Thursday, April 23, 2015

Worst Lie of them All: CDC Tells Public that Smoking is No Worse than Vaping

According to an article published this past Tuesday in New Scientist, the Centers for Disease Control and Prevention (CDC), our nation's leading public health agency, doesn't see smoking as any worse than experimenting with e-cigarettes.

The agency also continues to claim, despite evidence it the contrary from its own surveys, that e-cigarettes are leading nonsmoking youth to start smoking.

And CDC also continues to claim, without any evidence, that experimentation with e-cigarettes is causing youth addiction to vaping, along with brain damage.

According to the article:

"The study [the National Youth Tobacco Survey] was carried out by the US Centers for Disease Control (CDC). Its thinking on the matter is clear. "In the case of kids, e-cigarettes are harmful all by themselves because of the effects of nicotine on children's brains," says Brian King of the organisation's Office on Smoking and Health. "The big picture here is we're seeing a striking increase. It's very concerning. It more than counterbalances the decrease in cigarette smoking, which we've seen occurring over the last few years."

"King says the CDC rejects any notion that replacing cigarettes with e-cigarettes is positive, and claims that e-cigarettes are actually prompting youngsters to take up smoking, not just taking the place of cigarettes. "In just one year, the number of kids using hookah doubled, and the number of kids using e-cigarettes appears to have tripled," he says. "These increases are driving an uptick in the total number of our children who are using tobacco products for the first time in a generation."

The Rest of the Story

How can the CDC possibly claim that a youth smoker switching completely to e-cigarette use is not a good thing? Has the CDC not seen its own data on the number of smokers who die every year? Is the CDC not aware of the devastating toll that long-term smoking takes on the health and lives of the population? Does the agency not recognize that youth smokers are at great risk of long-term addiction to cigarettes, and that half of these youths will eventually end up dying because of it?

I can guarantee you that if I were still working at CDC, that statement would never have come out of the Office on Smoking and Health. Back then, we were extremely careful in documenting the scientific support for any statement we made. And we would never have even considered lying to the public. We also never would have undermined the public's appreciation of the severe hazards of smoking by telling the public that smoking is no worse than occasional use of a non-tobacco containing, non-combustible product that eliminates exposure to more than 10,000 of the chemicals and more than 60 of the carcinogens in tobacco smoke. We certainly wouldn't have claimed that smoking is no worse than vaping given the abundant scientific data that demonstrates exactly the opposite.

I have already discussed in detail why the assertion that e-cigarettes are a gateway to smoking is incorrect and why the claim that e-cigarettes are causing brain damage among youth who experiment with them cannot be verified.

To top it all off, the statement made by the CDC above is dishonest because it implies that e-cigarettes contain tobacco, which is not true. Electronic cigarettes are not tobacco products. They contain no tobacco. They burn no tobacco. They heat no tobacco. They are "tobacco products" only in a strictly legal sense (under the definition in one particular statute). Why does the CDC continue to tell the public that e-cigarettes are tobacco products? Furthermore, by lumping e-cigarettes into the same category as real cigarettes, the CDC is further deceiving the public into thinking that smoking is no worse than vaping.

The truth is that there is no actual evidence that e-cigarettes have caused any substantial health damage to any youth. To tell the public that experimentation with e-cigarettes is causing brain damage among our nation's youth is a hysterical, unsupported claim, and an irresponsible one.

I have long detested the idea of using Congressional inquiries into the actions of executive agencies as a tactic to interfere with the work of these agencies, and I am acutely sensitive to the political uses to which these inquiries have been used. However, as much as I hate to say it, I actually think that a Congressional inquiry into the recent CDC actions is warranted. I think the agency needs to be asked to defend the accuracy of these statements. I think the agency needs to be asked to provide scientific evidence to back up these statements. And I think the agency needs to explain why it is running a deceptive campaign whose effect is to undermine the public's appreciation of the hazards of smoking.

Why is the American Cancer Society Promoting Cancer by Favoring Real Cigarettes Over Fake Ones?

According to an article published in The Hill, the American Cancer Society (ACS) is discouraging smokers from quitting or trying to quit using e-cigarettes, claiming that vaping impedes, rather than aids smoking cessation.

The ACS was quoted as stating: “Every bit of delay is a new opportunity for the tobacco industry to hook new people on nicotine and get in the way of helping tobacco users quit."

At least one chapter of the ACS has gone even beyond discouraging smokers from trying to quit. The New York chapter has actually called for a ban on the sale of electronic cigarettes (to anyone, not just kids)!

According to the ACS web site: "We certainly support the development of therapies that help people quit smoking.  If these devices work as the manufacturers claim they do, we urge them to submit their products for clinical research and present the findings to the FDA to determine if they indeed should be classified as a smoking cessation product.  In the meantime, New York State should absolutely halt the sale of these products to children and prevent their sale to adults until they're proven safe."

The Rest of the Story

There are a huge number of smokers out there who have tried to quit using FDA-approved methods and failed. For these thousands of smokers, e-cigarettes represent their only viable option to quit smoking. Yet the American Cancer Society apparently wants to take this option away from them. That leaves them with no realistic option other than to continue smoking. Thus, by discouraging the use of e-cigarettes to quit smoking and by calling for a ban on these products, the American Cancer Society is actually favoring tobacco cigarettes over non-tobacco-containing e-cigarettes and promoting, instead of preventing cancer.

There is no evidence to support either of the major contentions of the ACS. First, there is no evidence that new people (i.e., youth) are becoming "hooked" on nicotine due to their experimentation with e-cigarettes. In fact, the preliminary evidence suggests that e-cigarettes are not particularly addictive and that youth experimenters are largely using these products only sporadically and in a social manner (e.g, at parties or in the presence of friends). Unlike cigarette smoking, an addictive pattern of e-cigarette use among youth has not been demonstrated. And as I discussed yesterday, evidence from the UK documents that few, if any, nonsmoking youth are using e-cigarettes regularly.

Second, there is no evidence to support the contention that vaping interferes with smoking cessation. The most rigorous studies conducted to date, clinical trials of e-cigarette use, found that e-cigarettes are as effective as the nicotine patch in promoting smoking cessation. These clinical trials did not find that vaping impeded smoking. Quite the opposite. They found that e-cigarette use significantly enhanced smoking cessation.

Recent data from the UK (Smoking Toolkit Study) have revealed that electronic cigarettes have now surpassed all the FDA-approved smoking cessation methods (including NRT, Chantix and other drugs, and behavioral therapy) as the most commonly used method in smoking cessation attempts. The same study found that electronic cigarette use led to a rather dramatic increase in smoking cessation attempts.

Far from impeding smoking cessation, e-cigarettes are a bona fide strategy for smoking cesation that have helped huge numbers of smokers to finally get off cigarettes.

Why is the American Cancer Society ignoring the science and simply making up its own conclusions? I believe it is because the scientific facts do not comport with the organization's deeply-entrenched ideology. But when ideology leads you to take a position and to take actions that run counter to the interests of public health, it is time to re-examine that ideology. This is something which few tobacco control organizations have been able to do.

Fortunately, the vapers out there know the truth. They can testify to the degree to which e-cigarettes have helped them to quit smoking or to greatly reduce their cigarette consumption and the level of their addiction. No one in the anti-smoking movement appears to be taking them seriously. But some of us are listening. And we'll keep fighting. It's sad that we have to fight our own organizations in this battle against cancer, but we can't give up that fight simply because our colleagues are the ones who are standing in the way of progress towards potentially taking a huge chunk out of smoking-related disease and death.

Wednesday, April 22, 2015

CDC Refuses to Ask Critical Survey Question So that Results Don't Foul Up Its Attack on E-Cigarettes

Since 2012, the CDC has known that past 30 day use of electronic cigarettes has been increasing dramatically among youth. This makes it essential for the agency to determine whether these kids are becoming addicted to vaping or whether they are merely experimenting with e-cigarettes on an occasional basis. So you would figure that the CDC would add a question to find out exactly how often youths are using e-cigarettes.

The CDC has failed to ask that question, and the only reason I can see for this glaring omission is that the agency doesn't want to find out that few youths are actually addicted to vaping because it would destroy CDC's propaganda about e-cigarettes being a gateway to smoking, addiction, and serious brain damage.

In the UK, however, they are not afraid to ask this question. In both 2013 and 2014, Action on Smoking and Health (ASH-UK) has asked youth not merely whether they used an e-cigarette in the past 30 days, but whether they use them regularly (more than once per week). The answer will astound you.

The Rest of the Story

ASH-UK found that among nonsmoking youth, all use of e-cigarettes was mere experimentation. There was zero (0) regular use of e-cigarettes (defined as using e-cigarettes more than once per week) (data presented by Martin Dockrell, Tobacco Control Programme Lead of Public Health England, at the 16th World Conference on Tobacco or Health). The only regular use of e-cigarettes was observed among current and former smokers.

These data suggest that CDC's gateway hypothesis may be incorrect and that e-cigarette experimentation is not leading to nicotine addiction and then to cigarette smoking. Instead, it appears that e-cigarette experimentation is not leading to anything other than e-cigarette experimentation (and perhaps diversion away from regular tobacco cigarettes, since these experimenters are largely kids who are at risk for smoking).

