Monday, March 27, 2017

IN MY VIEW: Campaign for Tobacco-Free Kids' Lying Has Got to Stop

In an action alert emailed today to its constituents, the Campaign for Tobacco-Free Kids insinuated that the tobacco companies are producing gummy worm electronic cigarettes. The title of the email is "Gummy worms," and the headline of the action alert states that "tobacco companies" are "luring kids with candy-flavored e-cigarettes and cigars."

As I've noted previously, this is simply not true. None of the tobacco companies is producing gummy worm-flavored electronic cigarettes.

While the Campaign for Tobacco-Free Kids has every right to fight for a ban on e-cigarette flavorings (a policy with which I vigorously disagree), it has no business lying to and deceiving its constituents in order to promote such a ban.

Telling the truth to its constituents would apparently not be glitzy enough for the Campaign. So instead, it has to lie by making the public think that Big Tobacco has sunk to the level of trying to get kids to use gummy worm-flavored nicotine products. This may be a catchy and eye-grabbing claim that succeeds in getting people riled up, opening up their pocket books, and eliciting donations, but it does so by misleading and deceiving them. That's fundamentally dishonest and unethical, and I don't believe a campaign like this has any place in public health.

Why is the truth not enough?

The Rest of the Story

Perhaps the reason that the truth is not enough is that the truth destroys the made-up story that the Campaign for Tobacco-Free Kids is trying to tell. Their story is that Big Tobacco is up to its old tricks, trying to seduce and addict kids to electronic cigarettes through outrageously blatant appeals to obvious youth-appealing flavors like gummy bear, gummy worm, and cotton candy. But unfortunately for the Campaign, that's not the truth. The truth is that the largest cigarette company in the United States - Altria - produces its MarkTen XL Bold e-cigarettes in only two flavors: tobacco and menthol. And their original MarkTen e-cigarettes come in only four flavors: tobacco, menthol, fusion, and winter mint.

If Altria were truly interested in getting kids addicted to e-cigarettes, I hardly think that it would restrict itself to tobacco, menthol, fusion, and winter mint, when there are thousands of sweet-tasting, candy, fruit, and dessert flavors available that they could be marketing.

The truth just destroys the Campaign's story. But apparently, the Campaign's motto is "never let the truth get in the way of a great story."

The real story is not a pretty one. The rest of the story is that the Campaign for Tobacco-Free Kids continues to incessantly deceive the public by falsely accusing tobacco companies of marketing gummy worm, gummy bear, and cotton candy electronic cigarettes to children.

Look - I have issued my fair share of accusations against the tobacco companies. I testified in about 10 cases against Big Tobacco, one of which resulted in a $145 billion verdict against the companies. But my testimony was always based on the facts. There were different ways to interpret those facts, but I would never lie or deceive the jury in order to try to make a point or embellish the case.

If we issue false accusations like this against the tobacco companies, then what reason is there for anyone to believe us when we complain about actions that they really have taken?

Perhaps this is why the actions of the Campaign for Tobacco-Free Kids are so disturbing to me. They tarnish the reputation of the entire tobacco control movement, including myself.

Tuesday, March 21, 2017

Anti-Vaping Advocates Support Indoor Vaping Bans Because We Don't Know if Secondhand Vaping is Harmful

In an interesting twist from the usual reasoning in public health, anti-vaping advocates are promoting the enactment of policies that ban vaping in public places not because secondhand vaping has been shown to have serious health hazards, but because it hasn't been proven to be benign.

In an opinion piece published in Tobacco Control, Dr. Simon Chapman and colleagues support a ban on vaping in public places because we don't know yet whether secondhand vaping is harmful. The authors write that: 

"those advocating for vaping to be allowed in smoke-free public places centre their case on gossamer-thin evidence that vaping emissions are all but benign and therefore pose negligible risks to others akin to inhaling steam from showers, kettles or saunas. This is likely to be baseless. Unlike vapourised water, electronic nicotine delivery system (ENDS) emissions comprise nicotine, carbonyls, metals, organic volatile compounds, besides particulate matter, and putative carcinogenic polycyclic aromatic hydrocarbon. ... Importantly, the short time span since the advent of ENDS and the latency of candidate respiratory and cardiovascular diseases that may be caused or exacerbated by ambient exposure to ENDS emissions preclude definitive risk inference. Taking the current immature evidence as a proof of safety and using it to advocate for policy that allows ENDS indoors could prove reckless."

The only known evidence of the hazards of secondhand vaping that the article is able to cite is that exhaled e-cigarette aerosol is "not harmless water vapor." And the only evidence it presents showing that vaping can result in high levels of particulate exposure is from the measurement of particle concentrations at a "vapefest," where literally hundreds of vapers are present in an enclosed location.

The Rest of the Story

In all the time that I spent lobbying for smoke-free bars and restaurants because of substantial evidence of life-threatening public health harm, little did I know that at a time in the future, we would be advocating for vape-free environments because a potential exposure was "not harmless." Little did I know that we would be supporting bans on a behavior in private facilities (like restaurants) because we did not have definitive evidence that the behavior in question was benign.

I thought it was the other way around. I always thought that to justify interfering with individual rights and freedom as well as business owners' autonomy, we had to demonstrate that there was a substantial public health hazard. These anti-vaping advocates suggest that it is the other way around. In order not to ban vaping, we have to prove that it is not harmful. In my view, this is antithetical to the justification for public health regulation. 

In order to justify societal policy that interferes with individual freedom and autonomy, we should be required to document - with reasonable evidence - that a significant public health hazard exists. We don't just ban everything that may or may not have significant risks and wait until behaviors are proven to be benign before we allow them.

When I testified at public hearings in support of smoke-free bars and restaurants, opponents would often argue that I only wanted to ban smoking in these workplaces because I was annoyed by smoke and that it didn't matter if secondhand smoke was actually known to be harmful. I countered this by explaining that in tobacco control, we respect individual rights and autonomy, including that of business owners, and that we would not call for a ban on smoking in these establishments in the absence of significant evidence that secondhand smoke exposure represents a substantial public health hazard.

What bothers me about this article, and about the campaign to ban vaping in public places generally, is that it essentially proves our opponents to be right. We aren't basing our support for bans on vaping on the presence of substantial evidence of a public health hazard. Instead, we're basing our support for these bans on the absence of substantial evidence that there is a public health hazard. If there were sufficient evidence to know that secondhand vaping is a significant public health hazard, this would be a no-brainer. So in essence, it is the lack of evidence of known health effects that is the basis of current campaigns.

New York State Senator Uses "Alternative Facts" to Promote Ban on Flavored E-Cigarettes

A New York State senator - Brad Hoylman (D-Manhattan) - has introduced legislation to ban the sale of flavored electronic cigarettes in New York. To promote this ban, he argued that cigarette companies are seducing kids to vape by selling fruit punch, gummy bear, and cotton candy e-cigarettes: "Kids are attracted to the numerous flavors that the cigarette companies are selling, such as fruit punch, gummy bear, cotton candy."

The Rest of the Story

Senator Hoylman's position is based on "alternative facts," or what prior to 2016 would have more simply been called a "lie."

Not a single one of the tobacco companies is producing gummy bear, cotton candy, or fruit punch e-cigarettes.

Altria's MarkTen e-cigarettes come in four flavors: classic (tobacco), menthol, fusion, and winter mint. Their MarkTen XL Bold e-cigarettes only come in two flavors: classic and menthol.

R.J. Reynolds Vapor Company's Vuse e-cigarettes come in seven flavors: original, mint, melon, nectar, berry, chai, and crema.

Imperial Brands' blu e-cigarettes come in 14 flavors: tobacco, menthol, vanilla, cherry, blueberry, peach schnapps, strawberry mint, Carolina bold, pina colada, mint chocolate, glacier mint, caramel cafe, gold leaf, and berry cobbler.

British American Tobacco's Vype e-cigarettes come in 12 basic flavor types: tobacco, apple, master blend, vanilla, mint, wild berry, green snap, scarlet kick, indigo dive, dark cherry, oriental spice, and rich aniseed.

Thus, not a single one of the tobacco companies are producing gummy bear, cotton candy, or fruit punch e-cigarettes.

The cotton candy, gummy bear, and fruit punch flavors of e-liquids are being produced by independent companies that have nothing to do with Big Tobacco. However, that apparently does not make a good enough story to support this legislation. So instead of just telling the truth, the senator decided to lie and tell people that Big Tobacco is the culprit for marketing these flavors.

This is not just bad legislation because it is based on a lie. It is bad legislation because if enacted, it would have a devastating effect on the public's health. Removing flavored e-cigarettes from the market is tantamount to a complete ban on e-cigarettes. There are literally millions of adults who use flavored e-cigarettes to stay off real cigarettes. Banning these products would result in tens of thousands of ex-smokers returning to smoking. It would also prevent quit attempts by many current smokers who are just not attracted by tobacco-flavored e-cigarettes. 

