Friday, April 18, 2014

IN MY VIEW: Why Attacking Tobacco Companies for Giving their Cigarette Brands Color Labels Makes No Sense

Earlier this week, I discussed an article published in the journal Tobacco Control and a blog commentary on the article, in which a set of anti-smoking researchers attacked the cigarette industry for complying with the law. The article and commentary criticize tobacco companies for changing their labeling of "light" and "ultra-light" cigarette brands by removing these terms and instead, giving the brands different colors to differentiate them. The study found that manufacturers removed the "lights" labels, as required by law, and substituted colors for the banned descriptors. The study concludes that the tobacco companies circumvented the law and argues that these brands should be labeled by the FDA as "adulterated" and pulled from the market.

In my blog post, I argued that the cigarette companies cannot possibly be found in violation of the law for using alternative names for their products when the law specifically allowed those products to remain on the market.

My argument was echoed in a response to the article by Steven Pinkerton, a public health researcher from the Medical College of Wisconsin, who pointed out that: "the major tobacco companies demonstrated 100% compliance with the law by eliminating all terms specified in the FSPTCA [Family Smoking Prevention and Tobacco Control Act]--the use of colour terms to designate sub-brands is not regulated by the FSPTCA."

In their reply to this response, the authors of the study clarify their reasoning for attacking the cigarette companies, even though they merely complied with the law:

"The findings demonstrated that manufacturers did not simply remove descriptors, to be in compliance with the law, but introduced new color-coded brand name descriptors which smokers were able to recognize and easily identify the formerly labeled "lights" brands. We did not examine the use of colors themselves, which may be protected by the First Amendment, but rather the use of color terms. The marketing materials examined make explicit the fact that the use of substituted color terms in brand names is similar to the dropped "descriptors, so that consumers will continue to recognize these brands as "lights"."

The Rest of the Story

The study authors attack the cigarette companies for substituting another term in the brand name for their products after removing the offending terms ("lights," "ultra-lights," "mild," etc.). But what they fail to acknowledge is that in order to comply with the law, the cigarette companies had no other choice. Had they simply removed the offending descriptor, this would have resulted in their having four or five brands with the exact same name, preventing consumers from having any way to distinguish these brands. Such a result would have effectively removed these brands from the market, which was clearly not the intent of Congress. Had Congress intended to remove these brands from the market, it would have simply banned these brands altogether.

Without adding a descriptor of some sort, the cigarette companies would not have been able to distinguish their sub-brands. For example, Marlboro "Lights" would now be called "Marlboro." Marlboro "Ultra-Lights" would now be called "Marlboro." And Marlboro "Milds" would now be called "Marlboro." Thus, there would be three brands on the market, all called simply "Marlboro," and consumers would have no way of telling them apart.

Let's suppose that Altria had decided to simply call these brands Marlboro A, Marlboro B, and Marlboro C. Consumers would have still learned which letter corresponded to which product, and if you conducted a study, you would find that despite banning the "lights" terms, consumers still recognized which product corresponded to which earlier brand name. By the reasoning of the study authors, this would have represented a circumvention of the law and resulted in the companies being attacked for evading the law.

The point is that there was no way for the cigarette companies to comply with the law, other than to change the banned descriptors to a new term. And no matter what term they chose, consumers would have figured out which brand was which. Moreover, the law did not specify or imply that the companies were prohibited from informing consumers which brand was which. 

In other words, it is time to acknowledge that the law was flawed. It is not the cigarette companies that are to blame for the fact that consumers still understand which brand is which. The law is to blame. If the intent of Congress were to ban any brand that might mislead consumers, then the Congress should simply have banned these brands, requiring them to be pulled from the market. 

But that wasn't the intent of Congress, or of the anti-smoking groups which supported the Family Smoking Prevention and Tobacco Control Act. The intent was to gain a political victory by making it look like they were doing something to protect the public's health, when in truth, they weren't actually doing anything to make cigarettes safer. If anything, they were putting obstacles in the way of transforming the tobacco market into one that is safer.