The CDC doesn't ask the same question. The answer would most likely ruin the agency's story about how e-cigarettes are a gateway to smoking, to nicotine addiction, and to brain damage.

Thus, in my opinion, CDC is misleading the public not only through its outright lies, dishonesty, and deception about e-cigarettes, but also by its failure to ask the right questions to actually test its pre-determined conclusions. Perhaps it's not surprising that CDC shows no interest in testing those conclusions. The answer might destroy the e-cigarette myths that the agency is trying to create.

Tuesday, April 21, 2015

E-Cigarette Opponent Admits that He Wants to Suppress the Truth About Vaping Success

Dr. Stan Glantz has admitted on his tobacco blog that he opposes an ad campaign in which a vaper truthfully informs the public that thanks to flavored e-cigarettes, he was able to quit smoking. Glantz wants FDA Center for Tobacco Products director Mitch Zeller to refuse to attend the upcoming SFATA meeting because of the group's involvement in this campaign.

The ad features a picture of Stefan Didek holding a vaping device, with the following text: "27 Year Smoker: Smoke and tobacco free for nearly 3 years thanks to vapor products and candy flavors."

Glantz accuses the ad campaign of trying to deceive the public and compares it to historic tobacco industry deception campaigns.

The Rest of the Story

The strategy of e-cigarette opponents is now clear: Suppress the truth! Prevent vapers from telling their real stories about how e-cigarettes and vaping devices have saved their lives by helping them quit smoking. Hide from the public the fact that thousands of smokers who were unable to quit using any "FDA-approved" method were finally able to quit using e-cigarettes and have experienced dramatic improvement in their health because of it.

In many ways, Stefan's story is a lot more sincere than the way the CDC depicted Kristy's story. Kristy is a smoker who failed to quit using e-cigarettes and went on to experience a collapsed lung. The CDC ad is actually somewhat disingenuous because the agency specifically recruited nationally and offered money to try to find someone who failed to quit using e-cigarettes and then experienced a smoking-related consequence. In contrast, Stefan created this campaign on his own, motivated solely by a desire to combat the misleading information being disseminated by numerous health organizations, which continue to insist that e-cigarettes cannot help with smoking cessation.

The facts are now so strongly against e-cigarette opponents that their only resort is to either suppress the facts or to just make them up. In addition to Glantz's attempts to silence the voices of vapers who have saved their lives by quitting smoking, e-cigarette opponents are insinuating to the public that e-cigarettes contain tobacco, that e-cigarettes are leading kids to become addicted to smoking, that e-cigarette experimenters are addicted to vaping, that kids who use e-cigarettes are experiencing serious brain damage, that e-cigarettes are no safer than real cigarettes, and that dual users who cut down substantially on their cigarette consumption experience no health benefits.

Why the need to lie, deceive, and suppress the truth? Because the truth is not on their side.

Monday, April 20, 2015

CDC is Running a Dishonest Campaign Against E-Cigarettes Which is Re-Normalizing Smoking

Almost the Entire Tobacco Control Movement is Helping to Spread CDC's Deception

In an ironic twist of devastating proportions, the Centers for Disease Control and Prevention (CDC) is running an enormous, dishonest campaign against electronic cigarettes that is being spread by almost the entire tobacco control movement and which is serving to re-normalize smoking and undermine decades of progress in educating the public about the hazards of cigarette smoking.

The CDC's campaign involves lying, dishonesty, and massive deception:

Lying

The CDC has been telling the public that its data from the National Youth Tobacco Survey provides evidence that e-cigarettes are a gateway to cigarette smoking among youth. The CDC misrepresented cross-sectional CDC survey data as conclusive evidence that electronic cigarettes are a gateway to smoking. Specifically, CDC Director Dr. Thomas Frieden stated, in response to the 2011-2012 increase in youth e-cigarette use: "Use of e-cigarettes in youth doubled just in the past year, and many kids are starting out with e-cigarettes and then going on to smoke conventional cigarettes." In addition, Dr. Frieden was quoted as stating that electronic cigarettes are "condemning many kids to struggling with a lifelong addiction to nicotine."

However, the CDC surveys do not provide any evidence that e-cigarette use is a gateway to smoking. If anything, they suggest the opposite: experimentation with e-cigarettes appears to be diverting kids away from smoking and contributing to the dramatic, accelerated decline in youth smoking that is contemporaneous with the more than tripling in youth e-cigarette use.

The surveys are cross-sectional and cannot determine whether youth are starting with e-cigarettes and progressing to smoking or whether dual users of e-cigarettes are smokers who subsequently starting using e-cigarettes. But this hasn't stopped CDC from drawing a conclusion, apparently a pre-determined one.

Moreover, the CDC surveys do not provide any evidence that e-cigarettes are condemning youth to a lifelong addiction to nicotine. In fact, what the current evidence suggests is that e-cigarettes are not particularly addictive. Despite the widespread use of these devices, very few youths have been found to be using e-cigarettes regularly, in a pattern that suggests nicotine addiction.

The surveys do not inquire about regular use of e-cigarettes, and thus they are not able to determine whether even a single youth has become addicted to vaping. But again, this hasn't stopped the CDC from disseminating what appears to be a pre-determined conclusion. 

I maintain that the CDC has intentionally failed to ask kids how often they use e-cigarettes because if they find out that most e-cigarette use is only occasional (as suggested by evidence from several studies), it would destroy the myth that e-cigarettes are a major gateway to long-term or lifelong nicotine addiction.

Dishonesty

The CDC is being dishonest with the public by classifying electronic cigarettes as tobacco products and by repeatedly referring to e-cigarettes as a form of tobacco use. Electronic cigarettes are not tobacco products, as understood by the public, because they do not contain any tobacco. Vaping is not a form of tobacco use.

E-cigarettes are tobacco products in only one sense: from purely a legal perspective, these products meet the definition of "tobacco product" under the Family Smoking Prevention and Tobacco Control Act because they contain nicotine, which is derived from tobacco and they are not marketed as drugs or devices. Were the very same product marketing as a drug or device, it would no longer be considered a tobacco product.

By dishonestly classifying e-cigarettes as tobacco products and by telling the public that e-cigarette use is a form of tobacco use, the CDC is deceiving perhaps millions of people into believing that electronic cigarettes contain tobacco. This is simply not true. I believe that it is both dishonest and unethical for CDC to repeatedly refer to e-cigarettes as a form of tobacco use and to classify e-cigarettes as tobacco products because this is dishonest, massively deceives the public, and completely undermines the public's appreciation of how severely toxic real cigarettes are. By essentially equating smoking and vaping, CDC is undermining its own campaign to highlight the severe dangers of smoking.

The CDC is also being dishonest with the public by failing to find out whether youth who are using e-cigarettes are using them regularly or only occasionally, such as in social situations. The CDC has only been able to report on the percentage of kids who have used e-cigarettes in the past month. However, these could easily be kids who picked up an e-cigarette to try it once and will never use one again. These could also be kids who use e-cigarettes only in social situations and so they may vape once a week or less. This would hardly constitute addiction.

The CDC is being particularly dishonest because it has failed to ask youth how often they use e-cigarettes. Moreover, the CDC is hoodwinking the public by not acknowledging that it has failed to document a single youth who is addicted to vaping.

Deception

The CDC is deceiving the public by implying that youth who use e-cigarettes are going to experience brain damage from the inhaled nicotine. The CDC is repeatedly scaring the public into believing that the pattern of e-cigarette use we are observing among youth is likely to cause brain damage. The CDC is repeatedly emphasizing that "nicotine can cause serious damage to the developing brains of teens."

This is very deceptive because it is unlikely that the sporadic exposure to the low levels of nicotine delivered by e-cigarettes is sufficient to cause serious brain damage. There is absolutely no evidence to support this contention. Moreover, the evidence that nicotine causes brain damage is based largely on animal studies and it is not clear whether one can extrapolate from animal models to humans. Furthermore, the few human studies that suggest possible neurological consequences from nicotine inhalation involve smokers, whose nicotine exposure is much higher and more frequent than that of the typical teenage e-cigarette experimenter. The observed decrease in pre-frontal cortex activity was highly correlated with the level of nicotine addiction.

The Rest of the Story

These lies, dishonesty, and deception have been widely incorporated as part of the tobacco control movement's mantra and are being spread like wildfire by virtually all major tobacco control organizations and policy makers who purport to be concerned about the long-term health of our nation's youth. Here is just a small sample of examples:

The chair of the New Jersey Breathes coalition stated: "This [the increase in e-cigarette use] could introduce a whole generation to cigarettes that may have not otherwise smoked." 

The American Heart Association stated: "We cannot stand by [while e-cigarette use increases] while more and more youth put themselves at risk for heart disease, stroke or even an early death."

Senator Dick Durbin (D-IL) stated: "While the FDA continues to drag its feet on finalizing commonsense regulations to protect children and teenagers from the dangers of e-cigarettes, the number of young people getting hooked on this potentially deadly habit is growing exponentially."

