May 11 2018, Rendez-vous #8
with Karl Lund
Karl is Senior Researcher at the Department of Drugs and Tobacco at the Norwegian Institute for Public Health
Karl Lund: In 1986, I started to work at the Norwegian Council on Tobacco or Health under one of the giants of international tobacco control, Dr. Kjell Bjartveit, who led the council for more than 20 years. Ever since, I have been involved in tobacco control and –research, working from different places including the University of Oslo, The Cancer Society, Institute for Alcohol and Drug Research (research director for the tobacco unit for 12 years) and Institute of Public Health (current).
My interest in the harm reduction concept evoked when my team of tobacco researchers joined forces with a larger group of alcohol- and drug researchers at the Norwegian Institute for Alcohol and Drug Research (SIRUS) in 2002. At SIRUS, the drug researchers had been working on harm reduction issues for a long time. Contrary to the tobacco field, the policy goal of a drug-free society had been abandoned, and the researchers were working on projects facilitating ways to reduce drug-related harm. As a tobacco researcher, I had spent more than 15 stifling years in the purist abstinence-only tradition of the tobacco control community (TCC), and the pragmatic approach of the drug researchers was new and inspiring. Moreover, I took interest in the classic writings of Michael Russell and other papers by the pioneers of tobacco harm reduction (THR). Inspired by this, I decided to study the Norwegian tobacco market through the lenses of THR.
I was in a very fortunate situation because Norway already had a developed and mature snus market waiting for scientific investigation, a robust infrastructure for monitoring tobacco behaviour was already in place, we had solid governmental funding, I received backing from the SIRUS leadership for the idea, and I was blessed with very skilled teammates. Then in 2007 SIRUS launched a comprehensive and long-lasting research program with an overall aim to see how snus would compete with cigarettes on the nicotine market. Along with Sweden - where the history of snus use was even longer - Norway could serve as natural real world experiment of THR in practise. Then e-cigarettes began to enter the scene some years later, and the international research community looked to Norway and Sweden for our experience on snus and the possibility of a transfer value.
Q1. You mentioned the late Kjell Bjartveit: I wonder if he took any position on harm reduction? I want to pick up on him because he made a lasting impression on me a long time ago during a training advocacy workshop in The Hague in 1993 where I learned (maybe from Nigel Gray) about his famous advocacy cocktail that concluded with the tobacco industry screaming test.
Karl Lund: Kjell Bjartveit was my boss for many years. He was also my PhD supervisor and mentor. Kjell took me to conferences around the world and introduced me to the international tobacco control elite. Old-timers in TCC still talk about his fantastic performances, and I was fortunate to serve as his regular test panel for the many talks he made worldwide.
In one way, dr. Bjartveit should be considered as one of the pioneers in THR. In the late 1960s, Kjell was the leader of the very influential “Committee for Smoking Research” in Norway, and from this position, he stated “direct change to the harmful products seems to be one of the decidedly most promising methods to combat harm caused by cigarette smoking”. His advice to the authorities was to “take advantage of the possibility to guide consumption towards the least harmful products through the conscious use of taxes and tithes and regulative policies”. In the current climate, this statement would have placed Kjell Bjartveit amongst the followers of the harm reduction concept. However, he never used the term 'harm reduction' as I recall.
On the other hand, Kjell was not very enthusiastic about the revival of snus that had started in the beginning of the 1990s in Norway. In fact, none of us were at that time. Trained as a pulmonary physician, he acknowledged that snus did not lead to COPD, lung cancer and other respiratory diseases that causes more than half of the smoking related deaths. However, this recognition was override by his unequivocally dislikes of the tobacco industry. Moreover, he feared that snus would delay – and not speed up - the endgame of the tobacco epidemic. When the SIRUS’ research program eventually demonstrated that snus was widely used by smokers to reduce smoking intensity and to quit smoking, he took a more balanced view.
Kjell refrained from taking part in the international dispute on THR, and he stayed out of the heated domestic discussion on snus as well. He stayed very wary towards the tobacco industry and doubted that this industry could provide anything positive for public health with their novel reduced risk products. We were in regular contact right up until he died in 2011, and often we discussed THR-issues. He was very influential, a great inspirer, a gifted rhetorician but also controversial in some circles.
