Criticism of e-cig study "Researchers don't know how vaping works"

Absurdly high nicotine levels. Incorrectly adjusted devices and apparent ignorance of how e-cigarettes work. The latest study on the risks of e-cigarettes from Danderyd Hospital has been heavily criticised.
"Given that the researchers clearly do not understand how to use an e-cigarette, the inputs are likely to be contaminated with smoke and other toxic substances not normally found in a vape. It is fortunate that no one has been harmed in their tests" says Karl-Åke Johansson, vejpare, former product developer and spokesperson for NNA Sweden.

"Smoking e-cigarettes is as dangerous as smoking regular cigarettes"
Newspaper headlines following the publication of Dr Magnus Lundbäck's recent study on how nicotine i from e-cigarettes affect blood vessels, did not sway the target.

"Nicotine is more dangerous than we previously thought. We must ban flavours in e-cigarettes to protect our young people," wrote Magnus Lundbäck, together with two like-minded researchers, in a opinion piece in Göteborgs Posten just a few days after the report was published at Danderyd Hospital.

"Terrified of e-cigarettes and white snuff"

Karl-Åke Johansson, an IT technician, but also spokesperson for the consumer organisation New Nicotine Alliance Sweden, says he's pretty weary. This is not the first time researchers, with the help of support from the Swedish Heart-Lung Foundation and the Swedish Cancer Society, have made headlines with "new findings" about the "unknown risks" of e-cigarettes. And it won't be the last, he says.

"They are terrified of vaping and nicotine pouches. If the proportion of smokers in Sweden drops below 5 per cent and Sweden is considered an official smoke-free country by the WHO, they will lose their right to exist. They will do everything to keep the millions of dollars they receive annually from the state to run their businesses. Many people's careers are financed by this money. They don't want a quick end to smoking, but preferably a long and protracted one," he says to Vejpkollen as we go through the latest report from Danderyd Hospital.

Strong lobby against e-cigarettes

E-cigarettes are controversial products that have sparked debate since their introduction to the market over 20 years ago. Within a few years, the traditional tobacco control apparatus had begun to creak. The rhetoric: This was probably just another trick by the tobacco industry to fool nicotine users that "smoking is not so bad". It wasn't long before calls for bans and restrictions on flavours began to appear in the lobbying channels. The campaigns ranged from pharmaceutical companies to traditional anti-tobacco activists.

Reducing risks "by magnitudes"

It soon turned out that vaping, i.e. the vaporisation of a glycerine liquid with nicotine, was indeed something completely different from smoking. The vapour, produced at a temperature of around 250 degrees, is not made up of a variety of toxins and soot particles produced by combustion. Instead, it consists of water-soluble glycerine droplets mixed with air, a substance that leaves no residual traces in the lungs. The scientific understanding of road transport has grown dramatically in the 20 years that the products have been on the market, and according to the most comprehensive meta-analytical studies funded by UK Public Health Agency in terms of magnitudes, vaping is significantly less risky than smoking cigarettes.

"It's really common sense. The key is that the temperature required to vaporise e-liquid is significantly lower than that required to burn tobacco. At 1000 degrees, the temperature of the embers at the top of a cigarette, tobacco turns into soot and ash as the material degrades. This also produces thousands of toxins, most of which are carcinogenic or directly harmful to cells and blood vessels. E-liquid and the wick material in an e-cigarette never have time to degrade to the same extent. Already at 300 degrees it starts to get too hot. If the e-juice or wick material overheats, it tastes so awful that most people start coughing by reflex. In everyday life, it is a self-regulating system for minimising damage," says Karl Åke Johansson.

"Had to learn from scratch"

E-cigarettes have looked different over the years, depending on fashion and demand. But the technology has remained the same.

"I started travelling sometime between 2010 and 2012. I don't really remember anymore. That's when I stopped smoking, anyway. Back then, the supply was very limited. Many of us who were vaping then had to learn the technique from scratch. It was everything from making e-juice to putting together parts of different devices to make it work. Nowadays, things are really different. A mostly positive development, although there is a constant struggle to explain the point of vaping to everyone from politicians to smokers," says Mr Johansson.

Variable knowledge about e-cigs

E-cigarettes are now available in their simplest form, disposable models, in almost every shop selling cigarettes and tobacco. At the same time, knowledge of the technology is highly variable, at least outside the growing network of users who help each other quit smoking by switching to e-cigarettes.

"This is particularly noticeable when researchers, like Magnus Lundbäck and his team in Danderyd, are unable to acquire basic knowledge about how an e-cigarette actually works. They have probably never used the products they use in their tests, never bothered to ask anyone who knows, and their test subjects have probably not had it so easy" says Karl Åke Johansson to Vejpkollen.

Swedish doctors focus on risks

The high-profile report from Danderyd concludes that people who use e-cigarettes and e-liquid with nicotine risk damage to blood vessels and cells to the same extent as if they had smoked cigarettes. However, previous research has demonstrated the opposite - clear improvements when smokers switch to e-cigarettes with nicotine. The message of the Danderyd research struck a chord in the media, where 'e-cigarettes are as dangerous as cigarettes'" became the dominant headlines.

"That was the first thing that surprised me. If the overwhelming majority of research to date has found that road users get better cardiovascular health - as a natural result of quitting smoking - how can a small Swedish study suddenly come up with something that contradicts world-leading research?" says Karl-Åke Johansson.

Misaligned appliances in the tests

However, it was only when Karl-Åke Johansson saw which products the researchers in Danderyd had used, and how they had used them, that he got the coffee in his mouth.

