Smoking prevalence in Norway dropping faster than ever

Yesterday I came across this blog post, which apparently an answer to someone asking for data on what happened to smoking trends in Norway when Snus became widely available in 2000. The post links to the Norwegian statistical institute (SSB) and their report on smoking habits, released in February this year.

Smoking habits in Norway, trendlines added by Atakan Befrits

As you can see prevalence has been dropping from 1973, but started dropping faster around 2000, and then even faster around 2009.

I haven't found any good statistics on vaping, I'm not sure they even exist yet, so I don't think we can be sure that vaping can be attributed the increased decline from 2009, but I wouldn't be surprised. But to be fair, from these data we can't really say for sure. What the data does show however, is that vaping has not led to an increase, or a graph that flattens out, like we would have seen if the gateway theory was valid.

I've never used Snus (for some reason SSB calls it snuff, which I believe quite a few will associate with something else), but I can't really remember that Snus was not available here in Norway. So to be honest I'm not sure why Befrits says it became widely available in 2000, and I couldn't find data from before 2008 on the SSB web-page. However, the Norwegian Institute of Public Health have some more data in their Public Health Report from 2014 (in Norwegian):

Daily smoking and use of snus 16-25 years old, 1985-2013. Shows "Men, daily smoking", "Women daily smoking", "Men, daily use of snus" and "Women, daily use of snus", in that order on the top.

Same as the above graph, but for people aged 16-74.

As you can see, the use of Snus, especially among young people, really started increasing around 2000. At the same time, again especially among young people, smoking prevalence starts to drop dramatically. This strongly indicates that Snus, which like e-cigarettes is a much lower risk product, is replacing smoking. Also notice that from around 2008-2009 the Snus graph, especially among men, is still increasing but not quite as fast as between 2000 and 2007. Still, from the first graph (and Befrits trendline) we see that smoking prevalence is dropping even faster from 2009. This makes it even more reasonable to believe that vaping has played a part here, but again, a lot of other factors, like anti smoking campaigns, needs to be taken into consideration here. Looking forward to seeing the next report from SSB that is to be published in January 2016. Hopefully they might have some numbers on vaping as well.

It's also interesting to see that prevalence is dropping the most among young people:

Personally I believe this shows that people are very aware of the dangers of smoking, and it seems also that they are aware that Snus is better for your health. I know a lot of former smokers that have used Snus as an aid to quit smoking. In other words, most people seems to understand, and use harm reducing products.

As I said it's a bit difficult to see how vaping and e-cigarettes have contributed to the decline in smoking prevalence here in Norway, as the data on vaping is quite limited. Most people (95%) have heard of e-cigarettes and 15% have tried them according to SSB. E-cigarettes were included in the yearly survey that SSB does on smoking from 2013. The Norwegian Institute for Alcohol and Drug Research (SIRUS) released a report on e-cigarettes earlier this year with some more numbers estimating around 50.000 weekly users in Norway and around 500.000 have tried e-cigarettes. Their numbers also shows that e-cigarettes are mainly used by smokers, to quit or reduce smoking.

It's good to see that we're moving in the right direction, and even if it's not surprising, it's great to have these numbers to show anyone claiming that vaping will lead to more smoking. On the SSB web-page you can even get more numbers and generate your own graphs. Looking forward to seeing the next report from SSB released in January next year to see how the graphs develop. And it might be even more interesting to see how the TPD will affect this when another year has passed... if we're not able to stop it that is. Not all hope is lost yet... on the 12th of December we hit the streets to convince our politicians that the TPD is not the way to keep those numbers going down as fast as possible.

Norwegian Department of Health positive to harm reducing e-cigarettes

The Norwegian Department of Health recently published and presented their Public Health Report to the Parliament. According to the Norwegian governments' official web-portal, regjeringen.no, this report presents new policies in areas that the government believes has not been sufficiently prioritized or that require new approaches.