Senator Richard Blumenthal (D-CT) stated: "As a gateway to nicotine addiction, e-cigarettes are a burgeoning market and public health menace."

The Campaign for Tobacco-Free Kids stated: "We cannot allow the tobacco industry to keep addicting kids and create another epidemic with a new generation of tobacco products."

The Campaign for Tobacco-Free Kids also stated: "the explosion of e-cigarette use among kids means these products are being taken up in record numbers with totally unknown long-term consequences that could potentially undermine all the progress we’ve made."

The FDA stated: "In today’s rapidly evolving tobacco marketplace, the surge in youth use of novel products, like e-cigarettes, forces us to confront the reality that the progress we have made in reducing youth cigarette smoking rates is being threatened."

The Massachusetts Medical Association stated: "We’re running the risk of creating a whole new generation of smokers which will undo 50 years of public health efforts in smoking-reduction."

It is clear that almost the entire tobacco control movement has fallen for the CDC's lies and dishonesty about electronic cigarettes hook, line, and sinker. These groups are now helping to widely disseminate this inaccurate information to the public. I don't recall any previous tobacco-related public information campaign as dishonest and deceptive as this one since the tobacco industry itself battled to undermine the public's appreciation of the health hazards of smoking.

In fact, the truth appears to be the exact opposite of what these groups are telling the public. Electronic cigarettes are not creating a whole new generation of smokers. Instead, they appear to be diverting smokers and potential smokers away from tobacco cigarettes and toward the fake ones, which are orders of magnitude safer. And by equating the health hazards of smoking with those of vaping, these groups are the ones who are actually guilty of undermining 50 years of public health efforts in smoking reduction.

Not only is the CDC undermining our progress in reducing smoking by suggesting that non-tobacco-containing, non-combusted e-cigarettes are just as bad as tobacco cigarettes, but it is also undermining progress by completely diverting attention away from the problem of youth smoking (which is the real problem that is causing disease and death) to the problem of e-cigarette experimentation (for which there is presently no evidence that existing patterns of use will cause disease and death).

In fact, the CDC failed to even celebrate the finding that youth smoking has reached its lowest level in decades and that the decline in youth smoking accelerated from 2013 to 2014. Instead, all the CDC wanted to talk about was how horrible it is that youth are experimenting with e-cigarettes, how this is going to lead to nicotine addiction and serious brain damage, and how it is going to reverse progress in reducing youth smoking (via a rather strange mechanism, since the dramatic rise in youth vaping was associated with an acceleration in the decline in youth smoking).

Joe Nocera, in his New York Times column, astutely points out this strange behavior for an agency that is supposed to be focused on preventing disease and death. He writes:

"equating smoking cigarettes with inhaling e-cigarettes, as the C.D.C. is doing in its messaging around teen tobacco use, is a huge disservice to public health. On the scale of potential harms, e-cigarettes aren’t even in the same ballpark as combustible cigarettes. They have the potential to save millions of lives if smokers could be convinced to switch—which is what the C.D.C. ought to be stressing. Jack Henningfield, a tobacco expert at Pinney Associates, told me that while youths should be discouraged from using nicotine, “putting electronic products in the same basket as cigarettes is not truthful, credible or helpful.” Invariably, teens do things they shouldn’t; that’s part of growing up. For decades, smoking cigarettes has been one of those things. The fact that they are doing less of it than ever before is not a cause for dismay. It is a cause for celebration."

Thursday, April 16, 2015

New Study Which Purports to Have Found that E-Cigs Inhibit Quitting is Complete Junk Science

A new study, released just moments ago and published online today in the American Journal of Public Health, purports to have found evidence that smokers who use e-cigarettes are significantly less likely to quit smoking than those who do not.

(See: Al-Delaimy W et al. E-cigarette use in the past and quitting behavior in the future: a population-based study. American Journal of Public Health. Published online ahead of print on April 16, 2015.)

The study involved a survey of 1000 smokers in California who were followed for one year to determine whether they had quit smoking at follow-up. Quit rates were compared between those who stated at both baseline and follow-up that they had ever used e-cigarettes and those who reported at both baseline and follow-up that they would never use e-cigarettes.

The study claims to have found that smokers "who ever used e-cigarettes" were less than half as likely to have quit smoking than those "who never used e-cigarettes."

The study concludes that e-cigarettes inhibit smoking cessation.

The Rest of the Story

The conclusions of this article are completely invalid, and the article's description of its own findings borders on being deceitful (or it may actually be deceitful: I'll let readers decide for themselves).

First of all, this was not a study of 1000 smokers. The authors present results only for 368 participants. What happened to the other 632 smokers (almost two-thirds of the sample)?

1. Well, anyone who had not heard of e-cigarettes was completely thrown out of the study. This eliminated a whopping 9% of the sample!

2. Next, anyone who had never used e-cigarettes but who reported that they "might" use e-cigarettes in the future was excluded from the primary analysis.

3. Then, anyone who stated at baseline that they had used e-cigarettes but at follow-up that they had not was thrown out of the study.

4. Finally, anyone who responded at baseline that they would never use e-cigarettes but at follow-up that they had used e-cigarettes or might use e-cigarettes was excluded from the analysis.

Second of all, the study abstract claims that it compared smokers "who ever used e-cigarettes" with those "who never used e-cigarettes." This is not true. The study actually compared smokers who had ever used e-cigarettes at baseline with those who reported, both at baseline and follow-up, that they would "never" use e-cigarettes.

This introduces a huge bias into the study. Why might someone say that they will never use e-cigarettes?

At baseline, a plausible reason why a respondent might have no interest in e-cigarettes is that the individual has a high degree of confidence in his or her ability to quit smoking on his or her own, or with traditional methods, and thus has no desire or need to try e-cigarettes. Such a person is at a much higher likelihood of quitting smoking because of their high level of confidence. Clearly, this would bias the results toward finding a higher quitting rate among the supposed "control" group compared to the e-cigarette group.

At follow-up, a plausible reason why a respondent might have no interest in e-cigarettes is that the individual has stopped smoking! Thus, by using as a criteria for defining the control group a variable derived at follow-up, the study has introduced a strong bias towards finding a much higher quit rate among the control group.

Generally, in a cohort study, the cohort groups should be defined based on the baseline variables, not based on the follow-up variables. Defining a cohort based on follow-up variables almost invariably introduces severe selection bias into a study.

Here, the study has specifically excluded smokers who did not quit smoking, and for that reason, may have changed their mind and decided that perhaps they might try e-cigarettes. Also excluded were smokers who thought they would not or might not use e-cigarettes, but who ended up using these devices between baseline and follow-up. Thus, all smokers in the study who quit successfully were excluded from the study if they made the decision to try e-cigarettes between the baseline and follow-up interviews. This most likely led to the exclusion of a number of successful quitters (successful in using e-cigarettes to quit).

Furthermore, one can easily imagine that smokers who have never even heard of e-cigarettes are most likely not particularly interested in quitting. In fact, these smokers are likely to have no interest whatsoever in quitting because with even a little effort looking into cessation approaches, they would likely have come across e-cigarettes. These smokers were thrown out of the study! Because these smokers probably had a very low quit rate, the effect of this procedure was to artificially increase the observed quit rate in the control group.

In summary, you can see that there are numerous sources of severe selection bias in this study, all of which would bias the results towards finding a lower quit rate among the e-cigarette users.

But the problems don't end there.

The study included anyone who had ever used e-cigarettes, even if they had done so on only one occasion. All smokers who had ever used e-cigarettes were included in the "intervention" group, even if they had not used the e-cigarette with an intent to quit and even if they had absolutely no intention to quit smoking. A person could have tried an e-cigarette two years ago on one occasion and that person would still be included in the e-cigarette group. Even more problematic is that such an individual might actually have tried to use NRT or a cessation drug to quit smoking at baseline and failed. But that failure to quit would be counted against the e-cigarette group!

The fundamental problem with the study design is that it relies upon self-selection to assign smokers to the e-cigarette group and the non-e-cigarette group. It is almost certainly the case that smokers who try e-cigarettes are much more addicted to smoking. In fact, the failure to quit using traditional therapies is often the driving force behind a smoker wanting to try e-cigarettes. Numerous surveys have demonstrated that in fact, one of the main reasons why some smokers use e-cigarettes is that they have failed using many other approaches. By definition, the group of ever e-cigarette users is going to be expected to have substantially lower quit rates. Thus, this type of study design incorporates a profound bias towards finding that e-cigarettes inhibit smoking cessation, even if that is not the case.

This study has so many flaws that I find its conclusions to be meaningless. It is an example of junk science at (almost) its worst. But what makes it even more problematic is the apparent deception with which the results and conclusions of the study were presented. They left out important details that are critical to understand what the study did and did not do. Anyone but the most thorough and critical reader would easily be deceived by these omissions.

To top things off, the press release accompanying this study includes one of the most ironic statements of all time. The director of the California Department of Public Health is quoted as stating that: "There is a lot of misinformation about e-cigarettes."