Any legislation so weak that you have to lie to support it is clearly not worth voting for. I hope the state Senate in New York sends this bill to a quick defeat.

Sunday, March 19, 2017

Campaign for Tobacco-Free Kids Admits that Its Secret Campaign Promoted Youth Cigarette Addiction

Through a shocking revelation, we learned last week that a major, national anti-tobacco organization ran a secret campaign to promote youth cigarette addiction.

The organization: The Campaign for Tobacco-Free Kids

The secret campaign: Federal lobbying against a ban on menthol-flavored cigarettes.

The admission: This campaign promoted youth cigarette addiction by protecting the cigarette companies' ability to market the most popular flavored cigarette (menthol) to youth and the campaign worked: menthol cigarette use among youth increased significantly thanks to the lobbying efforts of the Campaign for Tobacco-Free Kids.

The reason I call this revelation shocking is that I find it scandalous that an organization which is supposedly dedicated to fighting youth addiction to cigarettes would secretly lobby for legislation that protects cigarette companies' profits by blocking public health efforts to prohibit the companies' ability to use flavored cigarettes to attract and addict kids to smoking.

And instead of admitting its mistake and apologizing, the Campaign for Tobacco-Free Kids is now bemoaning the devastating damage that was caused by menthol cigarettes without acknowledging that it was largely responsible for this damage because it lobbied against taking menthol cigarettes off the market.

The Rest of the Story

When Congress debated the Family Smoking Prevention and Tobacco Control Act, which was signed into law by President Obama in 2009, perhaps the most critical issue it considered was whether or not to curtail the cigarette companies' ability to use menthol flavoring to attract and recruit kids to a lifetime of addiction to smoking.

The proposal on the table already banned non-menthol flavorings, but there was a problem: there were no non-menthol flavorings on the market. So while the proposal banned cherry, strawberry, banana, and pineapple cigarettes, there were no such products on the market. Candy-flavored cigarettes were not the problem. Menthol cigarettes were.

So the United States Senate debated whether to actually ban flavored cigarettes (i.e., menthol cigarettes) or whether to pretend to ban flavored cigarettes while exempting the only flavored cigarettes that were actually on the market (menthol cigarettes).

Understandably, a number of public health organizations came out strongly in favor of banning menthol cigarettes. But one organization - the Campaign for Tobacco-Free Kids - turned its back to the public's health and to the children it was supposedly committed to protecting.

Instead of lobbying for the menthol ban, it lobbied against it. The Campaign went to war, not to protect youth from a lifetime of addiction, but to protect the cigarette companies' ability to use flavored cigarettes to recruit and entice kids into a lifetime of addiction to smoking.

Last week, in a report entitled "The Flavor Trap," the Campaign for Tobacco-Free Kids revealed that data from the National Youth Tobacco Surveys demonstrates that its lobbying efforts resulted in the increased addiction of youth to menthol cigarette smoking, acknowledging that the "use of menthol cigarettes, the only remaining flavored cigarettes, increased significantly after the ban."

It is disingenuous for the Campaign to call menthol cigarettes "the only remaining flavored cigarettes" because menthol cigarettes were the only existing flavored cigarettes at the time the legislation was enacted. So yes, it is technically true that menthol cigarettes were the only remaining flavored cigarettes after the ban but they were the only remaining flavored cigarettes before the ban as well.

This admission - that the use of menthol cigarettes by kids increased significantly as a result of the legislation's menthol exemption - is quite damning. It essentially acknowledges that it was the Campaign for Tobacco-Free Kids' lobbying that was responsible for this rise in menthol cigarette use. Had this exemption not been granted, it is likely that youth cigarette smoking would have declined even more substantially.

What makes the report even more damning, however, is that the Campaign for Tobacco-Free Kids' hides from the public the fact that it actively lobbied against a ban on menthol-flavored cigarettes. While it boasts about having banned lime, bubble gum, chocolate, and raspberry cigarettes - none of which were on the market to begin with - the Campaign fails to disclose its role in protecting menthol cigarettes.

The Campaign hides the fact that it chose to come down on the side of Big Tobacco rather than on the side of America's youth.

Now - after the fact - the Campaign appears to be giving lip-service to the idea of extending the cigarette flavor ban to menthol. However, most of its attention is focused on banning flavored e-cigarettes - which are not addicted any nonsmoking youth- not on banning flavored real cigarettes, which the Campaign admits are addicting an increasing number of kids.

The rest of the story is that when it really mattered, the Campaign for Tobacco-Free Kids opted to protect the interests of Big Tobacco rather than to protect our nation's youth from a lifetime of addiction to the most deadly products on the market.

Wednesday, March 15, 2017

New York State Department of Health Urges Physicians to Discourage Patients from Quitting Unless They Use Big Pharma Products and Tells Vapers They Might as Well Go Back to Smoking

The New York State Department of Health has sent out a letter to medical professionals in the state, urging them to discourage patients from quitting smoking using e-cigarettes, even if they indicate unwillingness or lack of interest in nicotine replacement therapy or other smoking cessation drugs.

In the February 2017 letter, the state health commissioner writes:

"I encourage all health care providers to talk to their patients -- young and old alike -- about the dangers of e-cigarettes and to discourage their use. For patients who are already using traditional cigarettes or e-cigarettes, there are currently seven FDA-approved medications for smoking cessation, including five nicotine replacement therapies."

Further, in a letter sent to VapeNY five days ago, the director of the state health department's chronic disease prevention division castigates vapers by denying that switching from smoking to vaping has any public health value, thus telling vapers that they might as well return to cigarette smoking.

The director of the division writes:

"To date, the evidence on vapor products, electronic cigarettes and similar devices finds the products have no credible public health value in real world use...".

The Rest of the Story

I could hardly believe my eyes when I saw these letters. In the first letter, the New York state health department actually urges physicians to discourage patients from quitting smoking unless they are prepared to use nicotine replacement therapy, Zyban, or Chantix. For patients who have no interest in using one of those three products (or have used them and failed in the past) and wish to try quitting by switching to vaping, the official recommendation from the state of New York is to discourage these patients from using e-cigarettes to quit. In other words, physicians should essentially discourage such smokers from making such a quit attempt, since the reality is that they are not interested in using medication.

This advice to physicians to discourage quit attempts using e-cigarettes is unqualified. It does not say: "Encourage smokers to try an FDA-approved medication first, and recommend e-cigarettes only if that fails." It advises physicians to discourage e-cigarettes under all circumstances. Obviously, this includes the circumstance where the patient tells the physician that she has no interest in using Big Pharma products and instead, wants to try vaping.

This blanket recommendation is inappropriate and in my view, damaging. Essentially, smokers are being told that if they don't want to quit the way the health commissioner thinks they should quit, then they shouldn't even try. Clearly, this attitude from the state health department is going to discourage many quit attempts and therefore promote continued smoking by many.

The advice is particularly inappropriate because the scientific literature shows that smoking cessation medications only have a 10% success rate in the real world. Thus, 90% of smokers who take the health department's advice are going to fail, and thus remain smokers.

The existing evidence suggests that electronic cigarettes are at least as effective as nicotine replacement therapy. And newer products currently on the market are almost certainly more effective than the nicotine patch, since the products tested in the existing clinical trials were first-generation products with very poor nicotine delivery. The delivery of nicotine by vaping devices has increased substantially since that time, meaning that these devices are almost certainly more effective than the early products. But even those early products performed equally to the nicotine patch in the clinical trial setting.

The Department of Health's declaration that e-cigarettes have "no credible public health value" means that there must be no value in switching from smoking to vaping. The health department is essentially telling the millions of smokers in the United States who have done exactly that (quit smoking by switching to vaping), that they might as well return to smoking. After all, if vaping has no public health value, then why bother vaping? You might as well go back to smoking, and you haven't lost anything.

The problem is that this is patently false. There is abundant evidence that vaping is much safer than smoking and that smokers who switch to vaping experience an immediate and dramatic improvement in their health, especially in respiratory symptoms and lung function. Several studies by Dr. Riccardo Polosa and his colleagues have demonstrated significant improvement in respiratory symptoms and objectively measured lung function (spirometry) among smokers who switched to electronic cigarettes. Positive effects on health were observed for patients with both asthma and COPD. And while the improvement was most dramatic for smokers who switched completely to vaping, many of the dual users who cut down substantially on the amount they smoked did experience health improvement. Dr. Polosa also found that smokers with hypertension who switched to e-cigarettes experienced a significant decrease in their blood pressure.

While we can argue about the potential long-term risks associated with vaping, it is simply not the case that e-cigarettes have no credible public health value in real world use. What do you call more than one million smokers quitting using e-cigarettes? If that doesn't have public health value, then I don't know what does. And that is a conservative estimate, since there are an estimated 2.5 million ex-smokers who currently vape. (While some of them may represent ex-smokers who picked up vaping, the vast majority almost certainly are smokers who switched to vaping.)