As I've mentioned earlier, The Norwegian Institute for Alcohol and Drug Research (SIRUS), wrote an answer to a request for input by the Department of Health during the process of writing this report. SIRUS' answer focused on harm reduction. After this Public Health Report was published SIRUS' head of research, Karl Erik Lund, was positively surprised by the impact their input:

We prepared a note on the need for harm reduction in the tobacco area but had little hope that the Department of Health would anchor harm reduction ideology in the Public Health Report. Now, however, the Norwegian health authorities for the first time has given the topic discussion in an official, authoritative publication and additionally they've taken a quite positive stance.

I've translated what the report says about harm reduction in the tobacco area:

Harm reduction in the tobacco area

The emergence of electronic cigarettes has intensified the debate about whether harm reduction should be a supplement to the traditional tobacco politics. Smokers who do not manage to quit will be able reduce their health risks by switching to e-cigarettes, even if these are not necessarily completely harmless.

Harm reduction as a political strategy has until now had no place in the Norwegian tobacco policy. The government is open to a rethinking of this area when it comes to e-cigarettes, but have not yet concluded on how the products should be regulated. Traditionally the authorities' policy to reduce tobacco use have had it's roots in three principles of medical ethics: The no-harm principle discourages the use of products which cause harm due to toxic content. The precautionary principle warns against use of products where it can not be excluded that undiscovered harmful consequences may occur in the future, and that these may be irreversible. The loss of autonomy principle warns against use of products which can be addictive.

A comparative perspective implies that the adverse effects of cigarette smoking are used as basis for comparison when evaluating the adverse effects of the use of e-cigarettes. Conventional cigarettes and e-cigarettes are nicotine products in a so-called substitutional relationship, which means that their user functions and users are strongly overlapping. There are still no epidemiological studies of any consequential damage by prolonged use of e-cigarettes. However, a number of studies indicate that the transition from tobacco cigarettes to e-cigarettes will result in a significant risk reduction for the individual smoker. Expert groups have estimated that the overall health risks of using e-cigarettes probably constitute less than 10 percent of the overall risk of cigarette smoking.

Although the transition from tobacco cigarettes to e-cigarettes will be harm reducing for the individual smoker, their effectiveness on community level will depend on the extent to which e-cigarettes may come to recruit non-smokers, postponing quitting, lead to double-use and recruit youth smoking.

Based on current knowledge there is no basis for assuming that e-cigarettes will cause adverse effects on a large-scale population. Users of e-cigarettes is currently almost exclusively smokers or former smokers, and e-cigarettes are used to reduce tobacco consumption, to stop smoking or to prevent relapse to smoking. According to the Institute of Public Health smoking is the single most important cause of differences in life expectancy between people with high and low socio-economic status. The Norwegian Institute for Alcohol and Drug Research has estimated that about 200,000 of the 700,000 daily smokers in this country have characteristics associated with low probability of smoking cessation. The large difference in risk between tobacco and e-cigarettes suggests that access to e-cigarettes will improve the health of the vast majority of users - which is the smokers.There are currently many disreputable manufacturers of e-cigarettes and studies have shown that the content of the products often do not match the content declaration. It is therefore a prerequisite for an eventual repeal of the current prohibition that quality requirements for the products are set, that the sales are regulated and that e-cigarettes in no way will be marketed to young people.

As you've probably noticed there are some points here that are still not concluded on, regulation being the most important one. They do not say much about how much or what kinds of regulation they envision. However, the fact that they seem to have understood the enormous value and efficiency of a harm reduction strategy is a huge step in the right direction.

