WHO FCTC suggestions and Finland

It seems my dear little corner of northern Europe has taken a head start with regulation suggested by the WHO FCTC. Reading through the points they give for consideration versus our national law since 15th of august 2016:

Parties that have not banned the importation, sale, and distribution of ENDS/ENNDS may consider the following options: 
Our national health body suggested we should be banning ecigs alltogether, but EU is "forcing" us to allow them on the market. Ecigs were never banned, but all nicotine was classified as medication.

a. Banning the sale and distribution of ENDS/ENNDS to minors; 
In force
b. Banning the possession of ENDS/ENNDS by minors; 
In force for nicotine containing devices and liquids
c. Banning or restricting advertising, promotion and sponsorship of ENDS/ENNDS (see FCTC/COP/6/10 Rev.1); 
Complete ban of anything that might resemble any of these. Including product information on the internet, in face to face discussions with a store employee, and so on
d. Taxing ENDS/ENNDS at a level that makes the devices and e-liquids unaffordable to minors in order to deter its use in this age groupvii. In parallel, combustible tobacco products should be taxed at a higher level than ENDS/ENNDS to deter initiation and reduce regression to smoking; 
Draft legislation going to the parliament in september to add 30c/ml tax on liquids with or without nicotine, suggested to come into force 1.1.2017. However, the ministry of finance already budgeted the tax for next year. The tax would increase price of a 10ml bottle higher than a pack of cigarettes initially and level out to about the same in 2018. Possibly also adding things like 1500 euro tax on a 5 litre glycerine can if sold in a vape shop.
e. Banning or restricting the use of flavours that appeal to minors; 
Ban on characterizing flavors, as defined by the directive. Basically only cigarette flavour is allowed in liquids with or without nicotine.
f. Regulating places, density and channels of sales; and 
Channels restricted to physical stores only, places restricted somewhat. Health orgs suggest suppressing density of points of sale from 400 000 to 500, though this one is not in the legislation.
g. Taking measures to combat illicit trade in ENDS/ENNDS
No consideration given to black markets for some reason. Police has noted on snus that "sorry, but we have real work to do", presumably ecigs are not really different in that.

i. Testing heated and inhaled flavourants used in the e-liquids for safety, and banning or restricting the amount of those found to be of serious toxicological concern such as diacetyl, acetyl propionyl, cinnamaldehydes or benzaldehyde; 
Flavors banned.
ii. Requiring the use of ingredients that are not a risk to health and are, when allowed, of the highest purity; 
In force
iii. Regulating electrical and fire safety standards of ENDS/ENNDS devices; 
Not specific to ecigs, but exists
iv. Regulating the need for manufacturers to disclose product content to government; 
In force
v. Regulating appropriate labelling of devices and e-liquids;
In force. Though "appropriate" is highly debatable. 
vi. Requiring manufacturers to monitor and report adverse effects; and 
In force
vii. Providing for the removal of products that do not comply with regulations.
In force, with mandates offering the government officials power to do this simply at their own discretion. Includes trying to regulate cotton, wires, etc as ecigarette parts and flavorants and bases as nicotine free liquids.

b. Parties that have not banned the importation, sale, and distribution of ENDS/ENNDS may consider the following options to minimize health risks to non-users: 
i. Prohibiting by law the use of ENDS/ENNDS in indoor spaces or at least where smoking is not permittedviii;
In force for both
ii. Requiring health warnings about potential health risks deriving from their use. Health warnings may additionally inform the public about the addictive nature of nicotine in ENDS; and 
In force, requires two languages
iii. Reducing the risk of accidental acute nicotine intoxication by a) requiring tamperevident/child resistant packaging for e-liquids and leak-proof containers for devices and e-liquids and 
In force
b) limiting the nicotine concentration and total nicotine amount in devices and e-liquids. 
In force. Though legislators forgot to add empty tanks to this and now are in the process of changing that.

a. Prohibiting implicit or explicit claims about the effectiveness of ENDS/ENNDS as smoking cessation aids unless a specialized governmental agency has approved them; 
In force. No approval possible under tobacco act.
b. Prohibiting implicit or explicit claims that ENDS/ENNDS are innocuous or that ENDS are not addictive; and 
In force
c. Prohibiting implicit or explicit claims about the comparative safety or addictiveness of ENDS/ENNDS with respect to any product unless these have been approved by a specialized governmental agency.
In force, no approval possible under tobacco act.