The New York State Department of Health is also being irresponsible in its direct communications to the public. In a press release issued just 2 days ago, it incorrectly claimed that e-cigarettes are a form of tobacco use. The truth is that e-cigarettes are not a form of tobacco use because they don't actually contain any tobacco. They are no more a form of tobacco use than nicotine replacement therapy. We don't say that using the nicotine patch is a form of tobacco use. Neither is vaping.

The department, in the same press release, claimed that e-cigarette use can be a gateway to nicotine addiction. There is no evidence to support this conclusion. Despite dramatic increases in youth e-cigarette use, the prevalence of nonsmoking youth who have become regular users of e-cigarettes (and thus potentially addicted) is miniscule. Thus, the current evidence is that e-cigarettes actually have a very low potential to serve as a gateway to nicotine addiction.

New York's own data demonstrate that e-cigarettes are not serving as a gateway to smoking. Despite a doubling of e-cigarette use among youth between 2014 and 2016, youth smoking in New York in 2016 reached a historic low. Current smoking among youth in 2016 was only 4.3%.

In fact, while e-cigarette use among youth in New York state rose dramatically from 10.5% in 2014 to 20.6% in 2016, youth smoking plummeted from 7.3% to 4.3%. And if you go back to 2012, when youth e-cigarette use wasn't even measured, the decline in youth smoking is from 11.9% to 4.3%. These data are simply not consistent with the hypothesis that e-cigarette use is a gateway to smoking among youth. If anything, it appears that e-cigarettes may be contributing to the further de-normalization of youth smoking. The emergence of a vaping culture appears to serve as an alternative to the smoking culture, not the other way around.

The rest of the story is that the New York Department of Health is spreading dangerous misinformation and irresponsible medical advice that has the potential to do public health damage. Hopefully, they will correct this misinformation and retract their misguided advice to physicians. They need to do this in order to prevent the unintended effect of their communications, which is to promote smoking by protecting it from competition by vaping products.

Tuesday, March 14, 2017

New Survey Shows that Most Physicians are Completely Misguided on E-Cigarette Recommendations; Anti-Tobacco Groups' Propaganda is Wreaking Havoc on the Public's Health

A paper published in the current issue of the Annals of the American Thoracic Society reports the results of a survey regarding physician recommendations to their patients about the use of electronic cigarettes for smoking cessation.

(See: Nickels AS, Warner DO, Jenkins SM, Tilburt J, Hays JT. Pulmonologists’ and Primary Care Physicians’ Responses to an Adult Patient with Asthma Who Inquires about Using Electronic Cigarettes as a Smoking Cessation Tool. Annals of the American Thoracic Society 2017; 14(3): 466-468.)

Physicians were given a clinical scenario in which a patient who smokes seeks advice about smoking cessation. Most physicians report that they would recommend the patient try FDA-approved medication before trying e-cigarettes. However, physicians who recommended against e-cigarettes initially were then given a further scenario in which the patient tells the physician that they tried other medications to quit before, that they refuse a prescription, and that they ask the physician again whether they should try e-cigarettes to quit.

Shockingly, the survey finds that in this situation, only 27% of physicians would recommend e-cigarettes. The remaining 73% of physicians would recommend against the use of e-cigarettes, even after the patient indicated that using FDA-approved medications is not an option.

The Rest of the Story

The results of this survey are truly appalling. What they tell us is that more than two-thirds of physicians are essentially counseling their patients to continue to smoke rather than to attempt to quit by switching to electronic cigarettes.

After all, those are the only options that the patient is asking about in the scenario. The patient has made it clear that using FDA-approved medications is not an option. She has explicitly refused to take a prescription, meaning that she will almost certainly not be using NRT or other drugs to quit smoking. Essentially, the only options she is presenting to the physician are continuing to smoke are giving e-cigarettes a try.

And what the physicians are saying, or at least 73% of them, is: "In that case, continue smoking."

While this is truly appalling, I do not blame the physicians. They have been misled and confused by a major campaign of deception being waged by anti-tobacco groups and some health agencies, including the FDA and the CDC. These groups have lied to physicians and deceived them about the nature of e-cigarettes, their risks, and the relative risks of smoking compared to vaping.

For example, the CDC has told physicians that e-cigarettes are simply another "form of tobacco use." The FDA has told physicians that there is no evidence that vaping is any safer than smoking. Many anti-tobacco groups have told physicians that vaping is actually worse than smoking. Several anti-tobacco researchers have told physicians that vaping poses a higher cancer risk than smoking. Recently, some anti-tobacco researchers told physicians that vaping poses a higher risk of stroke than smoking. And many organizations have told physicians that vaping causes bronchiolitis obliterans ("popcorn lung") without even a suggestion that smoking also causes this severe, progressive lung disease.

Interestingly, the Mayo Clinic itself (with which four of this paper's authors are affiliated) has been a huge part of the problem. The Mayo Clinic lied to physicians about e-cigarettes, telling them that vaping is not any safer than smoking. The Mayo Clinic even went as far as to question the sanity of electronic cigarette users.

One thing I find surprising about this paper is that it fails to point out that there is a major problem with physicians advising patients who will not use NRT or other medications not to try e-cigarettes. While the paper does not explicitly state its position with regard to the appropriateness of this physician recommendation, it appears to be suggesting that the problem is not the physicians who recommend against e-cigarettes, but those who actually support this approach. I get this sense from the way that the paper frames the major result.

Instead of describing the major finding as "73% of physicians recommend against smoking cessation using e-cigarettes for smokers not willing to quit using other methods," the paper describes the major finding as follows:

"When confronted with a patient who prefers not to use FDA-approved medications, the majority of respondents either recommended electronic cigarette use or at least tolerated it."

One final point is worth mention. The authors fail to disclose any conflicts of interest related to this article. However, one of the study authors is a co-author of a manuscript reporting the results of a clinical trial of Chantix in which Pfizer was a collaborator (providing the study medication free of charge). And further, that co-author acknowledged having served "as an investigator for clinical trials funded by Pfizer." I believe that this conflict of interest should have been disclosed in the paper because Pfizer clearly has a significant financial interest in the information discussed in this study. In fact, e-cigarettes and Chantix are direct competitors in the smoking cessation market.

The rest of the story is that it appears that the majority of physicians are giving misguided advice to their patients regarding smoking cessation using e-cigarettes. Apparently, the campaign of deception being waged by anti-tobacco groups and some health agencies has been quite effective. It has led to the perverse result that the majority of physicians are actually recommending that some patients continue smoking rather than attempt to quit.

Sunday, March 12, 2017

Surgeon General Continues to Lie about Tobacco in E-Cigarettes

In an article published earlier this month in JAMA Pediatrics, the Surgeon General claimed that electronic cigarettes: "are now the most commonly used form of tobacco among youth in the United States, surpassing cigarettes, chewing tobacco, cigars, and hookah." The article repeatedly refers to e-cigarettes as a form of tobacco. In fact, the article contains four statements indicating that e-cigarettes are a "form of tobacco" or that vaping is a "form of tobacco use."

The Rest of the Story

There's just one problem with the Surgeon General's claim that vaping is a form of tobacco use: it's not true.

There is no tobacco in electronic cigarettes. Using e-cigarettes, even if they contain nicotine, is not a form of tobacco use. You are not using tobacco if you vape because the e-liquids do not contain tobacco. In fact, the entire point of vaping is that it represents a tobacco-free and smoke-free method of inhaling nicotine.

Even if the Surgeon General wrongly believes that consuming any product that contains nicotine is a form of tobacco use, then he is still lying to the public. Under that definition, e-cigarettes are not the most commonly used form of tobacco among youth. Potatoes are.

According to the Surgeon General, about one in six high school students have consumed e-cigarettes in the past month. But according to the National Youth Physical Activity and Nutrition Study, a whopping 69% of high school students have consumed potatoes in the past seven days. And if you include french fries, that percentage goes up to 79.4%.

The rest of the story is that the Surgeon General owes a huge apology. Either way, he was lying. The only question is whether he owes that apology to the American public (and especially vapers) or to the United Potato Growers of America.

Thursday, March 02, 2017

American Heart Association Sticks to Its Guns: "E-Cigarettes May Pose the Same or Higher Risk of Stroke" than Smoking

Earlier this week, I discussed a press release from the American Heart Association which claimed that vaping causes severe strokes and poses a higher risk of severe strokes than smoking. According to the press release: "E-cigarettes may pose the same or higher risk of stroke severity as tobacco smoke." 