This from the Department which claimed that (1) "E-cigarettes are just as addictive as regular cigarettes" and (2) "Studies show that e-cigarettes do not help people quit smoking cigarettes." Moreover, the Department's web site is full of lies, including the whopper that e-cigarettes are no healthier than regular cigarettes. Other web site lies include the insinuation  that e-cigarettes are actually more harmful than regular cigarettes because they contain more particles, that vaping causes asthma attacks, that e-cigarettes cause heart attacks, that vaping causes as much lung inflammation as smoking, and that nicotine is as addictive as heroin.

The pot is truly calling the kettle black.

The rest of the story is that this poorly conducted study is going to do great public health damage. It is going to add to the propaganda campaign that aims to demonize e-cigarettes, and which is using severely biased research to try to discredit the solid evidence that e-cigarettes can and do help many smokers quit smoking. This is further evidence that ideology has become more important than science in the modern anti-smoking movement.

New CDC Report on E-Cigarettes Shatters Gateway Myth, Suggests Shift from Hazardous Smoking to Much Safer Vaping among Youth

A new CDC report released moments ago and published in tomorrow's MMWR (Morbidity and Mortality Weekly Report) presents new data from the 2014 National Youth Tobacco Survey which show a tripling of past 30-day ("current") e-cigarette use from 2013 to 2014 among both high school and middle school students.

(See: Arrazola RA et al. Tobacco use among middle and high school students -- United States, 2011-2014. MMWR, Vol. 64, No. 14, April 17, 2015.)

The report shows a dramatic and statistically significant increase in current use of e-cigarettes among both high school and middle school students over the period 2011-2014. The actual data are as follows:

Current (past 30-day) E-Cigarette Use 

High school students
2011: 1.5%
2012: 2.8%
2013: 4.5%
2014: 13.4%

Middle school students
2011: 0.6%
2012: 1.1%
2013: 1.1%
2014: 3.9%

In a press release issued by CDC, the director of the FDA's Center for Tobacco Products stated: "In today’s rapidly evolving tobacco marketplace, the surge in youth use of novel products like e-cigarettes forces us to confront the reality that the progress we have made in reducing youth cigarette smoking rates is being threatened."

The Rest of the Story

The CDC, FDA, and anti-smoking groups are only telling one aspect of the story. There is indeed a "rest" of the story, and here it is:
What the CDC fails to mention in its report is that these new data pretty much shatter the gateway myth that the CDC has been disseminating over the past two years.

The CDC has been telling the public that its data from the National Youth Tobacco Survey provides evidence that e-cigarettes are a gateway to cigarette smoking among youth. Remember that the CDC misrepresented cross-sectional CDC survey data as conclusive evidence that electronic cigarettes are a gateway to smoking. Specifically, CDC Director Dr. Thomas Frieden stated, in response to the 2011-2012 increase in youth e-cigarette use: "Use of e-cigarettes in youth doubled just in the past year, and many kids are starting out with e-cigarettes and then going on to smoke conventional cigarettes." In addition, Dr. Frieden was quoted as stating that electronic cigarettes are "condemning many kids to struggling with a lifelong addiction to nicotine."

However, today's CDC report reveals that something very different appears to be occurring. It appears that rather than serving as a gateway toward cigarette smoking, e-cigarettes may actually be acting as a diversion away from cigarettes. Perhaps the most important finding of the new report is that despite the dramatic increase in e-cigarette use among youth, the prevalence of smoking among youth has fallen dramatically during the same time period.

Among high school students, while current use of e-cigarettes increased from 1.5% in 2011 to 13.4% in 2014, current use of real cigarettes declined from 15.8% to 9.2%. Moreover, the prevalence of overall tobacco use among youth has remained steady during this time period, both among high school and middle school students.

These data do not support, and in fact, help to refute the CDC's assertions that e-cigarettes are a gateway to cigarette smoking among youth. These new data are simply not consistent with such a conclusion. Moreover, the data suggest the opposite. The data suggest that overall tobacco use among youth is not changing, but the form of that use is shifting dramatically: away from combustible cigarettes and towards non-tobacco-containing and much safer electronic cigarettes.

This is actually a good thing. While we of course do not want the reduction in smoking among youth to be "offset" by increases in the use of safer products, such as e-cigarettes, because we would prefer that youth not use any form of nicotine, the reality is that the observed shift away from real tobacco cigarettes and towards the fake cigarettes is actually a positive phenomenon in terms of improving the public's health. This shift is going to result in a great reduction in disease and death down the road, because vaping is far safer than smoking.

The truth is that the increase in e-cigarette use is not "offsetting" the decline in cigarette smoking because a large component of the increase in non-cigarette tobacco products is a dramatic rise in hookah use, which among high school students increased from 4.1% in 2011 to 9.4% in 2014.

The rest of the story, then, is that what the CDC data show, but the CDC fails to acknowledge, is that overall use of tobacco among youth is stable, but the form of that use is shifting from the most hazardous type of nicotine-delivering product (real tobacco cigarettes) to less hazardous products (especially electronic cigarettes). There is no question that we need to redouble our efforts to discourage youth from all forms of tobacco and that our goal should be to reduce all tobacco use, not just cigarette use. However, that goal does not justify misrepresenting the scientific data as indicating that the rise in e-cigarette use is troubling because it is going to lead to eventual smoking addiction.

The rest of the story is that the opposite phenomenon appears to be occurring. The advent of this novel product (e-cigarettes) actually appears to be diverting youth who are at high risk of smoking away from tobacco cigarettes and towards e-cigarettes. In essence, e-cigarettes are a gateway product, but they are a gateway away from, rather than towards cigarette smoking.

Wednesday, April 15, 2015

Tobacco Companies Sue FDA Over Required Pre-Approval of Cigarette Label Changes in Substantial Equivalence Guidance

This Tuesday, the major tobacco companies filed suit against the FDA in federal district court. The chief claim is that in its March guidance on substantial equivalence, the FDA essentially promulgated a new rule requiring pre-approval of many cigarette package labeling changes, even if there is no change whatsoever in the cigarettes in the package.

According to a Reuters article: "the tobacco companies said the FDA's authority to regulate labeling was limited to products that claim to reduce tobacco-related harm or other circumstances addressed by formal rulemaking. The guidelines go far beyond that authority, the plaintiffs said, by requiring FDA authorization to make any labeling changes that would render a product already on the market "distinct," like a name change. Although the FDA has framed the guidelines as non-binding recommendations, they create "specific legal obligations with clear and draconian consequences for violations," including civil or criminal penalties, the lawsuit said. The companies said the guidelines violated First Amendment protections for commercial speech by presumptively blocking certain labeling statements until they receive FDA approval. They also accused the FDA of depriving stakeholders of the chance to weigh in on the directive by issuing it as guidance and not through formal rulemaking."

The contentious part of the FDA's guidance is the following:

"In the draft of this guidance issued September 2011, FDA indicated that it would consider the “label” of the tobacco product to be a “part” of that tobacco product, and accordingly, any modification to a tobacco product’s label after February 15, 2007 would make the product a new product subject to premarket review. After reviewing the comments and information submitted in response to the September 2011 draft guidance, FDA has carefully reconsidered this policy. We have concluded that a label is not a “part” of the tobacco product. FDA does conclude, however, that if a product’s label is modified in any way that renders the product distinct from the predicate, even if its characteristics remain the same, the modified product is a new product under section 910(a)(1)(A) of the FD&C Act because that product was not commercially marketed in the United States as of February 15, 2007."

The FDA provides some examples of what labeling changes might be considered to make a product distinct and thus to require pre-approval.

For example, changing the background color from green to red would make a product distinct, but changing the color from white to cream would not. Changing the logo from a star to a lion would render a product distinct, while changing the logo from a small lion to a large lion would not. Adding the words "premium tobacco" to a product label would make the product distinct, while italicizing descriptors already on the label would not.

The tobacco companies argue that these requirements are arbitrary and capricious. Moreover, they were issued without a formal rulemaking process and the FDA does not have such authority, according to the tobacco industry complaint.

Ultimately, the tobacco companies argue that by requiring pre-approval of certain package labeling changes, the agency is exercising prior restraint over the commercial speech of the companies and thus violating the First Amendment rights of these companies.

The Rest of the Story

There are two rather complex legal issues here. The first is whether or not the FDA guidance actually represents the promulgation of specific legal obligations or whether they are simply non-binding recommendations or guidance. The second is whether the pre-approval of cigarette package labeling is unauthorized under the Tobacco Act or whether it is simply a part of enforcing its pre-market application rules.

Several things, however, are quite clear. First, the FDA has completely contradicted itself in this guidance. On the one hand, the FDA concludes that the product labeling is not part of the product. But if the labeling is not part of the product, then how can a change in the labeling - with no change whatsoever in the product - constitute the creation of a new "product?" It would seem that a label change is not changing the product because the label is not part of the product. How then, can the agency declare authority to require pre-approval of labeling changes (unless it were to exercise its formal rule-making authority)?