I wonder, is Finland a breeding ground for these things? They keep passing with very little to no objection.
Most absurd thing is, Finnish ASH actually considers this a "decent middle ground".

Part 14: Testing my addiction again and some thoughts on dependence scales

Earlier today, I released a questionnaire in Finnish that is based on the nicotine dependence syndrome scale (NDSS). It's something that seems much more appropriate to the wider audience I want to capture, even though it is designed to measure the dependence in smokers specifically. I did edit it somewhat to suit the need of measuring nicotine dependence between different products, because that sort of thing is rarely if ever done.

The reason for that are mainly these:

- It is widely assumed that nicotine products are equivalent in their "addictive" potential, which is of course absurd considering the huge differences in chemistry.

- Simply introducing a chemical to the system is not even remotely enough to induce addiction in any meaningful sense, so logically also the amount of that chemical in the system cannot be used to determine how addicted a person is or even if they are at all.

- The only widely used instrument is the fagerström test for nicotine dependence (FTND), which is notoriously bad when it comes to anything that is not smoking. It's simply utterly uninformative when it comes to a product that is not highly standardized and as such, extremely consistent in the effect it has when it comes to heaviness of use.

For instance, when I was a smoker my FTND score was "8 - high dependence". Now I don't actually smoke in any consistent capacity and it still indicates a score of one, because it assumes cigarettes are consumed regularly. Trying to modify it to fit vaping seems like a fool's errand, because there simply is no reasonable method to determine what amount is equivalent to a specific number of cigarettes.

NDSS however, goes into much more detail and leans much more on aspects like social issues, impulse control and so on, while leaving out the explicit reliance on heavy use. It also corresponds well with the diagnostic and statistic manual for mental illnesses, which has one of the most common descriptions of addiction.

My interest in doing this on a wider scale came from reading through a lot of different methods of measurement and applying some of them on myself, including comparing my scores from when I was a smoker and now as a vaper. While very subjective of course, what I realized that at least I have a very radical difference experience and that actual studies of dependence in vapers and other alternative nicotine users are unbelievably rare, despite all the claims of "switching one addiction for another".

So, I'll show you what I mean by radical difference :)

NDSS uses different scales for it's multi-dimensional analysis, which in the source material I used were condensed like this:

Drive and priority, meaning the time and necessity to engage in nicotine use

Stereotypy and continuity, meaning the consistency of nicotine use from day to day

Tolerance, which is self evident

And a total score, which can be used as a sort of dependence score

Here's what came up in my calculations, which are rather rough approximations, but should give an idea:

Drive/priority - vaping score a bit under half of smoking

Stereotypy/continuity - vaping 1/3 lower

Tolerance - vaping 1/3 lower

Total score - vaping slightly less than half of smoking

These results are also fairly consistent with smokers defined as nondependent, except in the stereotypy and continuity scores, because my consistency of vaping is much higher.

Obviously the fact is that this is in no way scientifically rigorous (to be blunt. it is rather unscientific really, sorry about that), just my subjective analysis of myself. But it did give me a bit more information to add to the hypothesis, that vapers are significantly less dependent than smokers.

This also highlights something more about the fagerström test, suppose it was modified to a vaping dependence scale, I would very likely score substantially higher simply due to the fact that I do vape a lot.. Despite both the NDSS and DSM indicating my addiction is low to nonexistent.

Now, the problem does somewhat remain with NDSS too, it's not fully compatible with vaping either.. But it does seem to be the best option we do have right now. There remains a distinct need to design a scale that properly works with alternative nicotine products.

But I am hopeful NDSS offers a useful starting point.