In my commentary, I noted that the American Heart Association's conclusion that vaping poses an equal or higher risk of suffering a severe stroke is based on a single mouse study. In that study, which has not been published or peer reviewed, but was presented last week at the American Stroke Association’s International Stroke Conference, the investigators found that mice exposed to e-cigarette aerosol for 10 days or 30 days had more severe strokes than those exposed to tobacco smoke. To extrapolate from this single pre-clinical, animal study to population-based human health effects, as I pointed out, is ludicrous.

I sent my commentary to the American Heart Association, calling for an immediate retraction, correction, and apology for this action. I noted that if that happened, I would report it here as soon as I became aware of it.

The Rest of the Story

As a result of my notifying the American Heart Association of the mistake in its press release ...

... nothing happened.

There was no response, and the claim remains unchanged on its web site.

What am I to think? Can I continue to give the American Heart Association the benefit of the doubt and assume that this was just some sort of mistake or oversight? Hardly, when they failed to correct it after being notified of the error.

At this point, I have little choice but to consider this as a deliberate attempt to mislead and deceive the American public into believing that vaping is just as hazardous, or even more hazardous than smoking.

I have no choice but to view this as a negligent action on the part of the American Heart Association. Any reasonable health organization, after being made aware of a blatant factual error such as this one, would be expected to correct the error. It is therefore difficult not to see negligence in the AHA's apparent decision not to correct this ridiculously false claim.

I am frustrated because this is like banging my head against a brick wall. Despite pointing out factual errors, most anti-tobacco and health organizations or agencies are unwilling to, or uninterested in, correcting their misinformation. I have little choice left but to conclude that this is a deliberate campaign of deception.

Sunday, February 26, 2017

American Heart Association Claims that Vaping Causes Severe Strokes and is More Risky than Smoking

In a press release issued last Thursday, the American Heart Association claimed that vaping causes severe strokes and poses a higher risk of severe strokes than smoking.

According to the press release: "E-cigarettes may pose the same or higher risk of stroke severity as tobacco smoke. ... Electronic cigarette (e-cigarettes) vaping may pose just as much or even higher risk as smoking tobacco for worsening a stroke, according to a preliminary study in mice presented at the American Heart Association's International Stroke Conference 2017. ... From a brain health perspective, researchers said, electronic-cigarette vaping is not safer than tobacco smoking, and may pose a similar, if not higher risk for stroke severity."

The American Heart Association's statement was spread widely through the media. For example, here's just one headline that appeared: "E-cigs could raise the risk of suffering a stroke more than smoking."

The Rest of the Story

The American Heart Association's conclusion that vaping poses an equal or higher risk of suffering a severe stroke is based on a single mouse study. In this study, which has not been published or peer reviewed, but was presented last week at the American Stroke Association’s International Stroke Conference, the investigators found that mice exposed to e-cigarette aerosol for 10 days or 30 days had more severe strokes than those exposed to tobacco smoke.

To extrapolate from this single pre-clinical, animal study to population-based human health effects is ludicrous. There are many reasons why stroke-related findings from rodent studies do not translate well to humans. For example, as Braeuninger and Kleinschnitz point out:

"There are, of course, significant physiological, neuroanatomical and metabolic differences between humans and small rodents, which are the most widely used experimental animals in preclinical stroke research. For example, small rodents usually require higher drug doses on a mg/kg body weight basis for a similar effect than larger mammals. Thus, effective doses derived from preclinical stroke studies in small rodents cannot simply be transferred to the situation in humans, even if adjusted for body weight."

There is no scientific justification for the American Heart Association spreading the conclusion that vaping causes strokes. Nor is there any scientific justification for spreading the message that vaping poses a higher risk of suffering a stroke than smoking.

This blatant disregard for the truth, which I would term "public health malpractice," is not only unscientific but it is also damaging to public health. There are literally millions of smokers who have considered, or are currently considering, the question of whether or not to switch from smoking to vaping. Thanks to the American Heart Association, we can expect that huge numbers of smokers will choose to stick with smoking and that many ex-smokers - who quit via e-cigarettes - will decide to return to smoking.

After all, if vaping poses a greater risk of stroke than smoking, then there is absolutely no reason to quit smoking using e-cigarettes. You'd be better off smoking. And if you already quit smoking by switching to e-cigarettes, then you'd be better off returning to smoking than continuing to vape. Why take a chance of increasing your risk of suffering a stroke?

You can see why I call this an example of public health malpractice. The American Heart Association is essentially advising smokers that they are better off continuing to smoke than quitting smoking and switching completely to vaping. This is perhaps the most absurd medical advice I have ever heard in my entire career in medicine and public health. Even the tobacco companies - in the worst of their behavior - never told smokers that they would be at greater risk of disease if they quit smoking. But that is precisely what the American Heart Association is essentially telling smokers.

If the American Heart Association has any regard for scientific accuracy and professional responsibility in communication, it will offer an immediate retraction, correction, and apology for this action.

If that happens, I will report it here as soon as I become aware of it.

Monday, February 20, 2017

Tobacco Control Journal: There Can Be No Legitimate Discussion of Our Articles Without Our Permission

In a revelation of the religious-like character of the modern-day tobacco control movement, the journal Tobacco Control has suggested that there can be no legitimate discussion about articles it publishes without its permission; that is, on the Rapid Response forum at the journal's own web site. All other discussion of the scientific validity of journal articles is apparently illegitimate and inappropriate.

In an unprecedented editorial (I've never before seen a journal argue that the only legitimate forum for discussion of its articles is in the journal itself), the journal writes:

"the growing use of personal blogs to criticise published articles has led us to reflect on appropriate ways of engaging in such debate ... the proper place to pose questions and debate conclusions from research published in Tobacco Control is directly to the authors, in the form of a Rapid Response. ... placing personal blog posts or social media messages complaining about a study ... do not advance the field or allow an appropriate scientific dialogue and debate. ... As a result of discussion about these issues, the Tobacco Control editorial team has now established a policy that editors will not respond to external blog posts or social media messages about specific studies. ... We will always welcome legitimate criticism of methods, results and interpretation of published research. But we will discourage engagement with and dissemination of polemics that contribute to public misunderstandings and create conflict. As journal editors, we encourage constructive criticism and debate in ways that strengthen the evidence base for effective tobacco control policy rather than amplifying individual voices."

The Rest of the Story

I have never seen a scientific journal make such a bold statement. Do you mean to tell me that the only legitimate scientific discussion of an article published in a journal is that which takes place in the journal itself, in a forum that is managed and controlled by the journal? Do you mean to tell me that any other discussion or criticism of research articles is not constructive and serves only to "amplify individual voices?"

Moreover, what is wrong with creating "conflict" if it is warranted because the conclusions of an article are not supported by its findings? In fact, a blogger who is criticizing the conclusions of a study because they are warranted is not "creating" conflict. What is creating conflict is the fact that the paper disseminated those unwarranted conclusions and that the journal chose to publish this shoddy science in the first place.

The editorial does not specify exactly what irked the journal so much that it boldly went where no journal has gone before and declared that any discussion of its articles outside of its own purview is illegitimate. However, I think it's quite clear that what irked the journal was criticism on several blogs - including my own - of an article that concluded vaping is a gateway to youth smoking based on a sample of 4 nonsmoking youth who experimented with e-cigarettes and then went on to try one or two cigarettes.

In this study, the sample size of youth who were nonsmoking, recent vapers at baseline was only 13 and the number of youth in this category who "initiated" smoking was only 4. Thus, the sweeping conclusion of the paper, which has been publicized internationally, was based on only 4 kids! Moreover, despite having a sample size of 347 high school seniors, the study could not find a single student who became an actual new smoker after having experimented with e-cigarettes. The few students (a grand total of 4) who did try a cigarette or two did not progress beyond having one or two cigarettes.

Rather than simply admit that it made a mistake and this unwarranted conclusion slipped through the cracks, the journal instead tried to divert attention from its mistake by attacking the messengers: those like myself who pointed out the error.

It's unfortunate that the journal chose to respond in an ad hominem manner rather than to actually address the substantive scientific question, which is whether or not the conclusion that vaping is a "one-way bridge" to smoking among youth can be justified based on the finding that 4 youth who were nonsmokers at baseline and who had experimented with e-cigarettes went on to smoke one or two cigarettes in the next year (and did not become smokers).

The issue is whether that is the kind of scientific evidence that legitimately supports the paper's conclusion that vaping is a gateway to smoking, rather than the method by which a blogger who notes this study weakness should attempt to correct the public health damage done by the publication of the article.

I don't know whether the editorial was directed at me or at other bloggers, or both, but I can assure my readers that I will not stop providing discussion of the scientific research regarding electronic cigarettes just because one journal wants to control the entire discourse on the subject.