Instead, the law created a huge bureaucracy full of red tape and sluggish approval processes such that there are still close to 3500 substantial equivalence applications stacked up in a pile somewhere, and the FDA is so overburdened that it cannot even issue electronic cigarette regulations in a reasonable amount of time.

The failure of the Family Smoking Prevention and Tobacco Control Act does call for criticism. But that criticism should not be leveled at the colors Gold, Silver, and Blue. The criticism should be directed at the anti-smoking groups and politicians who sold out the health of the public for political gain.

Thursday, April 17, 2014

Anti-Smoking Advocate Claims that Inhaling Small Amounts of Nicotine Can Be Deadly

In an April 2 press release, anti-smoking advocate John Banzhaf, a law professor at George Washington University and former director of Action on Smoking and Health (ASH), claims that inhaling even small amounts of nicotine can be deadly. He also tells the public that breathing in tobacco smoke for only 30 minutes raises a nonsmoker's risk of a fatal heart attack to that of a long-time smoker's. And to top it off, he claims that inhalation of propylene glycol can cause seizures.

According to the press release:

"Nicotine, even when inhaled in small amounts by nonsmokers, can be deadly. That's why the CDC has warned that nonsmokers seated in the no-smoking sections of restaurants, and inhaling only the nicotine in the small amount of smoke which drifts to their table, nevertheless increase their risk of a heart attack to that of a smoker in as little as 30 minutes."

Also according to the release:

"Experts have warned that propylene glycol should not be inhaled because it can cause respiratory irritation, convulsions, and gastrointestinal distress."

The Rest of the Story

All of these claims are false or highly misleading.

First, the inhalation of nicotine is not deadly. While Banzhaf seems to imply that even the acute inhalation of nicotine is deadly, even if we take his statement to mean that the long-term inhalation of nicotine is deadly, it is still unsupported by scientific evidence. It is not the nicotine which makes cigarette smoking and secondhand smoke deadly; it is the tar, or the other components of the smoke. If what Banzhaf is saying were true, then would he not want to demand that the FDA take nicotine inhalers off the market. After all, if inhaling small amounts of nicotine can be deadly, then surely we would not want anyone to be using a nicotine inhaler.

Second, it is not true that breathing in tobacco smoke for 30 minutes raises a nonsmoker's risk of a heart attack to that of a smoker. The truth is that an otherwise healthy nonsmoker is not going to suffer a heart attack as a result of 30 minutes of exposure to secondhand smoke. A nonsmoker's risk of a heart attack from breathing tobacco smoke for 30 minutes is not the same as that of a smoker. It is actually zero. You are not going to have a heart attack if you don't have coronary artery disease; and 30 minutes of exposure to secondhand smoke is not going to clog your coronary arteries.

Third, the inhalation of propylene glycol from an electronic cigarette is not a cause of seizures. Would we not have expected to have heard reports of seizures from electronic cigarettes by now, given that more than 2 million Americans are using this product and it has been in widespread use across the world for the past 3 years?

I don't understand the point of this scare-mongering. But its effects are to undermine the public's appreciation of the severe health effects of smoking and potentially to promote a return to cigarette smoking among ex-smokers who achieved cessation using electronic cigarettes. Thus, these public statements are not only false but they are damaging as well.

Moreover, statements like these are going to eventually undermine or destroy the scientific reputation of the tobacco control movement. There is only so much of this we can tolerate before the public begins to dismiss everything we say.

Sadly, very few advocates in the tobacco control movement are willing to call other anti-smoking practitioners or groups on this kind of nonsense. And that is exactly what allows this to continue.

Wednesday, April 16, 2014

Anti-Smoking Researchers Attack Tobacco Companies for Complying with the Law

In a strange and ironic twist, in an article published in the journal Tobacco Control and a blog commentary on the article, a set of anti-smoking researchers are attacking the cigarette industry for complying with the law.

The article and commentary criticize tobacco companies for changing their labeling of "light" and "ultra-light" cigarette brands by removing these terms and instead, giving the brands different colors to differentiate them.