To be continued.. :D

E-liquid taxing scheme proposal doing the rounds in Finland

There are a few common constants in the way the Finnish government treats vaping products.

The primary one is that they release a legislation draft, and all the communication around the details in public are made with certainty. This is what we'll do and this is what will happen. No ambiguity whatsoever. Then various organizations and special interest groups make their statements, including whatever arguments and (occasionally, but mostly no) data they deem relevant to the issue.

More often than not, these statements include several points where the law could be stricter.

Committees hear out the statements, and then go on to change more or less nothing.

Makes you feel like the commenting process is just for show.

The other one is that most of the justifications so far have been disjointed to some degree. A lot of jumping to conclusions happens around issues where no substantial evidence exists, making assumptions about the impact of certain things without considering if such events are even plausible.

This time though, the tax law proposal manages to first make a rational assessment about the impact of a sin tax on e-liquids and instantly ignore it's implications completely:

"It can be assumed, that if e-liquids are not taxed, their consumption as a substitute for conventional cigarettes would decrease the consumption of products currently subject to tobacco tax" aka smoking, since all other forms are illegal.

And then they go on to claim this:

"The decrease om consumption of electronic cigarettes due to the implementation of the tax can be estimated to have a positive impact on public health. The positive impact is assumed to be associated with the prevention of uptake of electronic cigarettes, which would prevent the development of nicotine addiction"

No citations of any kind included. No consideration of the fact that the vast majority of vapers are current or former smokers. They also claim there's no tax on electronic cigarettes, which is blatantly false since VAT applies like everything else.

Like I said, disjointed. Very much so.

The Finnish goverment is proposing a tax of 30c per ml, or 3 euros per 10ml bottle. The proposal calculates that the cheapest liquids would double in price with the implementation of this tax. And they want to apply it to both nicotine liquids and nicotine free liquids, based on the idea that this way nobody needs to test if the liquids have nicotine in them or not. Though there's some more gaps in that logic, since every single liquid has to go through the notification process anyway with mandatory testing of the nicotine content and exposure and has to have nicotine volume marked on it..

They do note that the tax would likely increase overseas sales of nicotine free liquids, since they are not subject to distance sales restrictions like nicotine liquids are. I'd estimate that the future liquid market for knowledgeable vapers will develop something like this: People will order large amounts of nicotine free liquids overseas, since it's likely to be around 50-60% cheaper and non-tobacco flavored liquids are illegal here, possibly smuggle high strength nicotine and mix their own. The rest will buy home mixed liquids from other people in dedicated facebook groups.

Current smokers and very new vapers, as in the people who are not part of online communities though?

Screwed.

Basically people will either be ignoring the law or be hurt by it. It will cause unnecessary and arbitrary criminality and death.

Part 13: Thoughts on harm creation

Lately, I've been watching some very interesting lectures on the underlying factors that lead to and exasperate behaviours to such a degree, that they get defined as diseases or disorders under the umbrella of addiction.

Two basic premises came up that were suggested to lie at the core of pathological addictive behaviour:

Structural chages in the brain reward circuitry:

A process involving hypersensitization of the dopamine release process, that leads to overactivative reward pathways (and the physical tolerance-withdrawal cycle) and at the same time loss of activity in the regions that reguate things like impulse control. It has been suggested that the brain scans of these two regions is a reliable way of testing for the presence of addiction. This is kind of a potential objective measure which could be used, unfortunately it seems quite hard to implement on a larger scale, so the prevalence of subjective measures based on mostly frequency of use persist. But it does have some very interesting implications in comparing for instance different nicotine products and their effects on the functionality of the brain.

Chronic dysphoria:

Dysphoria refers to a sort of feeling of social unease, restlessness and is a source of fairly high stress. Others spell this out in with examples, like lack and dysfunctional social connections. It has been long established that functional social networks and relationships are a great resource for not only relapse prevention and helping people with problematic use, but protective against susceptibility for the development of problems in the first place. Dysphoria also seems to exasperate existing problems, due to an increased need to "self-medicate".