Monday, February 13, 2017

Kentucky Health Group is Deceiving Public About Risks of Smoking ... and It's Working

A Kentucky health group has orchestrated a campaign to deceive the public about the terrible health hazards associated with smoking by downplaying those risks. Sadly, a recent public opinion poll commissioned by the group demonstrated that its campaign of deceit is working. Adults in Kentucky have been completely fooled about the serious health risks of smoking.

According to the Foundation for a Healthy Kentucky: "Research suggests that e-cigs may be a gateway to using other forms of tobacco, and they can be just as harmful."

The Rest of the Story

There is abundant evidence that vaping is much safer than smoking. In stating that vaping is just as harmful as smoking, the Foundation for a Healthy Kentucky is lying to the public. Moreover, this campaign of deceit is undermining the public's appreciation of the severe health hazards associated with smoking. If smoking is no more hazardous than vaping - which doesn't involve the burning of tobacco - then it must not be as harmful as previously thought.

I can assure you that if the tobacco industry were making the same claims, we would be attacking them and taking them to court for public fraud. But the Foundation for a Healthy Kentucky is making precisely that claim which would have us dragging Big Tobacco into the courtroom. Why is it OK for us to lie, but not the tobacco companies?

A recent public opinion poll commissioned by the Foundation for a Healthy Kentucky showed how successful its campaign of deceit has been. According to this poll, 64% of Kentucky adults believe that smoking is no more hazardous than vaping. And nearly one in five (19%) actually believe that vaping is more hazardous than smoking!

Interestingly, nowhere in its report or press release does the Foundation point out that these 64% of Kentuckians are wrong in thinking that smoking is no more hazardous than vaping. If anything, the report appears to lament the fact that 29% of adults in Kentucky think that vaping is safer than smoking.

What a tremendous disservice the Foundation for a Health Kentucky is doing by misleading the people of Kentucky into thinking that smoking is no worse for your health than using a product which doesn't even contain any tobacco and doesn't involve any combustion.

It is also contrary to public health to bemoan the fact that a segment of the public has a correct understanding of relative health risks. Our goal should be to aim for 100% of the public to have a correct understanding of relative health risks, not to try to deceive the public so that they don't have correct information.

I'll be watching to see if the Foundation for a Healthy Kentucky corrects this misinformation. Until that happens, they are harming the public's health by decreasing the likelihood that smokers will quit and increasing the likelihood that vapers will return to smoking.

Thursday, February 09, 2017

Tobacco Control Study Provides Strong Evidence that Vaping is Not a One-Way Bridge to Smoking

I have already shown (post 1; post 2) why the recently published study in Tobacco Control which purported to demonstrate that vaping is a "one-way bridge to cigarette smoking among youth" actually provides no evidence that e-cigarette experimentation is a gateway to smoking.

First, the exposed group consisted of any youth who had even puffed once on an e-cigarette in the past 30 days. Second, the outcome variable was having puffed even once on a cigarette in the past year. Thus, the study cannot document either that the "recent vapers" were actually regular vapers or that the youth who "initiated" smoking were actually smokers. A more likely explanation of the study findings is that youth who engage in e-cigarette experimentation are also more likely to try cigarettes.

Second, I revealed that the sample size of youth who were nonsmoking, recent vapers at baseline was only 13 and that the number of youth in this category who "initiated" smoking was only 4. Thus, the sweeping conclusion of the paper, which has been publicized internationally, was based on only 4 kids.

Today, I reveal that not only does the study fail to provide any evidence that vaping is a gateway to smoking, but it actually provides strong evidence that vaping is not a gateway to smoking.

The Rest of the Story

If you read the fine print in the paper, there is a key finding which is not mentioned anywhere in the abstract, the discussion, or in any of the newspaper articles written about this study. The fine print is this:

"Among the group of new smokers at follow-up who had recently vaped at baseline, all reported that they had smoked cigarettes at the level of ‘once or twice’ in the past 12 months at follow-up."

Another way of stating this is that:

"Among the group of new smokers at follow-up who had recently vaped at baseline, not a single one had smoked more than two cigarettes in the entire past year."

In other words, this study actually confirms that none of the nonsmoking, recent vapers became actual smokers. Apparently, they tried a cigarette or two, but not a single one of them continued to smoke beyond that!

What this means is that despite having a sample size of 347 high school seniors, this study could not find a single student who became an actual new smoker after having experimented with e-cigarettes. The few students (a grand total of 4) who did try a cigarette or two did not progress beyond having one or two cigarettes.

It is striking to me that this study, which provides strong evidence that vaping is not a gateway to smoking, could conclude quite definitively that vaping is a "one-way bridge" to smoking. It creates the appearance that the study reached a pre-determined conclusion and was going to twist the findings any way it could to come up with this conclusion.

It is puzzling that not a single reviewer nor editor at Tobacco Control was able to detect this sleight-of-hand.

How do you get from a finding that not a single nonsmoking youth who experimented with vaping at baseline progressed to become an actual smoker at follow-up (and that only 4 kids in that category even tried a cigarette in the first place) to a sweeping conclusion that vaping is a one-way bridge to cigarette smoking among youth?

The answer, and the rest of the story, is that this is essentially hocus pocus. And while it may have gotten by the peer reviewers and editors, it doesn't get by me or any of the many colleagues with whom I have discussed this study. Even my students with whom I have discussed this easily see what is going on here.

Wednesday, February 08, 2017

Failure to Disclose Sample Size: A Flaw at Multiple Levels

Yesterday, I revealed that a new study published in the journal Tobacco Control which concluded that e-cigarettes are a "one-way bridge" to youth smoking failed to disclose the sample size upon which its major conclusion was based. It turns out that the paper's sweeping conclusion was based on only 4 kids who had tried an e-cigarette at baseline and went on to try a cigarette in the next year. That sample size was not even revealed in the online supplement to the article. I had to calculate it from the raw data. The supplement did reveal that there were only 13 nonsmokers in the study who had vaped in the past month. Thus, I argued that the paper really should have concluded not that vaping is a gateway to smoking but that e-cigarette experimentation among nonsmokers doesn't appear to even be a gateway to regular vaping.

A further analysis of the paper reveals that among the 4 youth who had supposedly progressed to smoking, none of them had smoked more than two cigarettes in the past year. According to the paper: "Among the group of new smokers at follow-up who had recently vaped at baseline, all reported that they had smoked cigarettes at the level of ‘once or twice’ in the past 12 months at follow-up."

What the paper doesn't reveal is that this "group" of new smokers consists of only about 4 kids.

This raises the question of why the paper doesn't share this information with the reader. To talk about a "group" of new smokers who had vaped at baseline, but without informing the reader that there are only 4 kids in this "group" seems misleading.

The Rest of the Story

It appears to me that there were three levels of failure which explain why this paper violated what is perhaps the most important aspect of scientific reporting: revealing the sample size upon which your major conclusion is based.

First, the paper itself should have disclosed this sample size. It seems critical for readers to understand that the paper's major conclusion - that there was a 4.8 times higher rate of "smoking initiation" among nonsmokers who had vaped in the past month - was based on 4 kids having tried a cigarette or two in the past year.

This failure has already led to deceptive headlines, such as this one in the Daily Mail: "E-cigarettes are a One-Way Bridge to Tobacco." A more accurate headline would have said something like: "Researchers Can't Find More than 4 Kids Who Progressed from Vaping to Smoking, and Even Those Four Had Only Smoked Once or Twice in their Lifetimes." Or: "E-cigarette Experimentation among Nonsmokers Found Not to Be a One-Way Bridge to Vaping, Much Less Smoking."

The second failure is upon the peer reviewers of the manuscript. How could the reviewers possibly have not caught the glaring omission from the paper of the sample size underlying its most important conclusion?

The third failure is that of the journal itself. It, too, should have caught the glaring omission from the paper of the sample size underlying its most important conclusion. I used to be a statistical/methodological editor for Tobacco Control and I can tell you that I never would have let a paper through that did not reveal the sample size upon which its major conclusion was drawn. It's difficult for me to understand how this occurred.

The rest of the story is that it is difficult not to agree with Professor Robert West's conclusion that e-cigarette researchers in the United States are "waging a ‘moral crusade’ against e-cigarettes" and that they are "exaggerating their findings." This may not be a conscious decision, but may reflect a deeper underlying bias against e-cigarettes.

Tuesday, February 07, 2017

New Study Concludes that Vaping is a One-Way Bridge to Cigarette Smoking among Youth

A new study published online ahead of print in the journal Tobacco Control concludes that vaping is “a one-way bridge to cigarette smoking among youth.”

(See: Miech R, Patrick ME, O’Malley PM, Johnston LD. E-cigarette use as a predictor of cigarette smoking: results from a 1-year follow-up of a national sample of 12th grade students. Tobacco Control. http://dx.doi.org/10.1136/tobaccocontrol-2016-0532910).

