Nicotine in a new guise

Vascular stiffness after vaping

One who early investigated the health effects of the new tobacco products is Magnus Lundbäck, associate professor of cardiology at the Department of Clinical Sciences, Danderyd Hospital. His research career began with studies on how blood vessels are affected by diesel exhaust. With the same methods, he has studied cigarettes, both conventional and vaping.

His first study on e-cigarettes, published in 2016, included 16 infrequent vapers who were asked to puff ten times on an e-cigarette over the course of ten minutes. Various controls were conducted over a 24-hour period. All values were compared with the study participants' own over a 24-hour period when they had not vaped.

One hour after vaping, biomarkers in the blood indicative of vascular damage were found. After 24 hours, however, the levels had returned to normal.

In recent studies, his research team have been able to show more acute effects from e-cigarettes. Shortly after vaping, airways are narrower, blood vessels are stiffer and blood-clotting properties increase.

Research on conventional cigarettes reveals a similar pattern: occasional use causes acute harm that eventually subsides. However, smoking conventional cigarettes over many years leads to chronic issues, including vascular stiffness, increasing the risk of heart attacks and strokes. The long-term effects of vaping remain unexplored, according to Magnus Lundbäck.

Interestingly, nicotine-free e-cigarettes do not produce the same vascular effects.

“The conclusion is that it is the nicotine itself that causes the damage," says Magnus Lundbäck.

Conventional cigarette smoke contains thousands of substances, such as tar, arsenic and hydrogen cyanide. Separating nicotine’s specific effects from this toxic mix has been challenging. Despite knowing for decades that conventional cigarettes harm vascular health, distinguishing between smoke and nicotine’s impact has proven difficult. Tobacco companies have positioned smoke-free cigarettes, i.e. e-cigarettes, as less harmful, suggesting they are a viable alternative for those who want to quit conventional cigarettes.

Helpful aid or gateway to addiction

This question is central to the discussions about new tobacco products. Is vaping a helpful aid for quitting smoking conventional cigarettes, or does it serve as a gateway for young people who have not previously used tobacco products? Or perhaps is it both? If so, how should the benefits balance against risks?

The New England Journal of Medicine recently published a study involving nearly 1 250 smokers who wanted to quit. Participants were randomly assigned to two groups: one group received standard smoking cessation treatment plus free, optional nicotine replacement therapy, while the other received standard smoking cessation treatment plus free e-cigarettes.

All participants set a quit date. After six months, 29 percent of the vapers had successfully quit and remained smoke-free, confirmed by urine tests. In the control group, progress was slower. Only 16 percent quitting on their planned quit date.

Interestingly, vapers clung more tightly to their nicotine habit. At the same six-month follow-up, 20 percent of those who vaped had completely quit nicotine. In the control group, the corresponding figure was 34 percent. Additionally, vapers experienced more respiratory issues, such as coughing.

Does this mean that e-cigarettes are beneficial for quitting, or do they perpetuate nicotine dependence?

Magnus Lundbäck emphasises that the long-term effects of e-cigarette use remain unexplored.

“The industry would like nothing more than for people like me to say that e-cigarettes are less harmful than conventional cigarettes. But why compare them to something as incredibly harmful to health as cigarettes? If that were the case, we should be highlighting the fact that conventional cigarettes are less dangerous than crack, but we are not. The only reasonable thing is to compare e-cigarettes with regular clean air, to compare use with non-use," he says.

Independent nicotine researchers face scrutiny from the tobacco industry," says Magnus Lundbäck. Following the publication of the 2016 study, industry-sponsored researchers challenged the interpretation of e-cigarettes as harmful.

“I think that is entirely appropriate. Everyone has the right to comment on research. We addressed their objections in a response we sent to the journal. In one passage, we mentioned that our critics had conflicts of interest because they were sponsored by the e-cigarette industry," says Magnus Lundbäck.

Shortly afterward, a subpoena arrived in the mailbox. The sender? Researchers with conflicts of interest to the industry. The journal received the same message. All this occurred during correspondence before publication. The result was that the journal backed down, and the section highlighting the conflicts of interest was removed. The rest was published.

“We have more examples of how closely we are monitored. For instance, representatives of the nicotine lobby were present and filmed an entire doctoral thesis defence a while back. Then they compiled a rather peculiar summary and published it through their own channel," Magnus Lundbäck recalls.

Rosaria Galanti, professor at the Department of Global Public Health at Karolinska Institutet, highlights several statistical sources commonly used in this context. These include the Public Health Agency of Sweden's Health on Equal Terms, The National School Survey by CAN (Centralförbundet för alcohol- och narkotikaupplysning) , and the City of Stockholm's Stockholm survey.

Snus use has increased sharply among girls

Navigating the data reveals that white snus use surged among girls when entered into the market. In the early 2010s, six percent of girls in the second year of secondary school had used snus in past 30 days. By 2023, the corresponding figure is 22 percent. For boys, the increase is also notable, though not as steep. These figures include both brown and white snus.

Recent health surveys have started specifically asking about white snus. CAN was the first to inquire about white snus in 2021. In the latest report from 2023, 22 percent of girls and 27 percent of boys in the second year of secondary school reported using white snus in the past 30 days.

Meanwhile, smoking rates have declined steadily. "In a steady downward trend, men's smoking rates have decreased since the 1970s, and women's since the 1990s," says Rosaria Galanti.

"This steady decline in smoking has been going on for a long time and cannot be attributed to the big change in snus use that has occurred in recent years," she continues.

The existing statistics do not support the claim that white snus is a product people turn to when quitting smoking. But what lies behind the graphs? How often do these young people, who have used white snus in the last 30 days actually use it? - What strengths do they choose? How much nicotine do they consume? Are they adopting other tobacco products? Rosaria Galanti hopes to explore these questions in an ongoing tracking how tobacco and nicotine use evolves over time.

She has already conducted a study involving over 3 000 eleven-year-olds, following them with annual check-ups until they reached 18 years old. However, this study was conducted before the emergence of new tobacco products. Regarding conventional cigarettes and brown snus, the average age for boys to start smoking was lower than that of girls, but girls became addicted more quickly. Many who began with cigarettes later added snus, and vice versa. The equivalent patterns for today's youth, who are also exposed to new products, remain unknown.

“The only way to find out is to follow a group of young people over time," says Rosaria Galanti.

Friends and price are important factors

Older knowledge highlights factors influencing smoking or snus initiation. Having parents or, especially, friends who use tobacco normalises its use. Another risk factor is mental illness.

Nicotine has a mood-regulating effect and can calm anxiety and stress. "We also observe that people with certain diagnoses, such as ADHD, use nicotine more frequently than others," says Rosaria Galanti.

Additionally, the macrosystem, i.e. society's policies, laws, and regulations, plays a role. The most significant deterrent to tobacco use is high prices.

“There is strong scientific evidence supporting this. Higher prices prevent smoking in all groups, especially among young people," says Rosaria Galanti.

There are many uncertainties regarding the new tobacco and nicotine products, particularly white snus. However, it is known that its use is widespread among young women. This trend leads to an increase in pregnancies where the mother uses snus.

Swedish pregnant women are asked about their tobacco habits during maternal health care visits. In 2016, 4.7 percent of expectant mothers reported using snus. In 2022, the corresponding figure was 7 percent.