Second, the requirements do appear to be problematic. Essentially, the agency has issued a rule that bans the use of the term "premium tobacco" on a cigarette label without agency pre-approval, an action that appears to go beyond its existing statutory authority under the Tobacco Act. Nowhere in the Tobacco Act is the FDA granted the authority to pre-approve all cigarette package labeling for products already on the market.

Third, the requirements do appear to be quite arbitrary. Why would changing a logo from a star to a lion create a new product, but a change from a tiny lion to an enormous lion not create a new product? If a change from white to cream does not create a new product, what about a change from beige to brown? How about a change from purple to fuchsia or from Navy blue to azure?

At the very least, this lawsuit helps to expose how inane the requirements of the Tobacco Act are, how arbitrary they are, how little direct connection they have with protecting the public's health. Never has such a huge bureaucratic system of applications, reviews, and guidances been created without having any substantial, tangible, and direct connection to protection of the public's health.

Banning lions on cigarette packs is not going to save lives. However, setting actual product standards to make cigarettes safer could save lives. But in six years, the FDA has yet to issue a single product standard or to do anything to make cigarettes safer and/or less addictive. The agency is wasting all of its time in creating and managing a huge bureaucratic nightmare in which its resources are wasted trying to regulate the changes in colors of cigarette packaging, rather than the safety and addictiveness of the actual product that is within the packaging.

Monday, April 13, 2015

Two Prominent Tobacco Control Researchers are Not Sure Smoking is Any More Harmful than Vaping

According to an article from Healthline News, two prominent tobacco control researchers are telling the public they are not sure that cigarette smoking is any more harmful than vaping.

For reference, electronic cigarettes contain no tobacco, involve no combustion, have tobacco-specific nitrosamine levels that are two to three orders of magnitude lower than real cigarettes, eliminate most of the more than 10,000 chemicals and 60+ carcinogens that are present in tobacco smoke, have been shown not to cause acute changes in spirometry-measured lung function (unlike real cigarettes), are not known to have caused any deaths in the U.S (compared to more than 400,000 per year for real cigarettes), and have been shown to reduce respiratory symptoms and improve lung function in asthmatic smokers who switch to them.

According to the article:

"someone who quits smoking before they turn 40 can expect to live as healthy a life as someone who never smoked at all, according to Dr. Jonathan Samet, a pulmonary physician and epidemiologist at the University of Southern California. ... But how about people who quit smoking regular cigarettes and switch to electronic cigarettes? Does their health likewise improve? The short answer is medical researchers aren’t sure. “We just don’t have the data,” Samet, scientific editor of the 2014 Surgeon General Report on smoking, told Healthline. “Getting into issues of long-term harm reduction, it’s something we need to sort through.”

Also according to the article:

"Jed Rose is a professor at Duke University who specializes in addiction and behavioral science. He told Healthline it’s difficult to say anything conclusive about e-cigarettes because they vary from one brand to another. ... As for those who switch from smoking to vaping, the verdict on whether they truly are improving their health is still being studied. It’s a question researchers are competing for millions of dollars to investigate.
“Using an e-cigarette exclusively may be advantageous when the results come in,” Rose said."

The Rest of the Story

Apparently, according to these prominent tobacco control researchers, the question of whether cigarette smoking is any more hazardous than vaping is a difficult one to which we don't yet have an answer. We "just don't have the data." It's something "we need to sort through." We won't know until "the results come in."

I find it difficult to believe that in 2015, we are telling the public that we're not yet sure whether cigarette smoking poses any more of a hazard than using non-tobacco-containing, non-combusted electronic cigarettes. And we're telling the public this despite our knowledge that smoking is killing more than 400,000 people a year, that tobacco smoke contains more than 10,000 chemicals and more than 60 carcinogens, that e-cigarettes have been found to eliminate most of these chemicals and carcinogens, and that several clinical studies have demonstrated dramatic clinical improvement in smokers who switch to electronic cigarettes.

What exactly is it that we need to wait for?

In my view, it is not only wrong but irresponsible to tell the public that smoking may be no more hazardous than using an electronic cigarette. Even the tobacco companies are not telling people this to defend their products. In fact, if any cigarette company made such a statement, I can guarantee that anti-smoking groups would have them in court the next day.

To me, telling the public that smoking may not be any more harmful than vaping is essentially public health malpractice. It is negligent because it really doesn't take a rocket scientist to figure out that heating a solution of nicotine and propylene glycol (that does not even contain any tobacco) is not going to be nearly as dangerous as burning tobacco. Moreover, it ignores the overwhelming scientific evidence that smokers who switch to vaping experience immediate improvement in their health, as well as abundant evidence that the exposure to harmful chemicals and carcinogens is greatly reduced in electronic cigarettes compared to the real ones. Even the tobacco companies understand that their combustible tobacco products are much more hazardous than their heated non-tobacco products.

Furthermore, I believe this is essentially public health malpractice because it is not only negligent, but it is also harmful to the public's health. It undermines the dangers of smoking while exaggerating the risks of vaping, which is almost certainly going to deter many smokers from quitting using e-cigarettes and may even encourage smokers who have quit using e-cigarettes to return to smoking. After all, if we're not sure that smoking is any worse than vaping, then what's the point of vaping? You might as well go back to your Marlboros, Camels, and Newports rather than your Logic, NJOY, or Vuse.

These researchers obviously recognize that quitting smoking yields immeasurable health benefits. Why, then, could they possibly think that smokers who quit smoking (but by switching to e-cigarettes) might not experience any health benefit?

Perhaps the contradiction lies in the ideology rampant in the tobacco control movement that views a complete switch from smoking to vaping as a continuation of smoking. Numerous public health groups are telling smokers that they need to quit smoking "completely," by which they mean quitting not only smoking but vaping. But that view is inaccurate. Someone who quits smoking via electronic cigarettes is no longer a smoker. He or she is a successful quitter. And until the tobacco control movement finally recognizes that, we are going to continue to see this malpractice of public health.

Thursday, April 09, 2015

New CDC Ads Challenge Value of NRT in Quitting Smoking

A new ad campaign released today by the Centers for Disease Containment (CDC) targets nicotine replacement therapy (NRT) for the first time. The agency says it is taking aim at NRT because its statistics show that the majority of users aren't quitting smoking.

One of the new ads takes on NRT directly. In the print ad, a 35-year-old woman named Kirsty says: "I started using the nicotine patch but it didn't work and I kept smoking. Right up until my lung collapsed." The image shows a surgical scar.

The CDC has expanded its anti-smoking campaign to include NRT because "the majority of users aren’t giving up smoking," said the senior medical officer at the CDC’s Office on Smoking and Health.

The CDC cited a 2013 article published in Future Medicine which reported that 87.5% of smokers who try NRT continue to smoke cigarettes.

Kirsty's full story was revealed on the CDC web site. After smoking for 20 years, she tried the nicotine patch in an attempt to quit smoking. However, she failed. Two weeks later, her lung collapsed.

Anti-smoking groups blasted CDC's new ads. The Campaign for Kid-Free Tobacco released the following response: "The anti-NRT side has been spewing crap like this constantly, but the NRT market continues to grow. People know the truth about NRT."

The American Pulmonary Association also attacked the new ads: "While NRT may have an 87.5% failure rate, it has a 12.5% success rate. It isn't fair to condemn this product entirely just because it doesn't work for everyone. We know it works for many people and that's what counts."

The American Cardiac Association expressed concern that this campaign could seriously undermine smokers' attempts and motivation to quit. Its chief medical scientist told the Rest of the Story: "This is a completely unfair attack on NRT. By pointing out the failure of NRT in the majority of users, this campaign is going to discourage smokers from trying to quit using these products. Thousands of smokers who would otherwise have quit are going to keep smoking instead, and that is going to cost lives."

The anti-smoking groups' harshest criticism for the campaign was directed at the way in which the actor - Kirsty - was recruited. The CDC put out an ad recruiting specifically for a smoker who had tried NRT and failed and then shortly thereafter suffered a smoking-related complication. According to the president of the American Pulmonary Association: "This was at best dubious, and at worst unethical. Why recruit for the smoker who tried NRT and failed? Why not recruit one of the many thousands of smokers who tried NRT and quit? Their stories also need to be told."

The CDC's recruitment ad stated: "Are you a former smoker who used the nicotine patch or nicotine gum to try to quit cigarettes, but ended up continuing to smoke cigarettes? Did you use nicotine replacement therapy because you thought it would successfully help you quit smoking? Share your story. We will provide an initial recruitment payment of $2500 as well as all travel and lodging expenses to the location for the filming and recording. Ongoing and residual talent fees will be based on Screen Actors Guild (SAG) rates and guidelines."

Specifically, the CDC was recruiting for a smoker who tried to quit using NRT but failed and then suffered a smoking-related complication, prompting them to quit cold turkey without medication. Kirsty's story fit the bill.