Q2. Thank you for bringing back memories of Kjell. I must admit that at the time (in the 1990s) I did not believe either in snus and was vehemently against its introduction in France and other non Scandinavian EU countries (as described in the point 8, page 46 of the Smokefree Europe brochure of November 1988). I now realize, a bit late, it was a very different product than the other much more dangerous smokeless chewing tobacco that we always linked with horrible cancers of the mouth. Can you tell us about snus story in Norway, as you phrased it an 2014 study how has the availability of snus influenced cigarette smoking in Norway?
Karl Lund: Both in Norway and Sweden, precursors to the modern low-nitrosamine snus have a long history but were in decline, only used by old men by the 1970s.
Snus emerged as a popular alternative to conventional cigarettes because of its ability to deliver nicotine without the combustion and the toxicants in tobacco smoke, the fact that snus can be used in smoke-free places, the competitive price and the perceived potential for harm reduction (even if this potential is under-estimated).
The new snus products that were introduced to the nicotine market in the 1990s differed from conventional smokeless tobacco in that they were lower in major carcinogens such as tobacco-specific nitrosamines and polycyclic aromatic hydrocarbons, did not require spitting, came in a variety of flavors, and were presented in small pouches packed in elegant and colorful tin boxes. These innovations certainly made snus more user-friendly and increased its appeal both to established smokers, and to young people with and without susceptibility traits for tobacco initiation.
Snus has contributed to a decrease in cigarette consumption in Norway and Sweden through three mechanisms: i) as a method of smoking cessation, ii) as an alternative product for new generations of tobacco-prone youth who otherwise would take up smoking (substitution), and iii) as an alternative to cigarettes for smokers who are unwilling or unable to quit smoking altogether (smoking reduction).
In both countries, snus use now exceeds smoking. The current rate of daily smoking in Norway and Sweden – especially among men - is far below any other country in the European Union. This shift from cigarettes to snus was not facilitated by a nationally coordinated initiative originating from the centers of political activity. On the contrary, the shift has happened in a ‘dark market’ where any active promotion of snus or any other tobacco product has been banned for decades. The price difference between snus and cigarettes has been narrow and have not produced a strong incitement for the transition. Moreover, the typical message from the health authorities has been that snus is not a safe alternative to cigarettes. Moreover, dissemination of information to correct the widespread misconceptions of relative risk to speed up the trajectory from cigarettes to snus has been limited.
Thus, the marked shift from cigarettes to snus has been a grassroots consumer-driven phenomenon that has occurred without any propelling from the authorities. Obviously, this change in the nicotine marked will eventually result in an enormous public health benefit – as we already can observe in Sweden. However, the health authorities continue to refuse to ascribe any positive public health effects to snus. It’s a bit comic….
Q3. I am sad (and stunned) to see the EU still bans the sale of snus (keeping Sweden exempt) thus preventing any other EU country to experience Sweden's and Norway's low prevalence of combustibles (see the EU Eurobarometer 2017 data). Do you have any comment, explanation about this denial of the harm reduction reality?
Karl Lund: Well, the experience from Norway and Sweden clearly suggest that snus has the potential to gain market share on behalf of cigarettes without increasing the total tobacco consumption. There is no reason why this marked shift not should take place in other European country if snus were allowed to compete with cigarettes on the nicotine marked. However, recently the European Court of Justice opined to uphold the ban on snus in the EU. As an expert witness, I followed the preparations for this case very close and I was present during the legal hearings in Luxembourg in January.
I have been expert witness in several court cases, but this time I was really horrified to see how good science was dismissed and bad science selected and emphasized by some parties. Representatives from Norway, the UK, the EU Parliament, the EU Commission, and the Council seemed to compete with each other on who had the guts to make the most outrageously exaggerated and factually incorrect claims. I was thinking that the roles now seem to be reverse; the anti-THR advocates are applying the same strategy of misinformation that Kjell Bjartveit among others once accused the tobacco industry of doing.
Worst of all was the state attorney representing Norway. Contrary to overwhelming available evidence, the state attorney misinformed the court that snus use in Norway was an “epidemic”, that its role in smoking cessation was minor, that snus could be a gateway to smoking and that the rapid decline in smoking prevalence was caused by other factors. On his behalf, I was ashamed.
Q4. On December 13, 2017 you submitted to the Norwegian Ministry of Health the 92 pages of the Evaluation of harm reduction as a strategic element in tobacco work report (pdf). In the introduction you mention 13 other contributors and the existence of conflicting opinions while you describe yourself as having developed along the years a 'conditional sympathy for harm reduction in the tobacco area'. Can you tell us about the role of this document in the present policies in Norway?