The results of the study were as follows: "Manufacturers substituted “Gold” for “Light” and “Silver” for “Ultra-light” in the names of Marlboro sub-brands, and “Blue”, “Gold”, and “Silver” for banned descriptors in sub-brand names."

The study concludes that the tobacco companies circumvented the law and argues that these brands should be labeled by the FDA as "adulterated" and pulled from the market.

The Rest of the Story

The truth is that Bill Godshall and I predicted, years ago, that the anti-smoking groups' were full of baloney in promising that the FDA legislation would protect children and adults. Bill and I predicted that exactly this scenario would unfold: the cigarette flavoring ban would have no effect because no cigarettes were actually affected by the ban (menthol cigarettes are exempt) and the "lights" ban would have no effect because cigarette companies would start using coloring to convey the differences between "lights" and other brands.

Instead of whining about the tobacco companies evading the FDA tobacco law by using colors to denote the brands formerly known as "lights" or "milds," the Campaign for Tobacco-Free Kids and the other major anti-smoking groups should be apologizing to its constituents and to the public for knowingly crafting legislation that would not accomplish its declared purpose.

The Campaign for Tobacco-Free Kids, along with the American Heart Association, American Lung Association, and American Cancer Society pulled one over on the American people by declaring that the legislation that the Campaign crafted in negotiations with Philip Morris would put an end to descriptors relating to "light" or "mild" cigarettes.

These groups agreed to and supported legislation would specifically did not remove these brands from the market. Instead, the legislation simply mandated that these descriptor terms not be used after June 21, 2010.

As the tobacco companies are no longer using these descriptor terms, they are in compliance with the federal law. They cannot possibly be found in violation of the law for using alternative names for their products when the law specifically allowed those products to remain on the market.

If it was the anti-smoking groups' intention to remove these products from the market, then they should have made sure that the legislation removed these products from the market. But given that they did not do that, these groups cannot stand up today and pretend that the problem is the tobacco companies circumventing the law. The problem is the law itself, and the fact that it expressly permits the companies to rename and repackage the products formerly known as "lights" or "milds." Thus, these anti-smoking groups have no one to blame but themselves.

It is not that the tobacco companies are evading the law; it is that the law is so weak that it allowed these products to remain on the market, as long as they simply changed their names to terms that do not directly convey the same meaning.

The Campaign for Tobacco-Free Kids argued that the tobacco companies and retailers not be allowed to tell consumers that the renamed products are the same as the former products. But this would have been an unconstitutional restriction of free speech. Unless the renamed product is banned, or the descriptor used is in violation of the law because it directly infers that the cigarette is safer, then I'm afraid that the companies are in compliance with the law and the anti-smoking groups are going to have to respect that.

You see, the problem is that the anti-smoking groups were willing to talk the talk, but not willing to walk the walk. They wanted to pass legislation in order to say that they had done something. They wanted to be able to tell their constituents that they accomplished something. You see, that's good for donations.

But when it really came down to it, these groups weren't willing to actually put any meat in the legislation. That's why they merely banned the descriptors, rather than banning the products. That's why they banned the flavorings that are never used, rather than the menthol which is used by millions. That's why they gave the FDA authority to lower the nicotine in cigarettes, but not remove it. That's why they gave the FDA authority to regulate tobacco sales to minors, but not to increase the legal age of purchase or outlaw the sale of tobacco in any particular type of retail establishment. And that's why they are pushing the FDA to outlaw electronic cigarettes and dissolvable tobacco products, but not touch the real ones.

I'm sorry, but the words "gold," "silver," "orange," "red," "green" and other colors do not imply levels of harm. In fact, there are existing cigarettes on the market with the names "gold" or "silver" and these products are not accused of implying different levels of health risk. The only reason why these color names imply different risk level is that people know they are the replacement names for the former "light" or "mild" cigarettes.

The Campaign for Tobacco-Free Kids, and the FDA, cannot simply rewrite the law because it was crafted improperly. They have to live within the statute, and within the constitution. And unfortunately, the anti-smoking groups screwed up (albeit intentionally). In other words, the tobacco companies are not evading the law. They are following the law.