The study involved a one-year follow-up of 347 high school seniors who were surveyed at baseline in 2014 and at follow-up in 2015. At baseline, they were classified as recent vapers (used an e-cigarette in the past 30 days) or non-vapers. At follow-up, smoking initiation was defined as having smoked a cigarette in the past year.

In the key analysis, smoking initiation (smoking a cigarette in the past year) was compared between recent vapers (used an e-cigarette in the past 30 days) and non-vapers who had never smoked at the time of the baseline survey. The paper reports that the rate of smoking initiation was 31% among the recent vapers and 7% among non-vapers. In an adjusted analysis, recent vapers were 4.8 times more likely than non-vapers to initiate smoking during the follow-up period.

The paper concludes that “vaping is a one-way bridge to cigarette smoking among youth.”

The Rest of the Story

At first glance, this paper appears to demolish the claim that vaping is not a known gateway to youth smoking. The conclusion that is drawn is a sweeping one: e-cigarettes are a one-way bridge to cigarette smoking among youth. If this conclusion is true, then I believe e-cigarettes are not a tenable harm reduction strategy because the benefits of adults quitting using e-cigarettes would be offset by a substantial increase in youth becoming addicted to smoking and possibly suffering life-long health effects, disease, disability, and premature death.

So am I going to renounce my earlier conclusions (that there is no evidence vaping causes kids to start smoking)?

Perhaps, but not without a closer look at the study.

To be a valid conclusion, there must not be a plausible, alternative explanation for the study findings. The paper does not present any alternative explanations. But this doesn’t mean that there isn’t one.

In fact, there is a very plausible (and in fact, highly likely) alternative interpretation of these findings:

Experimenting with e-cigarettes is a sensitive marker of substance-related, risk-taking behavior in general, which strongly predisposes a youth to trying cigarettes.

What could easily explain the observed findings is that youth who experiment with e-cigarettes are also more likely to experiment with other substances, including cigarettes. Therefore, of course you are going to find a higher rate of cigarette experimentation among youth who have already experimented with electronic cigarettes. This should come as a surprise to no one.

The observed relationship between e-cigarette experimentation and cigarette experimentation could well be a spurious one, confounded by an underlying predisposition to substance-related, risk-taking behavior. Importantly, the study did not make any attempt to control for any measures of risk-taking behavior. Moreover, the study did not even control for underlying susceptibility to smoking.

There are two additional and related factors that cast serious doubt on the study’s conclusion.

First, the exposure variable – recent vaping – was defined as having tried even one e-cigarette in the past month. All we know about the baseline “vapers” is that they had taken a puff on an e-cigarette in the past month. We do not know that they were regular vapers. We do not know that they had become addicted to nicotine or to vaping. We don’t even know that they had tried vaping more than once in their entire life! So to conclude that this study demonstrates that vaping is a one-way bridge to smoking is not warranted.

Second, the outcome variable – smoking initiation – was defined as having tried even one cigarette in the past year. All we know about the smoking initiators is that they had taken a puff on a cigarette in the past year. We don’t even know that they had tried more than one cigarette in the past year. So to conclude that vaping is a bridge to smoking based on this definition is not warranted.

The question that arises is why the study did not examine whether frequent vapers were more likely to progress to regular smoking (or at very least, current or established smoking). According to the paper, the sample size was not large enough to allow such an analysis. But that raises the question: If the sample size was not large enough to allow an analysis of frequent vapers, was it large enough to allow an analysis of all vapers? And most critically, how many youths were there who were nonsmoking, recent vapers at baseline who tried a cigarette in the next year? After all, this is the sample upon which the entire conclusion of the study is based.

So I took a closer look at the study – well, not the actual study because the sample size of baseline nonsmokers who had recently vaped is not reported anywhere in the study. You have to go to a separate, online appendix to find this out.

So take a guess: How many youths is the sweeping conclusion of this paper based on? (i.e., how many nonsmoking, recent vapers at baseline progressed to having tried a cigarette at follow-up?)

a. 122
b. 84
c. 42
d. 21
e. 9

If you guessed E (9) ...

… then you are wrong.

The correct answer is none of the above. The total number of nonsmoking, recent vapers who tried a cigarette in this study appears to be just 4!

So you mean to tell me that the sweeping conclusion of this paper – that vaping is a one-way bridge to smoking – is based on 4 youth? Moreover, on 4 youth about whom all we know is that they tried an e-cigarette during the month prior to the baseline survey and then tried a cigarette in the following year. That hardly seems like a sufficient sample of youth upon which to rely to formulate national policy.

In fact, there were apparently only 13 nonsmokers who were recent vapers in the entire study of 347 youth. That itself should tell you something. Namely, that it is very difficult to find nonsmokers who vape with any significant frequency. In other words, e-cigarette experimentation is not any kind of significant bridge to youth smoking because it doesn’t even appear to be a bridge to regular or frequent vaping.

The rest of the story is that far from providing evidence that vaping is a one-way bridge to cigarette smoking among youth, this study provides further evidence that e-cigarette experimentation among nonsmoking youth doesn’t even appear to be a bridge to regular vaping. It is very difficult to find nonsmoking youth who experiment with e-cigarettes and then progress to become frequent vapers. In fact, it’s such a rare phenomenon that this study failed to achieve a high enough sample size to even analyze the rate at which these nonsmoking frequent vapers progressed to smoking. That itself is really the key finding of the paper.

This story illustrates why you have to be very careful in reading and interpreting the scientific literature. If you didn’t look at the supplemental material, which was not part of the article itself, you would never even be aware that the sweeping conclusions of this study were based on 4 kids.

All I can say is that when the FDA commissioner signs his first order putting a vape shop out of business, these 4 kids should be invited to the signing ceremony. Because it’s based on those 4 kids that vaping opponents apparently would like us to formulate national smoking policy.

Monday, February 06, 2017

Anti-Smoking Leader Demands Prosecution of Tobacco Company Executives for "Crimes Against Humanity"

An international anti-smoking leader has called for prosecution of the heads of the tobacco companies for "crimes against humanity."

According to an article in the Jerusalem Post:

"Prof. Judith Mackay, the British, Hong Kong-based physician who has been described by the tobacco industry as “one of the three most dangerous people in the world,” has called for heads of the industry to be prosecuted for their “crimes against humanity.” Mackay, an international anti-tobacco advocate who has led a campaign against tobacco in Asia since 1984, appeared by video conference at the annual meeting, held in a Caesarea on Friday, of the Medical Society for the Prevention and Cessation of Smoking of the Israel Medical Association."

The Rest of the Story

While the tobacco industry has done many despicable things and should be held civilly liable for damages caused by its products to users who became addicted prior to the time when the industry acknowledged that its products were deadly, prosecuting tobacco industry executives for "crimes against humanity" is going way too far.

Not only does this accusation go beyond reason, but it also undermines the significance of world leaders who have committed real crimes against humanity and is insensitive to the victims of these crimes. Moreover, it obscures the fact that the tobacco industry is not the only entity that was complicit in the tobacco epidemic.

Despite the condemnation-worthy actions of the tobacco companies, it must be remembered that it was the government that sanctioned the sale of tobacco products. At all times, the tobacco companies were acting in an environment in which the government made it legal to sell cigarettes. And although smokers did not necessarily make an informed decision to smoke, neither were they forced to smoke. There is an element of behavioral decision-making involved. So to compare the sale of tobacco to "crimes against humanity" is an injustice to the many victims of actual crimes against humanity who did not play any role in their persecution.

In addition, many entities played a role in the tobacco epidemic. Should the owners of convenience stores which actually sold the cigarettes also be prosecuted for crimes against humanity? What about the government officials who accepted tobacco industry contributions and voted against policies to regulate cigarettes? How about the publishers of magazines that advertised cigarettes and the producers of movies who accepted money to depict branded cigarettes? The list goes on.

But there is a particularly ironic aspect to the rest of this story. It could be argued that Professor Mackay herself has helped to protect cigarette sales. How? Well, she supported a ban on nicotine-containing electronic cigarettes in Hong Kong. So apparently, she is OK with the youth and adults in Hong Kong purchasing deadly tobacco cigarettes but she doesn't want them to be able to buy much safer tobacco-free alternatives that could save their lives.

Moreover, Professor Mackay has publicly claimed that smoking may be no more hazardous than vaping. As recently as last May, she wrote a widely publicized op-ed in which she claimed that: "There have been signs that increasing numbers of young people are taking up vaping thinking that it is a less harmful alternative to smoking even though science is far from conclusive on this presumption."

So what she is saying is that we don't know for sure that smoking is any more hazardous than using a completely tobacco-free product that involves absolutely no combustion and which has no significant known chronic health effects. If this doesn't undermine the public's appreciation of the severe hazards of smoking, then I don't know what does. Furthermore, this is exactly the kind of false propaganda about the hazards of smoking that we have condemned the tobacco industry for spewing.

