik Lund: Until now, the pharma industry has been somewhat hesitant to enter into the e-cig business. Their strategy has been to fight the e-cig diffusion through political lobbying. The tobacco industry, however, has been more ambivalent towards e-cigarettes. Right now Big Tobacco are test-marketing their own products, so they have every intention to enter into the e-cig business. For the consumers, this is probably a good thing because they can afford to invest a lot of money which eventually will result in better products on the market. At the same time, Big Tobaccos engagement is bad news for the e-cig proponents advocating for market access. Politicians and policy makers connote bad representations to all products from Big Tobacco.     

Vaping Giraffe: The EU is from what I understand in the finishing stages of a new tobacco directive. Does Norway have to follow this directive, or can we choose not to?

Karl Erik Lund: There is a formal choice, but every practice indicates that Norway will follow the EU-regulations. However, as the tobacco-product-directive looks right now, before the final negotiations between the Parliament, the Commission and the Council, the member states can decide by themselves whether e-cigarettes should be regulated as a medical device or a consumer product. 
 
Vaping Giraffe: Have you heared of "Norsk Dampselskap" (the Norwegian Union of vapers) and if so what do you think of their work?
 
Karl Erik Lund: Yea, I take great pleasure in reading posts on their wall. Many competent people acting as counsellors and giving great advices to novices in vaporing. I am really touched by all the personal histories from smokers who have replaced tobacco by e-cigarettes.  
 
Vaping Giraffe: Do you have any recommendations for vapers that want to fight for their case? How could ordinary people get engaged?

Karl Erik Lund: Consumers groups are very powerful and have great impact on politicians and policy makers. We must not underestimate their potential influence. I was lucky enough to participate in a meeting with members of the European Parliament in October last year along with Clive Bates, Gerry Stimpson, Jaque LeHouzac and Konstantinos Farsalinos – all world-leading specialists on e-cigarettes. We were amazed how the politicians appeared to be attentive and responsive towards consumer groups. Letters to politicians is still a powerful channel of influence.  

I'd like to send a big thanks to Karl Erik Lund for taking the time to answer this. I'm really looking forward to following the research done by him and SIRUS. I did also notice that one of his colleagues posted on the "Norsk Dampselskap" Facebook group asking for participants for the upcoming study mentioned in part 1. I'm in!

Interview with Karl Erik Lund, Research Director for the SIRUS tobacco unit, Part 1

I've mentioned Karl Erik Lund, Ph.d. and Research Director at SIRUS, several times already on my blog. He has been in the media quite a lot lately, speaking about his research on e-cigarettes, and commented on the politics that has evolved around them. Should they be banned, regulated as medicines, regulated as a tobacco product, can they save lives etc. I had some questions I wanted to ask him... so I sent him an email and asked if I could do an interview, which he happily (I hope) agreed to. This is the first part of this interview. Hope you guys find it as interesting as I do, and stay tuned for the second part tomorrow.

Vaping Giraffe: Could you first tell us, in short, what is SIRUS and what is your role/position there?

Karl Erik Lund: The Norwegian Institute for Alcohol & Drug Research is an independent research institution but at the same time an administrative government body under the Ministry of Health and Care Services. SIRUS conducts social scientific research, compiles documentation and provides information on substance use and abuse. Work is divided into three areas, each catered for by a dedicated research team: alcohol research; drugs research; and tobacco research. I have been the Research Director for the tobacco unit since 2006.

Vaping Giraffe: When did you first hear of the e-cigarette, and when did you decide to do research on them?

Karl Erik Lund: As an assistant editor in a scientific journal – Nicotine & Tobacco Research – I handled perhaps the first of several subsequent papers on e-cigs submitted from Dr Polosa and his pioneering research team in Italy, and this must have been about three years ago. Since then, I have followed the very heterogeneous research on e-cigarettes very closely. In October 2013 I published a comprehensive review (70 pages) of the international research on e-cigarettes concerning use, motives for use, results from animal studies, analysis of chemical substances, acute physiological consequences, effects in smoking reduction and cessation etc.
  
Vaping Giraffe: Could you tell us a little about your findings? How dangerous is the e-cigarette (with nicotine) compared to a normal cigarette?