"I reacted to two things. One is that they used a device that is very powerful. Definitely not a beginner's device - it requires a certain technique to work properly. They also write that they used so-called temperature control, a built-in feature of the machine, to set a certain temperature for the "vapour". But then you read that they have installed a vaporiser that does not work for temperature control. This means that the e-cigarette will use its full power to bring the temperature up to what it still thinks is room temperature. The e-liquid could easily have reached 600 degrees and degraded significantly, which would have contaminated the test with a variety of toxic substances other than just nicotine, says Karl-Åke Johansson.

Used nicotine shots - with 19 mg/ml

Karl-Åke Johansson's second concern was the actual e-liquid used by the researchers in their tests. According to the report, it was an unflavoured e-juice with a nicotine concentration of 19 mg/ml, consisting of equal parts glycerine and propylene glycol.

"It is obvious that they used a so-called nicotine shot - a product that is meant to be mixed to much lower concentrations in a nicotine-free e-liquid. "What's striking is that they had the subjects vape this highly concentrated liquid at a power level as high as 32 watts. There can be a very strong vapour development, something that actually requires a lot of air and cooling via direct lung flares to even work." says Karl-Åke Johansson.

"Unnaturally high nicotine content for that effect"

He also believes that e-juice with such a high nicotine content, as used by the researchers in Danderyd, is not intended to be vaped at higher powers than 5-10 watts. This is a common effect in, for example, pod systems or disposable models. The device used by the researchers in Danderyd, an Evic Primo (75w) with associated tank, is therefore not suitable for use with highly concentrated nicotine, says Karl-Åke Johansson. And according to Karl-Åke Johansson, this is something the researchers should have been aware of.

'A conversation with an employee at one of Sweden's vape shops would have clarified the matter. With such high effects, it is customary to use a concentration of 3 to 6 mg/ml - not 19 mg/ml" says Karl-Åke Johansson. "The result was probably a heavy overdose of nicotine in each flare. In reality, no one had been vaping that way for a long time. 

May have become smoke instead of vapour

According to Karl-Åke Johansson, the combination of high nicotine levels and ignorant handling of the devices probably contributed to the fact that the input values from the experiment cannot be trusted. In addition, the test subjects could have suffered badly.

'They probably didn't inhale vapour, but a smoke mixture. It was just pure luck that some of the participants did not have heart problems. Nicotine in such large doses can cause cardiac arrest - it could have ended very badly." says Karl-Åke Johansson.

Research is important - but in the right way

According to Karl-Åke Johansson, the researchers behind the study should be held accountable for their methods. He believes that a study based on incorrect input values should be consigned to the wastepaper basket.

"It is of course very important to study the effects of weaning. But this study is so poorly done that it is impossible to draw any conclusions. Now I suspect that the purpose and background of the study is to simply highlight the risks of nicotine use and vaping in particular. Had they had a more reasonable methodology, say by using disposable models or similar, the results would probably not have been as hoped for. A sign of controlled research, where you have a ready-made message that you then "confirm" with a study. This is a clear warning flag for decision-makers who are likely to be curious about the report," says Karl-Åke Johansson.

Have applied to the responsible researcher

Behind the study from Danderyd is the doctor Magnus Lundbäck, who has also appeared in several media regarding the study. Vejpkollen has contacted him for a comment on the criticism and is awaiting a response.

Sources for this article:
The Swedish study on the risks of e-cigarettes (Danderyd Hospital):
Electronic Cigarette Vaping with Nicotine Causes Increased Thrombogenicity and Impaired Microvascular Function in Healthy Volunteers: A Randomised Clinical Trial.

Similar study on cardiovascular health during weighing (Vesuvius - British Heart Foundation):
Cardiovascular Effects of Switching From Tobacco Cigarettes to Electronic Cigarettes

2 Comments on “Kritik mot e-ciggstudie ”Forskarna vet inte hur vejpning fungerar”

  1. It is incredibly unethical to doubt that vaping could be anywhere near as harmful to health as smoking. It's like thinking that the risk of accidents is as high when travelling by train at 200 km/h as it is when riding a motorcycle without a helmet in just shorts and a t-shirt.

  2. Someone shared Vejpkollen's post on social media and wrote that the study's claims were "downright wrong". But that is not really true, and neither is what Vejpkollen writes here.

    I was reading here on Vejpkollen, then the study itself, and thought "but wait a minute - does the study even DO what social media is accusing it of?".

    The study was designed to investigate how 30 puffs of EC aerosol affected the coagulation and microcirculation of healthy volunteers. They compared before and after inhalation. Results: It had a negative impact.

    They consistently write EC aerosol - not e-cigarette, vaping or other. Nowhere in the study's purpose does it state that they intend to actually find out how "real vaping" itself affects - i.e. not actual e-cigarette smoking with realistic temperatures, doses or puffs. On the contrary, the authors mention under the heading "strengths and limitations" how the study method does not reflect real-life vaping.

    The results of the study itself are hardly wrong or misleading. It is only when you try to draw too far-reaching conclusions from the results that they become incorrect. This is the kind of error that some journalists seem to have made here. But the authors themselves do not claim anything in the discussion section of the study about the potential health risks in road users that they would have managed to identify - no, they speculate instead about pharmacodynamics.

    It is not clear what the researchers themselves have said in other contexts,
    and Vejpkollen is "awaiting a response" from the study manager. But regardless of whether the researchers and the study deserve criticism or not, one should at least criticise when OTHERS make too much out of a simple experimental study.

    Now I still think that the researchers screwed up and that they probably really wanted more realistic dosages. But then the criticism should be directed at ill-considered methods - not at "incorrect claims" if there are none. And criticism should always be directed at THOSE WHO OVER INTERPRET the study results (journalists, people on social media, other researchers). Vejpkollen can be useful here, clarifying and clearing up misunderstandings.

    In summary, I think much of the criticism of the study itself is misdirected - criticism should rather be directed at those who draw unsound conclusions from a study that has strong limitations.

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