ADDENDUM: This is obviously a satire. The CDC did not challenge the value of NRT in quitting smoking. Instead, they challenged the value of e-cigarettes. But the current scientific evidence shows that the value of these two products is roughly similar (although I think the value of e-cigarettes greatly exceeds that of NRT because a huge proportion of its users greatly reduce their cigarette consumption and the level of addiction to smoking is reduced in dual users). By substituting NRT for e-cigarettes, you can see exactly what CDC has done with this campaign in terms of undermining smoking cessation.

Tuesday, April 07, 2015

CDC's False Statements About E-Cigs are Still Doing Damage; Agency Needs to Retract Statements Immediately

Although it has been a year and a half since the CDC disseminated to the public inaccurate information about electronic cigarettes being a gateway to smoking among youth, this false propaganda is still doing damage.

It was in fall 2013 that CDC made the following statements regarding electronic cigarettes being a gateway to smoking:

1. The CDC misrepresented cross-sectional CDC survey data as conclusive evidence that electronic cigarettes are a gateway to smoking. Specifically, CDC Director Dr. Thomas Frieden stated: "Use of e-cigarettes in youth doubled just in the past year, and many kids are starting out with e-cigarettes and then going on to smoke conventional cigarettes." 

2. In addition, Dr. Frieden was quoted as stating that electronic cigarettes are "condemning many kids to struggling with a lifelong addiction to nicotine and conventional cigarettes."

This past Sunday, in an article in the Newburyport Daily News, the CDC was again quoted as concluding that electronic cigarettes are a gateway to youth smoking.

According to the article: "While supporters say e-cigarettes are a less dangerous alternative to cigarettes, health officials said they worry the devices could spur teen cigarette use, possibly undermining decades of work to reduce smoking rates. At least 10 percent of high school students say they tried e-cigarettes in 2012, up from 4.7 percent in 2011, according to a National Youth Tobacco Survey by the US Centers for Disease Control and Prevention. “The increased use of e-cigarettes by teens is deeply troubling,” CDC director Thomas Frieden said in a recent statement. “Many teens who start with e-cigarettes may be condemned to struggling with a lifelong addiction to nicotine and conventional cigarettes.”"

Even a brief search of the internet reveals that this statement continues to be relied upon by anti-smoking groups throughout the country in pressing the case that e-cigarettes are a gateway to youth smoking. The quote is even featured in an argumentative writing assignment for 9th graders at the Moore public schools in
Oklahoma.

The Rest of the Story

I can certainly understand if the CDC made a mistake. I do it all the time. Anyone can misspeak or say something in an interview that is not correct. The important thing is that you correct the error, especially if it will have a major effect on public policy.

But here we are a year and a half after the original statements and the CDC has failed to make any attempt to retract or correct these statements. They even have the original press release up with no note of any correction.

Given this failure to correct what is obviously a completely unsupported statement and one which appears to be false, one has to at this point infer that the deception of the public is intentional.

I call on the CDC to immediately retract these statements before any further damage is done. Failing to do so will only solidify my conclusion that the agency is intentionally misleading the public to promote its anti-e-cigarette agenda.

Monday, April 06, 2015

March E-Cigarette Madness: CDC Wins National Championship for Worst E-Cigarette Lie

The national championship for worst e-cigarette lie was held between CDC and the California Department of Health Services.

Here are the relevant statements (lies) of each finalist organization:

California Department of Health Services: The California Department of Health Services (CDHS), under a grant funded by the Centers for Disease Control and Prevention (CDC), produced a brochure entitled "Protect Your Family from E-Cigarettes: The Facts You Need to Know," which claimed that: (1) "E-cigarettes are just as addictive as regular cigarettes" and (2) "Studies show that e-cigarettes do not help people quit smoking cigarettes."

CDC: The CDC misrepresented cross-sectional CDC survey data as conclusive evidence that electronic cigarettes are a gateway to smoking. Specifically, CDC Director Dr. Thomas Frieden stated: "Use of e-cigarettes in youth doubled just in the past year, and many kids are starting out with e-cigarettes and then going on to smoke conventional cigarettes." In addition, Dr. Frieden was quoted as stating that electronic cigarettes are "condemning many kids to struggling with a lifelong addiction to nicotine."

While it was a closely contested match, the CDC pulled out the victory because the damage caused by its lies are likely to be much greater than those of the California state health department. Some of the lies from the state health department are so blatant that no one will actually believe them. However, the CDC's lies about e-cigarettes being a gateway to smoking have been widely accepted and repeated by local health departments and policy makers and are already serving as the basis for some local policies. Moreover, the CDC's lies are potentially devastating to the e-cigarette industry because if these statements were true, then it would be difficult, if not impossible, to show that e-cigarettes will have a net benefit for the public's health, and therefore, no e-cigarette pre-market applications could be approved. The effect of CDC's lies, if they are accepted as truth, could therefore be the complete destruction of the e-cigarette market. That would have a severe detrimental effect on the public's health, and it brought the CDC the championship trophy.

THE NATIONAL CHAMPION for Worst E-Cigarette Lie:

Centers for Disease Control and Prevention (CDC)

Thursday, April 02, 2015

March E-Cigarette Madness: Semifinal Results for Worst E-Cigarette Lie

Today, I reveal the semifinalists for the 2015 Rest of the Story Worst E-Cigarette Lie Championship. The champion will be revealed next week. Criteria for selection included: (1) the extent of the misinformation provided to the public about e-cigarettes; and (2) the amount of probable damage to the public's health resulting by the misinformation. See my previous post for a full description of the Elite Eight organizations that made it to the quarterfinals.

The semifinal matchups were as follows:

SEMIFINAL MATCHUPS

1. California Department of Health Services vs. Mayo Clinic

2. CDC vs. FDA

Here are the relevant statements (lies) of each semifinalist organization:

California Department of Health Services: The California Department of Health Services (CDHS), under a grant funded by the Centers for Disease Control and Prevention (CDC), produced a brochure entitled "Protect Your Family from E-Cigarettes: The Facts You Need to Know," which claimed that: (1) "E-cigarettes are just as addictive as regular cigarettes" and (2) "Studies show that e-cigarettes do not help people quit smoking cigarettes."

Mayo Clinic: The Mayo Clinic stated that: "with nicotine inhalers you receive only nicotine." Even the arch-enemy of electronic cigarettes - Dr. Stanton Glantz - has acknowledged that nicotine inhalers deliver to users the following chemicals: Formaldehyde; Acetaldehyde; o-methylbenzene; Cadmium; Nickel; and Lead. In fact, I have shown that nicotine inhalers actually deliver higher amounts of six carcinogens than electronic cigarettes. The Mayo Clinic also stated that: "No studies have been done to examine the safety of e-cigarettes." However, there have been many studies that examined the safety of electronic cigarettes.
 
CDC: The CDC misrepresented cross-sectional CDC survey data as conclusive evidence that electronic cigarettes are a gateway to smoking. Specifically, CDC Director Dr. Thomas Frieden stated: "Use of e-cigarettes in youth doubled just in the past year, and many kids are starting out with e-cigarettes and then going on to smoke conventional cigarettes." In addition, Dr. Frieden was quoted as stating that electronic cigarettes are "condemning many kids to struggling with a lifelong addiction to nicotine."

FDA: The FDA stated, in its proposed deeming regulations: "Many consumers believe that e-cigarettes are "safe" tobacco products or are "safer" than cigarettes. FDA has not made such a determination and conclusive research is not available." That the FDA is not sure whether smoking is any more hazardous than vaping does not say a lot for the agency's scientific standards.

THE WINNERS
 
 1. California Department of Health Services vs. Mayo Clinic

The California Department of Health Services wins in a blowout. Buoyed up by further lies coming out of the state health department, the team was in rare form. The Department's web site is full of lies, including the whopper that e-cigarettes are no healthier than regular cigarettes. Other web site lies include the insinuation  that e-cigarettes are actually more harmful than regular cigarettes because they contain more particles, that vaping causes asthma attacks, that e-cigarettes cause heart attacks, that vaping causes as much lung inflammation as smoking, and that nicotine is as addictive as heroin. In addition, the Department is running a campaign to keep smokers from quitting by switching to electronic cigarettes.

2. The Centers for Disease Control and Prevention vs. the Food and Drug Administration

In a close contest, CDC defeats the FDA. This was a tightly contested battle, and the CDC only pulled ahead in the final minutes. The CDC's lies about e-cigarettes being a gateway to smoking have had such a huge impact on public policy throughout the nation that CDC pulled away with the victory.

FINAL MATCHUP

California Department of Health Services vs. CDC

Dr. Alan Blum Points Out Big Tobacco Connections of Sponsor of Film on Cancer

Dr. Alan Blum - the Gerald Leon Wallace, M.D., Endowed Chair in Family Medicine at the University of Alabama and director of the Center for the Study of Tobacco and Society - published an interesting op-ed last Friday in the Tuscaloosa News. The commentary reveals that several of the sponsors of the recent PBS documentary on cancer as well as the Stand Up to Cancer telethon have strong connections to Big Tobacco and are actually helping contribute to the tobacco epidemic.