Karl Lund: The backdrop for this document was that the Norwegian Ministry of Health was starting up its work on a new strategy plan for tobacco prevention. In association with this, my current employer, The Norwegian Institute of Public Health (NIPH), received an assignment from the Ministry to illuminate different perspectives on tobacco harm reduction, review the international discourse in the area, and reflect on which implications THR can have on the tobacco strategy’s goals and instruments. Having worked with THR topics for the last 10 years, nationally and internationally, this task was given to me.
I reviewed the scientific literature, read debate articles, watched relevant oral presentations on Youtube, and collected inputs from both opponents and proponents of THR. My aim was to make a clear and balanced presentation of the THR concept. I don’t know if I succeeded, but at least Clive Bates thought so. After having skimmed an English translation of the document, Clive posted to Nicotine and Policy listserv:
“The Norwegian document, “Evaluation of harm reduction as a strategic element in tobacco work”, is a quite remarkable effort and well worth a look. As an attempt to articulate the controversy around tobacco harm reduction, in my view, it is unsurpassed in its balance and thoroughness. (Though I would also say in its generosity to the abstinence-only arguments and advocates). It also provides an excellent reference resource. I suspect it is an understatement to say this would be controversial in the Norwegian Institute of Public Health, so it should be seen as the outcome of a struggle as well. The main author is Karl Erik Lund of the Norwegian Institute of Public Health (who is on this list), who deserves congratulations and some sort of medal, but probably won't be getting one!
Clive was right not only about the absence of the medal ceremony for the author, but also about the struggle of writing such a document as an employee at the Norwegian Institute of Public Health (NIPH). The perspectives at this institute are basically grounded in a reductionist toxicological and bio-medical approach. The NIPH has a tradition to oppose novel nicotine products from a ‘do-no-harm principle’ and from the ‘precautionary principle’.
However, my approach was to identify positive and negative effects from introducing reduced risk products on the nicotine market, and then present a framework in which these effects could be weighted on a population level. I asked; what would be the net effect for public health given a) different scenarios of user configurations (smokers vs non-smokers) and given b) different estimates for relative risk between cigarettes and the reduced risk products (snus, e-cigarettes, Heat-not-Burn etc). I used a classic public health approach, and it is a bit ironic that an Institute of Public Health find it so difficult to accept the logic of trading positive against negative outcomes on an aggregate level. When tiny SIRUS - with 30 social scientists and tradition of public health reasoning - was swallowed into the huge bio-medical Public Health Institute with its 1000 employees in 2016, the prevailing reductionist ontological climate there became a problem for us. It has been a struggle and still is.
The 92-pages document was formally delivered to the Ministry of Health in January, and the first phase of my mission was then accomplished. However, the second phase was to start revising the document into a report that could address a much wider readership than the two or three bureaucrats at the Ministry of Health who were working on the new strategy plan. Having spent half a year on the task and having confiscated the time of 13 internal reviewers, I thought it would appear expedient to publish this as an NIPH-authorised report. My closest superiors held the same opinion. However, the leadership of NIPH did not agree, and gave some dubious reasons for their rejection (lack of quality was not one). I mention this, because it illustrates how anti-THR attitudes by a handful of leaders can hinder information to the public. The funny thing is, that someone – and I really don’t know who – took on the effort to translate the whole document into English (without my authorisation) and placed it on the internet for an international audience. And from the feedback I am receiving, it seems like the document have reached a wider audience after all.
Q5. You have looked at how tobacco harm reduction is accepted or completely rejected in various countries. The divide among experts has been/is deep: has this difference of opinion impacted you personally with colleagues?
Karl Lund: You are absolutely right. In my more than 30 years in tobacco control, I have never experienced such a hostile disagreement. The frontiers are unusually sharp.
On one hand you have the proponents of THR who are inclined to accept continued widespread nicotine dependence as long as this is not related to cigarette smoking. They believe the level of taxation and regulations for novel nicotine products should be proportionate to risk. Furthermore, that health authorities should disclose risk differences between nicotine products, let the risks inherent in cigarette smoking be the reference for the comparison and encourage smokers to change to safer products through information campaigns. They justify the need for innovative products by referring to the many illnesses and deaths caused by cigarettes and believe that the application of a precautionary principle that prevents market access could result in the nicotine market being a status quo situation weighted towards the most dangerous product - cigarettes. And most controversial, proponents are also no stranger to collaborating with the nicotine industry in making harm-reducing nicotine products attractive, available and as safe as possible.