The concepts around dysphoria are a great interest to me, and I've touched on similar things in this blog in the past on some thoughts on "creating" addicts by conjuring a problem out of thin air in people that do not actually have addictive behaviour. What I got to thinking during the lectures is somewhat along the same lines of that, but involving the people that are actually addicted.

It seems clear, that if dysphoria is a driving factor in problematic use, then the de-normalization efforts of shame and stigma in reality are not just immoral. They are extremely counter-productive, possibly making the existing problems much worse. 

Potentially so much worse, that it's entirely possible the intentionally created social discomfort and anxiety is potentially acting as a cause of moving to more dangerous, even deadly behaviours AND making them worse.

A self-fulfilling profecy if you will, as low risk product use is generally opposed on the back of this effect happening caused by the product use itself.

A core rule of any policy and regulation measures is (or should be), that the action is weighed against inaction and trying to analyze which option is actually beneficial.

This, simply does not exist in the field of tobacco control. They seem to want any and all possible restrictions they can possibly think of, regardless of the consequences. And if the stick doesn't work, get a bigger stick with more pointy things on it.

it's a steep hill to climb, but I do hope we can get to a point, where people can be treated as human beings again.

As for THR-product use.. My hypothesis so far is that for instance vaping should likely have a fairly radical difference to smoking in the measures for both the addiction inventory questionnaires (excluding things like FTND, which is useless for vaping) but also in the decreases and increases of brain activity potentially associated with addiction.

I would love to see that study!

Maybe then we could see some of the intentional creation of dysphoria fade away and start being rational about nicotine use in a wider scale, not just the echo chambers of advocates.

Part 12: Conflicts of self-interest

Two days ago, I dropped a gofundme page (https://www.gofundme.com/deetwo7) on twitter, after a long time of thinking about doing it and two more weeks of not telling anybody about it. 

Asking for financial help, even when it became absolutely necessary, while doing something I'm perfectly willing to do for free felt weird. It still feels weird.

Advocacy is something that feels like you do because there's a passion and necessity, and getting paid for that is somehow antithetical to the whole idea. But that does get me thinking.. why is there so much assumed conflict of interest in this area?

Anti-tobacco crusaders and various other public health advocates that oppose nicotine use generally tend to be actually paid to do that. They generally work in healthcare or NGOs that drive health-related political agendas. 

And they often seem genuinely surprised people on the other side are not paid by anybody. So much that they might not even believe it, and resort to some form of financial incentive blame game.

Why doesn't the same standards apply to them?

Why do I have this idea in my head that getting something in return for hundreds of hours of work is somehow "wrong"? I'm honestly not entirely sure.

And if the financial angle fails, the final determination in their chain of logic seems to be "you're just addicted". And everybody "knows" you can't trust an addict.

But addiction can only be measured by asking the addict about their behaviour. No truly objective measure or test exists for the determination. There's no machine that can detect addiction, no kind of physical biomarkers that could be investigated.

So, if an addict cannot be trusted, can the tests be trusted?

Is "you're just addicted" even a meaningful argument anyway? Because even if they are, that certainly does not mean they are lying or wrong. It just means a very subjective set of criteria happens to match their behavioural patterns, without necessarily meaning problematic use.

Is addiction a conflict of interest, if it cannot even be meaningfully defined?

What I wonder is, how deep is the (for the lack of a better word) "brainwashing" of temperance movements, that even me as a fairly libertarian advocate have these notions coloring my perceptions of doing this work..

I'm quite certain that promotion of THR is helping reduce the burden of death and disease and I'd like to think I'm having some sort of impact, but still there's a feeling of embarrasment lurking at the back of my head when I'm asking for financial help.

Intellectually, it's quite strange and counter-intuitive. Really feels like being forced to play by the rules of zealots and having no say in what's actually rational. The kind of influential manipulation scheme the tobacco companies can only dream of.

Tobacco control really is an inherently dishonest field.

And as a more positive note, enormous thanks to everybody who has helped. Got a LOT of stress off my shoulders.