You see, no matter what term a tobacco company uses to rename its product, it is going to be known that the name is the new name for whatever the product's old name was. No matter how bland and non-descriptive the new name is, it is still going to infer the same attributes as the old name.

Thus, if it had been the intent of Congress to eliminate this problem, Congress would have chosen to simply mandate the removal of these "light" products from the market. But Congress did not do that.

The rest of the story is that the anti-smoking groups are whining loudly because they need to: they need to cover up their own indiscretion -- negotiating and supporting a bill with no teeth, while misleading the public about the strength of the bill and its effects. In other words, unless the anti-smoking groups shift the blame over to the tobacco companies, then the fact that these groups lied to the American people is going to become clear.

Tuesday, April 15, 2014

New York State Senator Wants to Ban Most Electronic Cigarettes, While Keeping the Toxic Real Ones

New York State Senator Kemp Hannon has introduced legislation that would ban most electronic cigarettes, including both the rechargeable and modular types, while keeping toxic tobacco cigarettes on the market.

Senate Bill 6939 would ban the sale of all electronic cigarette liquids. Under the proposed law, an e-liquid is defined as "A LIQUID COMPOSED OF NICOTINE AND OTHER CHEMICALS, AND WHICH IS SOLD AS A PRODUCT THAT MAY BE USED IN AN ELECTRONIC CIGARETTE."

By this definition, it would be illegal to sell not only the e-liquids used in modular electronic cigarettes, but also the refill cartridges used in rechargeable electronic cigarettes. Thus, this legislation would remove from the market a huge chunk of the electronic cigarettes that are currently sold in New York State. Only disposable electronic cigarettes would remain, and it is unclear if even these would be allowed to be sold, since they do contain "a liquid composed of nicotine and other chemicals" that is "used in an electronic cigarette." Thus, it is conceivable that this legislation would ban the sale of all electronic cigarettes in the state of New York.

The Rest of the Story

If the goal here were to simply protect children and infants from accidentally ingesting nicotine, then Senator Hannon could simply have introduced legislation to require childproof packaging and warning labels on these products. Instead, it appears that the goal is actually to protect the sale of cigarettes in New York by eliminating competition from a rapidly proliferating smoking cessation product that is projected to give tobacco cigarettes a run for their money.

It makes no sense, from a public health perspective, to ban a product which is almost uniformly used by smokers in an effort to quit smoking or significantly reduce the amount of cigarette consumption, while at the same time, to sanction the sale of the real thing: deadly cigarettes. What Senator Hannon is saying is that he would rather have smokers continue to smoke cigarettes than quit smoking with the aid of a much safer alternative product.

If Senator Hannon were truly committed to protecting the health of children in New York, he would propose banning the sale of cigarettes, which are the primary source of nicotine poisoning among New York residents. Why ban the non-tobacco cigarettes which are helping thousands of smokers get off cigarettes, while leaving the real ones on the market to continue to kill New York residents?

This bill would serve to protect the profits of Big Tobacco. Most troublesome is the fact that it would protect the sale of the most toxic market segment - combustible cigarettes - at the expense of a smoking cessation product that has been shown to be much safer to users. 

Senator Hannon is not alone in this craziness. The Israeli Health Ministry has proposed a complete ban on the sale of electronic cigarettes.

The benefits of electronic cigarettes are clear: they help many smokers to quit smoking. They are especially advantageous to smokers who have failed to quit using traditional methods. Taking these products off the market is essentially condemning many smokers to continued smoking by taking away a viable option for them to try to kick the addiction.

The proposed policies in New York State and Israel would severely harm the public's health by causing many vapers to go back to cigarette smoking. What justification is there for a law that we know would harm the public's health? 

Monday, April 14, 2014

ANR Apparently Decides to Keep Defamatory Statement on Its Web Site

Last week, I revealed that Americans for Nonsmokers' Rights (ANR) is making defamatory statements on its web site about electronic cigarette companies, claiming that all of them are owned by Big Tobacco and that Mistic, in particular, is a tobacco-owned company that is distributing misinformation based on a Harris Interactive survey it commissioned.