Karl Erik Lund: Even if we do not have exact knowledge of any long-term health consequence that might occur, there is scientific consensus that e-cigarettes are far less risky than conventional cigarettes. We are not saying that vaporing is totally risk-free, but the magnitude of risk between inhaling tobacco from a cigarette that burns and clean nicotine thorough mist is probably huge.  

Vaping Giraffe: Are you familiar with other researchers in other countries that have come to other conclusions than your own? If so, do you think these are unbiased?

Karl Erik Lund: My impression is that most – if not all - researchers do recognize the large different risk potential between the two products, but some researchers tend to emphasize that some e-cigarettes still contain toxic substances more than they want to focus on the risk-reduction aspects. For researchers that aim for a totally nicotine-free society, a transition from tobacco to e-cigarettes have no value. It really depends on the perspective of the researcher – you are either in favour of a harm reduction approach in tobacco control or you are not.    

Vaping Giraffe: Do you, or SIRUS have any on-going studies concerting e-cigarettes you can tell us about right now?
 
Karl Erik Lund: Yes, we are about to launch a project in which we aim to study the culture of vaporing. What characterize the users, what are their motives, what impact has the ban on e-cigarettes on the in-group mentality and the way they communicate about e-cigs. Do e-cigarettes recruit youngsters who otherwise wouldn’t have started to smoke cigarettes? We will also monitor the use of e-cigarettes in population-based surveys over the next years. In addition, we will study changes in the nicotine market. What will happen on this market if the authorities decide to let e-cigarettes compete with tobacco cigarettes, snus and pharmaceutical nicotine? 

Vaping Giraffe: A lot of pro-e-cigarette people shake their heads when the authorities claim there is to little research done on the health effects of e-cigarettes to allow them. They say the research is done and available on the internet, most of it concluding that e-cigarettes are close to harmless both to the user and the surroundings. Can you comment on this?

Karl Erik Lund: I am really impressed by the level of knowledge of some members in the user organizations. They seem to be very on top of new research, and I learn quite a lot thorough reading posts on Facebook and other websites that organize vapers. I do understand their frustration when health authorities repeatedly claim that the scientific base still is too weak to lift the e-cig ban. On the other side, we have to understand how the health authorities work. In order to act, they want knowledge established thorough systematic reviews, long time observations and randomized controlled trials. The burden of proof has been put on the producers that do not have the skills or the resources to conduct such advanced research. The authorities have used – or some would say misused – the precautionary principle in order to keep a clearly risk-reducing and perhaps life-saving alternative out of reach for smokers. The costs of the precautionary principle are very high, and based on what we already know many feel it is enough for the authorities to act.      

Vaping Giraffe: What is SIRUS relation to the department of health and have the health authorities asked SIRUS to do any research on e-cigarettes?

Karl Erik Lund: The Ministry of Health and Care Services do support our research and our updates on e-cigarettes. We are instructed by the Ministry to initiate debates on harm-reduction alternatives, even if the anti-tobacco community might find this provocative. There is a lot of understanding for a tobacco harm reduction approach among politicians, policy makers and particularly among researchers. The tobacco control movement seem to be more hesitant and some are even very hostile.

Vaping Giraffe: Do you think e-cigarettes could solve the "tobacco problem"? And do you think the health authorities here in Norway will repeal the ban in time?

Karl Erik Lund: I am quite certain that e-cigarettes will make their way to the marked. The remaining question is what kind of regulation that will replace the ban. There are toxicants in e-cigarettes that do not have to be there, so we need regulation standards in order to improve product safety. The new government seems to be willing to assess the appropriateness of the ban, and the new Tobacco-Product-Directive in EU will also put a pressure on Norwegians policy on e-cigarettes. I do not think availability to e-cigarettes will solve the tobacco problem entirely, but I am quite certain that it might help. We have approximately 1 million smokers and 200 000 of those do not manage or do not want to quit using nicotine. Now, we are forcing this crowd to use the most dangerous device for nicotine uptake, even if we know that a very harm-reducing product exists. We also know that 10-15% of teenagers in future generations will start to use tobacco. It is not so much the efficacy of e-cigarettes as temporary aids to cessation, but their potential as long-term alternatives to tobacco that makes the virtual elimination of tobacco a realistic future target.