So, while politicians in a lot of other places seem to work for strict regulations or even bans on e-cigarettes, seemingly unable to grasp the concepts of harm reduction, it looks like we're moving in the other direction here in Norway, where we already have a ban (on nicotine e-liquid that is). This is quite remarkable actually, as we have a strong tradition for over-usage of the precautionary principle here. As I've mentioned before, we even had a total ban on skateboarding from 1978 to 1989 here. So what is the reason that our politicians and health officials seems to have a relatively positive attitude towards the harm reducing e-cigarettes now? Well, we are indeed lucky to have SIRUS on "our side" here in Norway, but a lot of hard work and fighting is also done by the vapers themselves and we must not forget the tireless efforts made by members and the leadership of the Norwegian Union of Vapers (NDS). Here is what Karl Erik Lund wrote in the NDS Facebook group after the report was published:

This must be interpreted as a more sympathetic attitude to harm reduction in general and e-cigarettes in particular. Our note has been important, but it's still all inquiries and activity from you vapers which have prepared the ground for this shift in views on e-cigarettes among the political leadership.

Personally I also believe that the way e-cigarettes have been presented in the media lately have contributed a lot to this. We've seen vapers telling their stories about how the e-cigarettes have affected their lives, stories about how Norwegians travel across the border to Sweden to buy e-cigarettes and liquid, and Karl Erik Lund and SIRUS have done some extremely important work here by quickly debunking the horror stories that hit the media.

Harm reduction in Sweden down the drain

The Swedish government has decided to increase the tax on Snus (Swedish smokeless tobacco) by 12% according to Swedish newspaper Expressen: http://goo.gl/LE7HKD. Cigarettes, and other smoking tobacco on the other hand, gets only a 6% increase. I'd like to quote my fellow blogger Dan, who started an excellent blog last month and lives in Sweden:

This batshit crazy policy will cause harm – as some people might decide to choose to smoke, instead of using a product that is so much safer that it isn’t just in a different ballpark, it’s a different sport altogether.

Couldn't have said it better myself, Dan. I mean, why would the country that has the lowest cigarette consumption and the lowest rate of tobacco related harms and diseases in the EU put a tax on a product that actually is one of the main reasons they are in that position? Can you think of one reason? I bet you can... and you're right again: It's all about the money. Expressen wasn't able to get hold of the Swedish Minister of Finance, Magdalena Andersson, but was able to get comments from Fredrik Olovsson who I guess answers on her behalf. My knowledge of all Swedish political titles isn't all that good, but he's a finance guy at least. Anyway, here is his reasoning: "We need the money. We are borrowing 10 million each hour in Sweden today [...] we really need this money." Well, Mr. Olovsson, making a country dependent on sin taxes isn't just a bad idea, it's a horrible idea. It doesn't really take a political mastermind to figure that out, now does it? If you make your country dependent on people destroying their health, you're in deep shit. I don't really have to explain that do I? Well, I kind of did a while ago: http://goo.gl/ilDxwT.

So, what does this all have to do with e-cigarettes? Well the Swedish government is also trying their best to ban e-cigarettes, which, as Snus, is a lot less harmful than cigarettes. It seems to me that the Swedish government is willing to sacrifice the health of their people to pay their bills. They seem determined to flush all harm reduction alternatives down the drain, because it will reduce their income as well as harm.

I'd like to finish today's post by recommending another blog, especially for the ones that are interested in Scandinavian e-cigarette politics: argvargen. "Argvargen" means something like "the angry wolf". Especially I'd like to recommend this post from a few days ago on the topic of snus and e-cigarettes in Sweden. Great, well written blog, Dan. I hope you keep biting their head of with your razor sharp wolf teeth.

Tobacco harm elimination: An experiment with human life and health

I was reading an article published on Norwegian TV channel NRK's website (http://goo.gl/1Nb3PC, in Norwegian) some days ago. It's written by cancer researchers Dr. Tom K. Grimsrud (from the Norwegian Cancer Registry) Professor Tore Sanner (from the University in Oslo I think). The headline:

"An experiment with life and health"

I'm not going to go through all the details here (don't bother trying google translate, it changes the meaning of a lot of stuff in there) but the heading says a lot about the content I think. This is how they choose to start their article:

"For long we believed that nicotine was relatively harmless, and that the harm in tobacco use came from other substances in smoke and tobacco. This understanding characterizes the debate on e-cigarettes, but it is obsolete"