I recommend reading the whole piece, but a few of the most relevant excerpts follow:

"At the 16th World Conference on Tobacco or Health in Abu Dhabi last week, the latest grim statistics shocked even veteran anti-smoking advocates. In spite of the growing number of nations that have banned smoking in public places and have prohibited or restricted cigarette advertising and marketing, the annual death toll from cigarette smoking keeps rising. ... The assumption of the more than 2000 public health professionals from over 100 countries at the conference is that the tobacco industry is the villain, wielding enormous economic and political clout."

"But it’s not just the cigarette companies who benefit from smoking. Without its business allies, the tobacco industry couldn’t exist. These include retailers such as the major chain supermarkets, drugstores, and convenience stores. Then there are the suppliers of packaging, chemicals, paper and the very machines used to manufacture cigarettes."

"Take Siemens, a global engineering and electronics corporation that cultivates an image of a health-care company in advertisements in major magazines and newspapers, and that runs a science competition for high school students. Chances are that anyone undergoing diagnostic testing for cancer will have blood analyzed — or one’s entire body scanned — in a machine made by Siemens. But Siemens also has a division unknown to the health community and the public — its “tobacco segment,” which provides technical know-how for the largest international cigarette makers such as Philip Morris, RJ Reynolds and British American Tobacco. Siemens boasts on its website of helping them produce hundreds of billions of cigarettes each year throughout the world. One Siemens machine operates “at speeds of 4,000 to 20,000 cigarettes per minute.”

"So it was dismaying to see in advertisements for Public Broadcasting Service’s new film “Cancer: The Emperor of All Maladies” (to air on PBS stations over three nights March 30-April 1) that one of its major sponsors is Siemens. During the six-hour documentary, a single Siemens machine will produce 7,800,000 cigarettes."

"Siemens also helps fund the national telethon Stand Up To Cancer, which happens to be the lead sponsor of the PBS film. Stand Up To Cancer also partners with several companies that either sell, promote, or otherwise derive income from the sale of cigarettes, including Safeway Stores’ foundation, the Steve Tisch Foundation (with funding derived in part from family-owned Lorillard Tobacco, maker of Newport) and the publishers Conde Nast and Time Inc., which continue to advertise cigarettes in their magazines."

Australian Medical Groups Want to Give Cigarettes a Monopoly by Keeping the Real Ones and Banning the Fake Ones

According to a recent article in the Herald Sun, several medical and health groups including the Royal Australasian College of Physicians, the Australian Medical Society, and Quit Victoria are supporting a complete ban on electronic cigarettes, despite whether they contain nicotine or not.

According to the article:

"Bans on e-cigarettes should be widened to outlaw non-nicotine vaping and close a loophole that allows the importation of prohibited devices with a prescription, doctors groups have demanded. Warning that the long-term health impacts of electronic cigarettes are not known, the Royal Australasian College of Physicians has rejected tobacco company claims the devices are able help people quit. The Australian Medical Association and Quit Victoria are also calling for tougher regulations on e-cigarettes as they become increasingly popular in Melbourne’s bars and clubs. The sale, use and importation of e-cigarettes containing nicotine is prohibited in Victoria and all other states. However, the sale of almost identical non-nicotine electronic cigarettes is allowed at stores across the state, with many sold in flavours that appeal to children."

"While nicotine vaporisers can be legally used overseas, RACP president Prof Nicholas Talley said there was little evidence about their safety and Australian regulators needed to maintain bans. “We must step with caution when it comes to promoting e-cigarettes as a safer alternative because the jury is still out as to whether there are no side effects,” Prof Talley said. “We don’t know if e-cigarettes help people quit traditional cigarettes, and even if they do it is too early to rule out any possible long-term health effects that they may or may not cause. “It took many years for the serious health impacts of smoking tobacco to be realised so to say that e-cigarettes are the solution is premature.”"

The Rest of the Story

It is difficult to believe that these health and medical groups want to give Big Tobacco a monopoly on the Australian market by forcing out competition from electronic cigarettes, which are much safer and less addictive than the real ones and which have helped tens of thousands of smokers to quit smoking.

Financial analysts have predicted that electronic cigarettes are going to save many lives over the next decade by shifting sales from combustible cigarettes to non-tobacco-containing and non-combustible electronic cigarettes. However, thanks to the health and medical groups in Australia, this life-saving shift in the form of nicotine consumption will not take place in that country.

The reasoning given for supporting a ban on electronic cigarettes is inane. So what if there are some side effects? The side effects of smoking are disease and death. The side effects of e-cigarettes are certainly a whole lot better than that. Even pharmaceutical products can be allowed on the market if they have side effects. The side effects have to be weighed against the benefits. Why should e-cigarettes be allowed on the market only if there are no side effects?

The rest of the story is that the Australian medical and health groups are doing a tremendous favor for Big Tobacco, and especially for the future of smoking-related disease and death in Australia.

Wednesday, April 01, 2015

New Pilot Study Finds High Cessation Rate among Smokers Making First Purchase at Vape Shops in Italy

A new study published in the International Journal of Environmental Research and Public Health reports high rates of smoking cessation at one-year follow-up among smokers visiting a vape shop for the first time. The study was conducted in Catania by Dr. Riccardo Polosa and colleagues.

Smokers who were first time visitors to one of seven vape shops in Catania were followed for one year to determine their smoking status after their first vape shop purchases. A total of 71 smokers were recruited into the study.

The follow-up rate was 69%. Those lost to follow-up were assumed to be continuing smokers. The researchers report the proportion of smokers who had quit smoking or reduced substantially (by 80% or more) at the one-year follow-up.

The quit rate at one-year follow-up was 40.8%. The proportion of heavy reducers at one-year follow-up was 15.5%. Thus, the combined proportion of quitters and heavy reducers was 56.3%. An additional 10% of smokers reduced their cigarette consumption by at least 50%. Just more than one-third of the smokers were considered to be "treatment failures."

The authors conclude that "smokers purchasing e-cigarettes from vape shops with professional advice and support can achieve high success rates.

The Rest of the Story

This is the first study I am aware of that specifically examines the effectiveness of the types of vaping devices sold at vape shops. The study is not only measuring the effectiveness of the device type but also the potential benefits of the social and technical support provided by vape shops. The sample is biased because it is self-selected: the smokers were motivated enough to seek out and visit a vape shop. Nevertheless, this study reports very high rates of smoking cessation under these conditions.

To be clear, the results of this study are not relevant to the overall effectiveness of e-cigarettes for smoking cessation. However, the study does suggest that for a subset of smokers who are highly motivated to quit and who visit vape shops to purchase e-cigarettes, a very high rate of smoking cessation can potentially be achieved.

This study adds to the growing body of evidence that among a subset of smokers, electronic cigarettes can be quite effective for achieving smoking cessation or substantial reduction in cigarette consumption. The study also suggests that the types of devices available at vape shops and/or the support and assistance provided at these shops may enhance the chances of quitting success.

Unfortunately, despite the great promise of vape shops for enhancing smoking cessation, the proposed FDA deeming regulations would essentially shut down the tens of thousands of vape shops in the United States. These are small businesses that generally do not have the resources necessary to conduct the research and prepare the applications that would be required by the FDA in order to keep their products on the market. Unless the FDA makes drastic changes before promulgating its final regulations, the potential promise of vape shops in enhancing smoking cessation will not be realized.

Tuesday, March 31, 2015

E-Cigarette Opponent Uses Cross-Sectional Study to Conclude that E-Cigs are a Gateway to Smoking

On his blog Sunday, Stan Glantz cited a new UK study as supporting the conclusion that e-cigarettes are a gateway to smoking among youth.

The study was a cross-sectional survey of nonsmoking 10-11 year-old children in Wales. They reported on their e-cigarette use and on their intentions to smoke in the future. The study found that users of e-cigarettes were significantly more likely to have intentions to smoke.

Specifically: "Having used an e-cigarette was associated with intentions to smoke (OR=3.21; 95% CI 1.66 to 6.23). While few children reported that they would smoke in 2 years’ time, children who had used an e-cigarette were less likely to report that they definitely would not smoke tobacco in 2 years’ time and were more likely to say that they might."

From these findings, Glantz concludes: "While a cross-sectional study, susceptibility to smoking is a well-validated measure of future smoking, so the results support the gateway effect."

The Rest of the Story

Because this is a cross-sectional study, it is unable to determine the direction of causality. Which came first? The e-cigarette use or the intention to smoke?

While Glantz reports the result as e-cigarette users being more likely to have intentions to smoke, the results could just as easily presented as youth with intentions to smoke being more likely to try e-cigarettes.

Clearly, except for Stan, one cannot discern from this study whether youth who try e-cigarettes then develop an intention to smoke or whether youth with a predisposition to smoking are more likely to experiment with e-cigarettes.

That Stan draws a conclusion anyway suggests that he has come to a pre-determined conclusion and is twisting the data to support this conclusion.

However, it is entirely possible that what these results indicate is that e-cigarettes appeal much more to kids who are highly predisposed to try tobacco cigarettes. In fact, it is possible that by diverting these youth to e-cigarettes and their flavorings, e-cigarette experimentation may actually prevent youth from smoking. After all, once they try the sweet flavors of e-cigarettes, it would be extremely difficult to imagine them then transitioning to a Marlboro cigarette.