On the site, ANR makes the following claim: "A recent survey conducted by Harris Decima, a Harris Interactive company, for Mistic e- cigarettes purports to document public support for use of e-cigarettes in in a variety of places, including airplanes, workplaces, sporting events, restaurants and bars, and more. But the survey should be looked at skeptically, inasmuch as, historically, research funded by the tobacco industry tends to yield results favorable to the industry's position. One only needs to refer to the landmark Department of Justice case against the tobacco companies to know their history of disseminating misinformation designed to protect industry profits."

I argued as follows:

"This statement insinuates that Mistic is a tobacco company. The statement refers to the survey as "research funded by the tobacco industry" and reminds readers of the history of the dissemination of misinformation by "the tobacco companies." I read this as a clear assertion that Mistic is a tobacco company, or owned by a tobacco company.

To the best of my knowledge, this assertion is false. I do not believe that Mistic is a tobacco company. I believe that Mistic is an electronic cigarette company, and I do not believe that Mistic is owned by any tobacco company. Thus, I believe that this accusation is false.

Because ANR is falsely accusing Mistic of being part of Big Tobacco, I am afraid that ANR is making a potentially defamatory statement. The false accusation appears to be malicious, as it ties Mistic to the historical fraud and conspiracy for which the tobacco companies were found guilty in the Department of Justice lawsuit. The accusation also appears to represent a blatant disregard for the truth, since there is absolutely no reason to even think that Mistic is owned by Big Tobacco, and because ANR does not list Mistic in its list of e-cigarette brands that are owned by tobacco companies. Thus, it appears that ANR is aware that Mistic is just an independent e-cigarette company."

The Rest of the Story

Today, it has become apparent that ANR has no intention of retracting or clarifying its defamatory statement attacking Mistic E-Cigarettes, accusing it of being owned by Big Tobacco, and claiming that it is putting out misinformation similar to the historical fraudulent actions of the tobacco industry. I wrote my colleagues at ANR to inform them about the inaccuracy in their public accusation, but received no response. Moreover, the claim remains on ANR's website, unchanged.

Unless ANR has evidence that Mistic is owned by Big Tobacco, I believe that ANR may be in serious legal trouble. ANR is now aware, for certain, that its claim that Mistic is a tobacco company is false. So any continuation to make this claim on its web site is most definitely a blatant disregard for the truth. And there is no doubt that it is being done with malicious intent.

But the question is: why even take this chance? Why is there a need to rely upon defamatory and false statements to promote the public's health? Why isn't telling the truth good enough for ANR?

To be sure, ANR could simply have suggested that any poll commissioned by a company should be questioned because there is a potential bias. There was no need to claim that Mistic is actually a tobacco company and that Big Tobacco's history of fraud therefore applies to Mistic. Moreover, there was no need to claim that all electronic cigarette companies are tobacco companies. ANR could simply have stated that some electronic cigarette companies are owned by tobacco companies.

I just do not understand why ANR finds it necessary to lie in order to make its point. Couldn't ANR just tell the truth? There are enough truthful reasons for the public to be cautious about electronic cigarettes that lies are not necessary.

While I didn't highlight this in my earlier post, ANR makes another false statement on its site. It claims that electronic cigarette companies are calling what comes out of their products a "vapor" rather than an "aerosol" because they are trying to connote "reduced harm." ANR then calls this a "tobacco industry tactic," implying that the electronic cigarette companies are acting in a fraudulent manner.

If the electronic cigarette companies are acting fraudulently, then I guess so am I. If you review my blog, you will find that I referred to what comes out of electronic cigarettes as a vapor until quite recently. It wasn't until several months ago that I learned that it is actually an aerosol rather than a vapor. I wasn't using a tobacco industry tactic; I was simply using the term that was most commonly used, and I was using the term that I believed was correct. I don't have any reason to believe that electronic cigarette companies were doing anything different. Moreover, it is not fraudulent for these companies to try to connote reduced harm. Electronic cigarettes are undeniably less harmful than real cigarettes.