Part 11: Feeling ranty. Finnish Tobacco Act ratified today.

Today, one of the most stringent implementations of the tobacco products directive was ratified in Finland.

The one I've been blogging about, fighting over with health organizations, trying to correct misconceptions in the media and written official statements as a part of an editorial team of a vaping association based on various studies and also as myself personally, where I've been leaning more heavily on pragmatic sense of morality and various standards of legislative actions that are supposed to be in effect in the European Union and Finland as a part of it.

Namely the principle of proportionality, which states that two different products should not be regulated in the same way without substantial justification. 

And yet, that is exactly what Finland did today. Despite being offered vast amounts of argumentation and evidence showing they are substantially different. They simply refused to listen and referred to their unsubstantiated claims made without citations, that we and I already specifically answered to, and stated there is no need to make changes. Including issues that were simple flaws of grade school math or basic understanding of human behaviour.

Our constitutional committee didn't even comment on the issue of low risk products at all.

 

Our social and health affairs committee referred to the same unsubstantiated claims made without citations.

They basically insisted on justifying all the vaping restrictions based on the harms of smoking and proclaimed the violations of proportionality with pride.

But, at least they promised us that availability of nicotine liquids would not be interrupted and set a grace period so people can order them abroad during the mandatory 6 month notification period.

They just neglected to set the grace period AS 6 months... 

So now it's a static date and the tobacco act is almost two months late (because some MPs felt like we're falling behind in the "strictest tobacco act" game, they forced in an amendment to add an unenforceable ban on smoking (and vaping) in cars if a child under 15 is present that doesn't even have a penalty, but is supposed to "spark discussion at daycare centers").. 

As a consequence, at a minimum a 1,5 month gap is going to happen in january-february when there will be no legal way to get nicotine liquids other than physically importing them 10ml at a time, because apparently that's enough for a vaper for two weeks and is equivalent to 200 cigarettes.

Which means there will be people going back to smoking and also likely others becoming criminals because a law that was not based on logic or evidence was passed.

And after we do get nicotine liquids on the market, the only flavor allowed is tobacco. Because apparently kids learn how to smoke with liquids that taste good and then move on to cigarettes that don't?

That kind of causal pathway might be likely to happen to somebody somewhere at some point, but in trying this hard to prevent that they seem to be shifting the net effect to the side of more smoking, not less.

I'll just quote the first paragraph of the tobacco act here, which I think will illustrate this whole unmitigated disaster perfectly (my own translation):

"1§

Aim of the act

The aim of this act is to end the use of addictive tobacco products that contain substances toxic to humans and other nicotine containing products.

To achieve the aims mentioned in paragraph 1 this act enacts measures that prevent the initiation of tobacco products and formation of nicotine addiction as well as promote ending the use of tobacco and similar products and protect the public from exposure to their smoke."

I recently dropped a little soundbyte on twitter and I think it will fit perfectly here:

"Denial of the principles of harm reduction is the implicit acceptance of avoidable misery, disease and death"

I just...

I'm ashamed. I really don't feel proud to be finnish today.

Just a random aside from Warsaw

Well, warsaw is kind of amazing. So glad I got to be here :)

Plenty of things to disseminate, new ideas and a lot of new energy to go with them. Been talking to a lot of people and it has helped me further some of my thoughts about addiction from especially a sociological standpoint.. Especially the lovely and brilliant Amelia Howard. Her presentation and just discussing all kinds of issues got me back to thinking of the underlying mechanisms.. And I really do believe there's a legitimate cases to be made on multiple fronts, ranging from the neurochemistry to the social to simple pleasure and evolutionary psychology sort of serving as groundwork.

Whether or not I'm actually capable of connecting those things remains to be seen, but I think I'm going to try. I think we need a much more comprehensive model of dependence, addiction and where we can draw lines between continuous use and pathological behaviour.

I think vaping not only improves the quality of life for a lot of people, maybe even saves them, but the phenomenon importantly has the potential to open up new lines of thought and understanding how people work.