Basically it's a collection of vague references to studies that the don't even provide links to. Dr. Grimsrud and Professor Sanner are, if not deliberately lying to scare people, and I'm not saying they are not, guilty of just plowing through summaries and conclusions and without any further investigation cherry picking the ones that fits well into their scaremongering tactics. And there is a lot of "reason to maybe believe that nicotine is dangerous" and "we can't rule out that nicotine causes some harm". They go public with a headline that will scare a lot smokers enough to keep them smoking and eventually die because of it, followed by an article based on some vague study that can't rule out that nicotine may have caused some Swedish mice that already had cancer to die a faster and a gateway argument that has been proved wrong by a bunch of studies lately. The ASH study for example: http://goo.gl/Rz3BH0. The numbers they use for supporting their gateway argument seem to come from the CDC study published last year (http://goo.gl/Zyscks) that actually shows nothing of the sort but is rather a study in how to twist your irrelevant numbers to fit your pre-written conclusion. If anything is obsolete here it's their gateway argument and the so called science they use to back it up.

I'm convinced that Grimsrud and Sanner are fully aware of these studies, as they are fully aware of the studies of Dr. Farsalinos (http://www.ecigarette-research.com), but these does not support their case, and they have not been able to find any good arguments against them so they just refrain from mentioning them. If you're going to put Dr. or Professor in front of your name you should know better.

I am also convinced that if Grimsrud or Sanner had to choose either e-cigarettes or cigarettes for themselves or their children, they would go for the e-cigarette. Well, actually they would probably try to choose neither. And this seems to be their biggest problem, and the biggest problem with the whole anti-e-cig movement: They seem completely unable to understand that for a lot of people there is no third option, which is kind of dangerous actually, considering the influence their statement may have on smokers. They simply refuse to accept the fact that a lot of smokers are unable to get rid of their nicotine addiction. So they cling to their harm elimination strategy.

One of the problems with only going for harm elimination is that it is only successful if a user manages to completely manages to quit whatever he is addicted to. If it fails, you're back to square one. Another problem is that the barrier an addict has to cross to succeed is much more intimidating, making a lot of users reluctant to even try. Harm reduction on the other hand, is more user friendly and more motivating for the user, and you're not back to square one if you fail. If you want to quit smoking and your strategy is to quit cold turkey, and you fail, you're back on the cigarettes (unless a harm reducing option is available). If your strategy is to switch to e-cigarettes and then gradually reduce the nicotine content, failing to do the latter means you're just standing still or in the worst case you've just taken a step back. But the biggest problem is that a lot of users are simply unable to succeed at harm elimination. This leaves them with no other option than to stick with the cigarettes.

Harm reduction can also be a gateway to harm elimination. The steps to cut down your nicotine content from say 18mg/ml, via 12 and 6 (just examples) are much easier and less intimidating to users than having to take one giant leap and quit cold turkey. In addition to this harm reduction can act as a safety net for people failing in harm elimination. I've read several forum posts and blog posts from former smokers that tried to cut cold turkey and "failed", but instead of reverting to cigarettes, they've started vaping. I think even Grimsrud and Sanner would agree that this is better. As I said, if they were left with two options, cigarettes or e-cigarettes, they'd both go for e-cigarettes. (If any of you two are reading this, feel free to comment if you disagree.) And why is that? Well, it lets the user get rid of thousands of known carcinogens, and leaves them with just one potential one, reducing the chances of a premature death dramatically.

So do Sanner and Grimsrud really understand the concept of harm reduction and why it's the solution to the worlds tobacco problem. I think they do, but they still chose to publish that article, with no mention of nicotine gum or patches I may add. In fact they end their article with this: "The marketing of e-cigarettes is a gigantic experiment with human lives and health". Which is a bit strange as they're main argument is that nicotine itself is dangerous. Their motives for doing so? I don't really know, but the options I can think of scares me a bit. Whatever their motives are, I say the the real experiment with human lives and health here lies within their harm elimination only strategy and their choice to publish this article.



photo credit: Brad Bethell Photography via photopin cc