On the other hand, the opponents of THR believe that the purpose of the tobacco policy should be to eliminate any use of nicotine for recreational purposes. They think the disadvantages are greater than the benefits of granting competitive advantages for the supposedly least harmful products and do not subscribe to the proportionality principle of taxation and regulation. Opponents claim that the evidence base for the effect when giving up smoking is not robust and that such products will be able to delay smokers quitting and lead to dual use. The opponents also fear that the products will recruit non-smokers and, at worst, act as a gateway to the subsequent launch of tobacco smoking for young people who would otherwise not have started to use nicotine. They fear that the product's similarity to cigarettes of some products and that a mode of use similar to smoking could renormalize smoking and undermine the work of de-normalizing cigarettes. They believe that the risk of using harm-reducing products cannot be clarified before there is documented evidence based on long-term use, and that risk should not be compared to the risk of cigarette smoking, but instead with the non-use of tobacco products. In anticipation of a longer observation period to study possible effects on health and in light of the rapid rate of innovation for the development of ever-new generations of products, the opponents strongly endorse the precautionary principle. The possible development of harm-reducing products should not take place in conjunction with the tobacco industry or other branches of the nicotine industry, with the exception of the pharmaceutical industry that opponents regard as an ally in the work to reduce tobacco-related illness.
The academic camp within the tobacco control community seem to be split in the middle between proponents and opponents, while the bulk of the more active-oriented camp (most NGOs) seem to be on the opponent side. So my life - as a proponent of THR - is probably a lot smoother as an academic than it would have been if I had continued to work for the Cancer Society e.g. I am happy to say that at my institute, the debate among researchers is civilized and we tend to respect each other’s positions. However, from the activist camp, the attacks on me through the media have sometimes been personal, harsh and attributing.
Q6. How do you think this controversy is going to evolve? Can prohibition win or will nicotine become a more accepted drug?
Karl Lund: In western countries where smoking is declining, the main effect of THR-products will increasingly be in reducing smoking initiation, while its effect in smoking cessation may eventually diminish. A continuing decline in smoking will eventually lead to a continued increase in the relative share of never smokers among users of novel nicotine products. Thus, we have to ask ourselves; Can availability to THR-products be justified in an imaginary situation where cigarettes no longer seem to be attractive for anyone?
I am quite confident that there will always be some kind of recreational use of nicotine in society because of its rewarding and stimulating effects. The pleasure principle should not be underestimated, but the enjoyable sides of nicotine is fatally understudied. Likewise is the social and identify-formative functions of nicotine use. As long as people use nicotine for reasons other than cigarette substitution, we should strive to find the most harm-reducing delivery devices. For many, also for me, it is difficult to accept that we probably have to work with the nicotine industry to succeed in this manner.
Philip Morris and several others have repeatedly made statements about wanting to transition away from combustibles. One can look upon this as a ploy and simply oppose it as a sham and make regulations not facilitating novel nicotine products over cigarettes. Then the industry might stick to producing the most deadly product. However, if they are serious and we promote risk-proportionate regulation, we might get a public health breakthrough of historic significance. It’s a dilemma.
I think nicotine will become a more accepted drug if delivered without severe health risks. The tobacco control community will eventually have to accept that we have to separate nicotine from tobacco. In the 1990s the strategy was to warn against the axis of evil; cigarettes – nicotine – tobacco industry. Now we are paying the price for this merging. The goal should be to reduce tobacco-related deaths, not to make the society nicotine-free.
I think much of the opposition against THR and novel nicotine products comes from the fact that health side has been on the outside and not in the driver-seat of its development. These innovative products have emerged without their control and approval. This is a consumer-driven process. It is difficult for us to realize and accept that these products may have greater potential to make smoking obsolete than the regulations many of us have spent a lifetime fighting for.
The opposition towards novel reduced risk products, especially from some NGOs, may also be rooted in their need for ‘a good enemy’. Many NGOs have profiled their organisation on the fight against smoking, knowing that this will increase donations. As smoking declines, these organisations may look for other ‘enemies’ that can keep the donations coming. Cancer Societies fight against snus is not about preventing cancer – because it won’t. Heart and Lung foundations fight against snus is not about preventing COPD or CVD – because it won’t. It is more about profiling, reputation, goodwill etc.
Thank you Karl for having taken the time to be with us today.
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