The rest of the story is that many e-cigarette opponents have drawn a pre-determined conclusion that e-cigarettes are evil and are therefore so biased that they are skewing the interpretation of scientific studies to support their pre-determined conclusions, even when the science does not support these conclusions.

This is another way of saying that ideology has taken over for science in the anti-smoking movement.

Thursday, March 26, 2015

California Department of Public Health E-Cigarette Web Site is Full of Lies; Why Can't They Just Tell the Truth?

I never thought I would say this, but in March 2015, public health officials are telling more lies to the public about the health effects of smoking than the tobacco industry.

I took the time to review the web site that the California Department of Public Health put together about electronic cigarettes and tobacco cigarettes and was appalled to find that the site is full of lies.

Here they are (these are not direct quotes but assertions that are clearly insinuated):

1. E-cigarettes are no healthier than tobacco cigarettes.

This is blatantly false. Farsalinos et al. published a paper just today showing that the levels of TSNAs in e-cigarettes are two to three orders of magnitude lower than in tobacco cigarettes. Polosa et al. have shown that switching from cigarettes to e-cigarettes leads to dramatic improvement in respiratory symptoms and lung function. The scientific evidence is overwhelming: cigarette smoking is far more harmful than vaping. There really is no question about this. The California Department of Public Health is disseminating a blatant lie.

2. E-cigarettes turn kids into addicts.

There is absolutely no evidence to support this contention. In fact, the existing evidence shows that e-cigarettes are much less addictive than real cigarettes and that their addictive potential is more comparable with nicotine replacement therapy. Despite the dramatic increase in e-cigarette experimentation among youth, there is no evidence that there is any substantial proportion of these youth who have become e-cigarette addicts. The evidence shows, on the contrary, that most youth use is social use and that a pattern of addictive use of these products has not yet appeared among adolescents.

3. E-cigarettes are more harmful than real cigarettes because they contain more particles.

This is a bizarre conclusion that is completely false. Asthma inhalers deliver numerous particles to the lungs as well, but that doesn't mean that puffing on an inhaler is more dangerous than smoking. The statement is not only a lie, but is an embarrassment to science itself.

4. Vaping causes asthma attacks.

There is no evidence that vaping contributes to asthma exacerbation. On the contrary, asthmatic smokers who switch to e-cigarettes have been found to experience a significant reduction in their respiratory symptoms and an improvement in their lung function. Rather than exacerbating asthma, switching from cigarettes to e-cigarettes greatly improves asthma.

5. E-cigarettes cause heart attacks.

There is absolutely no evidence to suggest that e-cigarettes have ever caused any individual to suffer a heart attack.

6. Vaping causes as much lung inflammation as smoking.

There is no evidence to support this. On the contrary, while smoking causes enough inflammation to obstruct air flow in the lungs, vaping has been shown not to cause obstruction that is detectable through spirometry.

7. Nicotine is as addictive as heroin.

This is an absurd and false assertion. Nicotine itself is certainly not as addictive as heroin. When was the last time you saw a nicotine patch user who was hopelessly addicted to the patch? It is smoking that is perhaps as addictive as heroin, not nicotine. Everything about the smoking experience contributes to its strong addictive power, including the way the nicotine is delivered and the behavioral, social, and physical stimuli associated with the behavior.

The Rest of the Story

Why can't the California Department of Public Health simply tell the truth?

Probably because they realize they don't have a leg to stand on. Almost every reputable scientist - and even the tobacco companies themselves - know that smoking is certainly more hazardous than vaping, which involves no tobacco and no combustion. But that message is not consistent with the ideology that the California DPH apparently holds. So rather than abandon that ideology, they chose instead to lie.

The overwhelming scientific evidence that switching from smoking to vaping results in dramatic improvement in respiratory symptoms and lung function is also inconsistent with the health department's apparent ideology. So they chose to lie about that too.

Demonizing nicotine is apparently part of the health department's ideology. So instead of telling the truth - that smoking is as addictive as heroin - they lie and tell the public that nicotine by itself is more addictive than heroin.  

Apparently, it is also not consistent with the health department's ideology that vaping is actually less destructive to the airways than smoking. So despite the evidence that vaping causes no observable changes in spirometric measures of lung function, the health department chose to lie and tell the public that vaping actually causes the same amount of lung inflammation than smoking. That's complete rubbish.

There is no evidence, nor any reason to believe that e-cigarettes cause heart disease leading to heart attacks. But that's not a good sound bite when you're trying to demonize e-cigs, so instead, the health department chose to lie and tell the public that e-cigarettes do cause heart attacks.

To be clear, I fully support measures to educate kids about the truth about e-cigarettes. I do think there is a need for educational campaigns that inform kids that e-cigarettes, while safer than cigarettes, do not merely deliver harmless water vapor. However, why do we need to lie to get this message across?

Is there no room for the truth in the tobacco control movement anymore?

Wednesday, March 25, 2015

California Department of Public Health Running Campaign to Keep Smokers from Switching to Electronic Cigarettes

I was absolutely shocked when I viewed the new print ad campaign coming from the California Department of Public Health, which Stan Glantz had touted as being outstanding. The campaign could not be any more advantageous for the combustible cigarette industry than if cigarette manufacturers had designed the campaign themselves. But to top off this sad story, the cigarette companies are not spewing forth the same false and misleading propaganda, even though it would benefit their cigarette sales. Instead, it is the California state health department that is doing the industry's bidding. This is a startling and sad retreat from the days when California was truly a leader in tobacco control.

In a press release touting the campaign, the director of the California Department of Public Health - Dr. Karen Smith - stated: "California has been a world leader in tobacco use prevention and cessation since 1990, with one of the lowest youth and adult smoking rates in the nation. The aggressive marketing and escalating use of e-cigarettes threatens to erode that progress."

Some of the text from the print ad campaign reads as follows:

"Sure, e-cigs are healthier, if inhaling toxic chemicals sounds healthier to you. Wake up."

"It's the next generation cigarette. For the next generation of addicts."

"Big Tobacco calls e-cigs a smarter alternative to smoking. We can trust them, right?"

The Rest of the Story

Unfortunately, the California Department of Public Health has it all wrong. It is the California state health department that needs to wake up, not the public. Literally millions of vapers out there know the truth: that e-cigarettes are indeed healthier than tobacco cigarettes and that these products are a smarter alternative to smoking. And these vapers also realize that even if they do become addicted to e-cigarettes, it is still much better than smoking. In fact, it is an addiction that just might save their lives. The vapers out there have woken up. It is the state public health officials in California who are need of the wake up call.

Dr. Smith has it all wrong when she states that the escalating use of e-cigarettes is going to erode progress in reducing adult smoking rates. That is an inane statement because the more the use of e-cigarettes among adults escalates, the lower and lower cigarette consumption will fall. A dramatic escalation in the use of e-cigarettes among adult smokers would in fact create much greater progress in decreasing adult cigarette consumption than we have seen in years.

Even the use of e-cigarettes among youth is not eroding the progress in reducing youth smoking. There is no evidence that e-cigarettes are a gateway to smoking. In fact, the current evidence suggests the opposite: that flavored e-cigarettes may actually be deterring youth from smoking the real, non-flavored, unpalatable tobacco cigarettes.

This campaign is extremely destructive to public health because it is sharply deterring smokers from quitting smoking by switching to electronic cigarettes. Instead of trying to quit using these innovative, tobacco-free products, many smokers in California will now decide that they might as well just keep smoking. After all, if e-cigarettes are not healthier than tobacco cigarettes, then what's the point in making the switch? If e-cigarettes are not a smarter choice than tobacco cigarettes, then why quit smoking?

The worst part of the campaign is its dishonesty. It is lying to the public by asserting that electronic cigarettes are not healthier than tobacco cigarettes.

In other words, the rest of the story is that the California Department of Public Health is actually spending taxpayer money to try to convince the public that smoking is no more hazardous than using non-tobacco-containing, non-combusted electronic cigarettes, which have been shown to drastically reduce exposure to the tens of thousands of toxins and more than 60 carcinogens in tobacco smoke and to immediately improve respiratory health among smokers who switch to them, even if used together with cigarettes.

The rest of the story is that the California state health department is lying to the public and that lie is going to cause tremendous public health damage.

Why is it that the California and Washington state health departments are spending so much money to protect tobacco cigarette profits?

Apparently, public health officials in these states are so blinded by anti-nicotine ideology that there are unable to separate out the issue of addiction from the issue of disease and death. They are now engaged in an ideological fight against addiction in and of itself, even if that fight results in an actual increase in disease and death.

It is a very sad day for me: it is stomach-curdling for me to see supposedly anti-smoking officials lose sight of what they are supposed to be fighting. We in public health are supposed to be trying to reduce disease and save lives, not engage in an ideological battle against the concept of the use of an addictive substance.


ADDENDUM: Fortunately, several vaping groups are running a counter-campaign that helps to correct the lies being spread by the California Department of Public Health.