On top of this, her organization - the World Lung Foundation - has spread false information about vaping, claiming that it is a gateway to smoking. In fact, the World Lung Foundation disseminated the conclusion that e-cigarettes are a gateway to smoking based on a barely comprehensible quote of a single kid in Fife.

Hyperbole is often acceptable to make a point. But not when it involves placing individuals in jail or being insensitive to the victims of horrible human rights violations.

Thursday, February 02, 2017

Without Evidence, NIH Director Claims E-Cigarettes Cause Respiratory Infections and Asthma

In a commentary by the director of the National Institutes of Health (NIH), it is claimed that electronic cigarettes cause respiratory infections and asthma. According to the NIH director:

"E-cigarettes come with their own health risks, including lung inflammation, asthma, and respiratory infections."

The Rest of the Story

There is clinical evidence that vaping causes lung inflammation, so that part of the statement is supported by evidence. Specifically, vaping can cause lung irritation, leading to short-term increases in airway resistance as measured by sensitive technology, although not apparent by routine spirometry. Whether this acute irritation has consequences for the risk of actually developing chronic respiratory disease is not known.

However, when it comes to the claim that e-cigarettes cause asthma and respiratory infections, the story is quite different.

There is no clinical or epidemiological evidence that e-cigarettes cause either asthma or respiratory infections. There is one cell culture study which found an increased susceptibility to infection of respiratory epithelial cells. However, there is not a single clinical or epidemiological study I am aware of that documents an increase in the risk of respiratory infection due to vaping. Nor is there a single clinical or epidemiological study that documents an increased risk of asthma due to vaping.

In fact, on the contrary, there is evidence that switching from smoking to vaping actually decreases asthma symptoms and improves lung function and that it may reduce the risk of respiratory infections and pneumonia. Moreover, propylene glycol - the excipient in most e-liquids - is known to have bactericidal properties. In one study, smokers who switched to vaping reported a decreased incidence of respiratory infections.

That vaping can cause respiratory irritation is a fact. But the claim that vaping causes asthma and respiratory infections is what in today's lexicon might be referred to as an "alternative fact."

Tuesday, January 31, 2017

New Study Casts Serious Doubt on Claim that E-Cigarettes Lead to Youth Smoking

A new study published online ahead of print in the journal Nicotine & Tobacco Research pretty much blows out of the water the hypothesis that youth e-cigarette experimentation causes kids to progress to cigarette smoking.

(See: Villanti AC, et al. Frequency of youth e-cigarette and tobacco use patterns in the U.S.: Measurement precision is critical to inform public health. Nicotine & Tobacco Research. Published online on December 24, 2016.)

The study is novel because unlike similar research reported by the Centers for Disease Control and Prevention, this one doesn't just analyze current e-cigarette use (any use in the past 30 days) but quantifies the frequency of use (number of days used in the past 30 days). In addition, he breaks down e-cigarette use at each frequency level by concomitant tobacco product usage.

The main finding of the paper is that only 0.1% of all middle- and high-school students are nonsmoking, frequent e-cigarette users (defined as those who have vaped at least 10 days of the past 30 days):

"It was rare that tobacco naive youth reported using e-cigarettes and if they did, rarer still to find them using them frequently (i.e., fewer than 0.1% used on 10 or more days per month)."

The paper criticizes all previous studies which have been cited by anti-tobacco advocates as demonstrating that e-cigarettes are a gateway to smoking for: (1) not adequately measuring the frequency of e-cigarette use and classifying youth as vapers even if they use e-cigarettes only one or twice a month; and (2) not adequately accounting for dual use of e-cigarettes and tobacco products.

The authors conclude with an admonition to tobacco control researchers: "When interpreting findings for purposes of tobacco control strategy and policymaking, care must be taken to avoid biases, confounding, over or underestimates of trajectories and interpretations of results that go beyond the limitations of the data."

The Rest of the Story

This study casts serious doubt on the claims of many anti-tobacco advocates and groups that e-cigarettes cause youth to initiate smoking. Based on the findings of this research, it is extremely rare to find nonsmoking youth who experiment with e-cigarettes and then go on to become regular vapers. It appears that most e-cigarette use among nonsmokers is infrequent and experimental, reflecting the likelihood that vaping among nonsmokers remains a purely social phenomenon without any addictive component. This makes it implausible that e-cigarettes represent a gateway to youth smoking. Further research from longitudinal studies is necessary to confirm this finding, but for now, there is no reason to believe that e-cigarette use increases the use of tobacco among adolescents.

Sunday, January 29, 2017

How We Know Vaping Opponents are Driven by Ideology and Not Science

I have presented many examples on this blog over the past months demonstrating the fact that vaping opponents are being driven by ideology rather than science. But there is one observation I made which is dispositive. In legal terminology, dispositive means "evidence that unqualifiedly brings a conclusion to a legal controversy." This observation brings a conclusion to any controversy about whether the position and actions of vaping opponents have been science-based or ideology-based.

The Rest of the Story

The observation is actually quite simple:

Not a single anti-tobacco or health group or agency which has warned the public about the risks of "popcorn lung" from vaping has warned smokers about the risks of popcorn lung.

Let us assume, for a moment, that it is true that vaping puts people at risk of developing popcorn lung because it contains diacetyl, a chemical which was found to cause popcorn lung in several popcorn factory workers. Well, it turns out that cigarettes deliver hundreds of times more diacetyl to smokers than vapers get from e-cigarettes. Given the exposure difference, if diacetyl poses a risk of popcorn lung to vapers, then it certainly poses a much larger risk of popcorn lung to smokers.

Yet I am unable to find a single web site of a health or anti-tobacco group that warns smokers about the risk of popcorn lung from smoking, based on the presence of high levels of diacetyl.

It seems to me that if the actions of vaping opponents were science-based, then they should be plastering the headlines with warnings about the risks of popcorn lung to smokers. But they're not. They are only telling the public that e-cigarettes poses such a risk, not real cigarettes. This can only be explained by ideology: a huge bias against vaping. Without realizing it, these groups are actually defending smoking by not calling out the risks of popcorn lung.

Now the truth is that there is no evidence that vaping is associated with popcorn lung. While cigarettes deliver much higher levels of diacetyl, cigarette smoking itself has not been associated with popcorn lung. So the hysterical claims about the relationship between vaping and popcorn lung have little basis in science. But if we assume that there really is a risk of developing popcorn lung if you vape, then certainly these health groups should be warning smokers, who would face a much larger risk.

As an example, take the American Lung Association. They have a web page entitled "Popcorn Lung: A Dangerous Risk of Flavored E-Cigarettes." The first problem with this page is that it isn't true. There is no reason to believe that popcorn lung is a dangerous risk of flavored e-cigarettes. As far as I know, despite millions of e-cigarette users, there has not been a single documented case of popcorn lung caused by vaping. 

But the second problem is that even if we assume that the risk is real, the American Lung Association nowhere warns smokers of this risk. Shamefully, while the American Lung Association demands that "FDA act quickly to require that diacetyl and other harmful chemicals be removed from e-cigarettes," the Lung Association is not calling on the FDA to require that diacetyl be removed from real cigarettes.

Is this really about health, or is it just about demonizing e-cigarettes?

With that said, I agree completely with other vaping advocates, however, that diacetyl should not be used as a flavoring in e-cigarettes. It is not an essential ingredient, so why use it. There is no need to even take the risk, as small as it may be.

Also, in retrospect, it may have been unreasonable to have suggested that the ALA would ever request the FDA to have diacetyl removed from tobacco smoke: it is a product of the combustion process in tobacco cigarettes, and it cannot be removed.

Monday, January 23, 2017

New Study in Pediatrics Shows How Anti-Vaping Researchers are Trying to Fool the Public

A new study published online ahead of print in the journal Pediatrics purports to provide evidence that e-cigarettes are encouraging youth to smoke. According to the article, "youth who initiate use with e-cigarettes are more likely to start smoking conventional cigarettes." An accompanying press release concluded that "E-cigarettes are encouraging – not discouraging – youth to smoke...". 

(See: Dutra LM, Glantz SA. E-cigarettes and national adolescent e-cigarette use: 2004-2014. Pediatrics 2017. DOI: 10.1542/peds.2016-2450.)

Using annual, cross-sectional data from the National Youth Tobacco Survey, the study found that the rate of decline in youth smoking from 2009-2014 was no different than the rate of decline in youth smoking from 2004 to 2009. Based on this finding, the authors conclude that experimentation with e-cigarettes did not contribute to the observed decline in smoking.

The ultimate study conclusion is that e-cigarettes have led to an increase in the "tobacco market" by attracting youth to "smoke."

The Rest of the Story

There's a major flaw in the study conclusion. And once you're aware of it, you'll realize that the study is really trying to pull the wool over the eyes of the public.

The best way I can demonstrate the trick the study is playing is through an analogy. Suppose we are interested in whether the acquisition of Al Horford led to a decline in the performance of the Boston Celtics. Controlling for a number of psychosocial variables that might affect the Celtics' performance, we find no change in the record of the Celtics from before to after Horford joined the team (this is a hypothetical example because I think they're actually playing better this year).

OK - it's time for our conclusion. And here it is:

The acquisition of Al Horford has led to an improvement in the performance of the Boston Celtics.

But wait one second. How can you conclude that the acquisition improved the Celtics' record when your analysis demonstrated that the acquisition was not associated with any change in the team's performance?

You can't. Unless you are trying to fool people.

This is exactly what is happening with this study. The researchers showed that experimentation with e-cigarettes did not lead to a decline in smoking. But that's only half the story. The rest of the story is that experimentation with e-cigarettes did not lead to an increase in smoking.

You see - it works both ways. You can't tell just the half of the story that you happen to like. If this study provides evidence that e-cigarettes didn't result in a decline in youth smoking because there was no change in the rate of decline then the study also provides evidence that e-cigarettes didn't result in an increase in youth smoking.

And that's not consistent with the authors' conclusion that e-cigarettes are encouraging youth to smoke and thereby increasing the tobacco market.

The study actually demonstrates the opposite of what the authors are telling the public. It provides evidence that e-cigarettes are not attracting kids to smoke. If that were the case, one would have expected to see lower rates of decline in youth smoking following the drastic proliferation of vaping among young people.

There is a more technical flaw with the analysis as well. The investigators choose a split point of 2009 to test the before and after trends in smoking. But there was little difference in youth smoking as measured by the NYTS between 2009 and 2011. Thus, using 2009 as the split point creates an artificially low estimate of the decline in youth smoking from 2011 to 2014. You can see from Figure 1 in the paper that there was a substantial increase in the rate of decline in youth smoking from 2011 to 2014, compared to the period from 2004 to 2011. That the model used in the paper doesn't fit the data is clear from how far off the 2011 data point is from the trend line.

The truth is that there does appear to have been an acceleration in the rate of decline in youth smoking from 2011 to 2014. This observation is consistent with results from other national surveys, including the Youth Risk Behavior Survey and the Monitoring the Future study. This doesn't mean that e-cigarettes are the reason for this accelerated decline, but it does suggest that the study has obscured the actual trend by choosing an inappropriate split point. Since e-cigarettes were not at all popular among youth in 2009 and only used by a small fraction of youth in 2011, it doesn't make sense to place the split point at 2009. Unless you're out to show that there was no change in the trend line.

The rest of the story is that by providing only half of the story, this study fools the public into believing that this research is providing evidence that e-cigarettes are encouraging kids to smoke. The truth is just the opposite. The paper also shows that e-cigarettes have not led to an increase in the youth smoking trend. There is no support for the study's conclusion that e-cigarettes are encouraging kids to smoke and thereby expanding the use of tobacco among our nation's youth.

Wednesday, January 18, 2017

Nurses Get Into the Act: Smoking is No Worse than Vaping! Don't Commend Patients for Quitting Smoking Using E-Cigarettes

Apparently, irresponsible medical advice being given to smokers about quitting is not restricted to physicians. Nurses are getting in on the act and publicly making the most reckless medical recommendations to smokers. Two egregious examples highlight the incompetent and ill-considered information being disseminated to the public in the nursing literature.

1. Smoking is No Worse than Vaping

According to an article in the current issue of the journal Nursing, two instructors at the Georgetown University School of Nursing and Health Studies claim that smoking may be no more hazardous than vaping. According to the article:

"Because e-cigarettes don't contain tobacco, they're purported to be “less toxic” than traditional tobacco products, but the lack of long-term research and the variability among available products makes this claim unsubstantiated to date."

This is complete nonsense. There is abundant evidence that vaping is much safer than smoking. Even the most ardent opponents of vaping agree that although not absolutely safe, vaping is much safer than smoking. There is abundant research which demonstrates this. But it is also common sense, as electronic cigarettes contain no tobacco and do not involve combustion. How could they be as dangerous as tobacco cigarettes, which we know kill more than 400,000 Americans each year? There is no legitimate scientific dispute over the fact that vaping is much safer than smoking.

Spreading this kind of misinformation demonstrates both incompetency and a lack of responsibility. Medical practitioners should not be disseminating false health information, especially about something so important as the severe hazards of smoking. To undermine the public's appreciation of the severity of smoking's hazards by comparing real cigarettes to fake ones is doing a huge disservice to the public and to smokers in particular. 
 
2. Smokers Who Quit Using E-Cigarettes Should Not be Commended

According to an article in the Journal of the American Association of Nurse Practitioners, nurses discourage patients who smoke from trying to quit using e-cigarettes and furthermore, they should not commend patients who have already quit smoking using e-cigarettes!

According to the article: "Currently, it is neither advisable for practitioners to recommend e-cigarettes for smoking cessation, nor is it recommended to commend patients for making the switch to e-cigarette use over traditional cigarette smoking."

It is certainly inappropriate medical advice to discourage smokers from using e-cigarettes in a quit attempt, especially if they are highly motivated about the idea of e-cigarettes and have not had success with traditional approaches. But it is insane to recommend that nurses not commend patients who have successfully quit smoking just because they happened to achieve success using e-cigarettes.

Have we completely lost our mind? 

I just cannot understand how a nurse could possibly be advised not to commend a patient who successfully quit smoking. It is an amazing accomplishment and the patient deserves the highest commendation for such an achievement. To withhold such a commendation simply because you don't happen to like the methods the patient used is, frankly, sick. It suggests that the health of the patient doesn't matter. What matters is that the patient quits the way this particular nurse thinks is best.

It would be one thing to suggest that nurses caution smokers that e-cigarettes are not effective for everyone. But if a smoker has tried e-cigarettes and succeeded in quitting smoking, then what is there not to like? What is the problem with that? I'd call that a public health miracle. 

It is like a spit in the face to the estimated two million Americans who have successfully quit smoking using electronic cigarettes.

Thursday, January 12, 2017

E-Cigarettes May Cause Kids to Break into Homes and Turn to a Life of Street Crime, Physician Warns

An emergency medicine physician has warned that e-cigarettes may lead to kids breaking into homes and turning to a life of street crime in order to feed their addictions to serious drugs.

In a Huffington Post column, he claims that due to e-cigarette experimentation: "teenagers — and even younger children — are getting addicted early, which could lead to smoking, and e-cigs can easily become a gateway to trying and developing an addiction to more serious drugs. Addiction correlates to crime. People need to feed their habit, they break into homes to steal things to resell, they commit robberies on the streets, all to get money to feed their addiction."

In the column, the physician also claims that vaping causes popcorn lung: "We know that when inhaled, diacetyl causes a type of bronchitis known as “popcorn lung” — a scarring of the tiny air sacs in the lungs resulting in the thickening and narrowing of the airways."

To put the icing on the cake, he claims that smoking may not be any more hazardous than vaping: "The act of “vaping” is often thought of as a safer alternative to smoking, but that’s not necessarily the case."

The Rest of the Story

Not a day has passed in 2017 that an anti-tobacco group or health professional hasn't lied to the public about the health risks of e-cigarettes. The contestants for the 2017 Lie of the Year Award are already lining up in huge numbers, and it's only early January.

Just to set the records straight, there is no current evidence that e-cigarette experimentation leads to an addiction to smoking or any other drugs. There isn't even evidence that e-cigarette use causes nonsmoking youth to become addicted to vaping itself. The overwhelming majority of nonsmoking youth who have experimented with e-cigarettes have not become regular vapers. The proportion of nonsmoking youth who report having vaped in the past 30 days is substantial, but the percentage of those who vape daily - a pattern suggesting addiction - is very small. So it's a bit of a stretch perhaps to argue that a kid who tries an e-cigarette today will tomorrow be breaking into homes to feed a serious drug addiction.

There is also no evidence that vaping causes popcorn lung. Despite of the fact that there are millions of vapers in the U.S., there has not been a single reported case of popcorn lung among this population. Moreover, smoking itself has not been associated with popcorn lung, and cigarette smoking exposes users to levels of diacetyl that are hundreds of times higher than with vaping.

Finally, there is abundant evidence that smoking is far more hazardous than vaping. This is hardly surprising, since e-cigarettes do not contain tobacco and there is no combustion or smoke.

I'm sure this physician is well-intended and is just trying to protect kids from potential risks; however, I don't think we need to lie to kids or greatly exaggerate the risks. Not only is it inappropriate to lie to and mislead youth, but this strategy has been shown many times over not to work.

The rest of the story: Just remember, the kid you see blowing vape rings today in the school courtyard at recess will soon be a street criminal who is breaking into homes to feed an insatiable addiction to heroin. It's bubble gum and cotton candy vapes today, but it's smack tomorrow.