Ironically, while ANR is attacking the electronic cigarettes in general, and Mistic in particular, for spreading "misinformation," the rest of the story is that it is ANR that is spreading the misinformation. Moreover, not only is ANR spreading misinformation, but it is doing so in an intentionally malicious way, while blatantly disregarding the truth.

Were I still on the ANR Executive Board, I would be very concerned about a potential lawsuit. Fortunately, I am no longer on that Board. And it was in anticipation of a problem like this that I resigned. I took my leave from ANR when I learned that the organization cared more about attacking its opponents than about telling the truth. I left when I realized that ANR was not interested in the truth, but was obsessed with smearing its perceived enemies and was willing to use defamatory attacks to achieve this end.

At the end of the day, if you need to lie in order to make your point, it seems to me that you need to go back and reassess your position. I think today would be a good day for ANR to go back to the drawing board.

Thursday, April 10, 2014

New Data from England Suggest that Electronic Cigarettes are Helping to Accelerate Smoking Cessation, Not Hinder It

In contrast to the claims of many anti-smoking advocates, led by Stan Glantz, new evidence from England suggests that electronic cigarettes are helping to accelerate smoking cessation, rather than hinder it.

(See: West R, Brown J, Beard E. Trends in electronic cigarette use in England. Smoking Toolkit Study. London: University College London, April 4, 2014.)

According to this study, the prevalence of electronic cigarette use in England was very low in 2011, but it took off in 2012 and has continued to climb steadily through the first quarter of 2014. The key finding from the study is that the annual rate of smoking cessation (that is, the percentage of current smokers who quit smoking during the past year), which had reached a low of 4.6% in 2011, increased markedly to 6.2% in 2012, 6.1% in 2013, and 8.7% for the first quarter of 2014, concomitant with the dramatic rise in electronic cigarette use among these smokers.

The proliferation of electronic cigarettes in England has also been associated with a dramatic increase in the proportion of smokers who tried to stop in the past year (from 33.5% in 2011 to 40.3% in 2014) and an increase in the success rate for smokers who tried to quit (from 13.7% in 2011 to 21.4% in 2014).

The proliferation of electronic cigarettes was also associated with an acceleration in the decline in smoking prevalence.

Taken together, these data suggest that the widespread use of electronic cigarette among smokers in England has advanced the degree of smoking cessation.

The authors conclude that: 
  • "Evidence does not support the view that electronic cigarettes are undermining motivation to quit or reduction in smoking prevalence"; and
  • "Evidence conflicts with the view that electronic cigarettes are undermining tobacco control or ‘renormalizing’ smoking, and they may be contributing to a reduction in smoking prevalence through increased success at quitting smoking."
The Rest of the Story

Opponents of electronic cigarettes have spent most of their time speculating about the negative impact of these products. They have argued that electronic cigarettes undermine the motivation to quit, normalize smoking, and undermine years of tobacco control efforts. However, a look at the actual scientific evidence suggests that this is not the case at all. Quite the opposite, it appears that electronic cigarettes are enhancing the process of smoking cessation among active smokers.

This evidence needs to be confirmed in other countries, but it does suggest that electronic cigarettes could play a role in helping to facilitate or enhance smoking cessation, rather than detract from it. In contrast to the arguments of opponents, vaping does not appear to renormalize smoking, but to further de-normalize it.

Wednesday, April 09, 2014

Contrary to Claims of Many Anti-Smoking Advocates, New Study Shows that Electronic Cigarettes Decrease Nicotine Addiction

Many anti-smoking groups and advocates have been opposing electronic cigarettes on the grounds that these products perpetuate or even increase nicotine addiction, rather than decreasing it. But a new study presented at the 2014 annual conference of the Society for Research on Nicotine and Tobacco (SRNT) provides evidence that nicotine addiction levels are actually decreased, not increased, in smokers who have switched to electronic cigarettes.

(Jonathan Foulds PhD, Susan Veldheer MS RD, Jessica Yingst, Shari Hrabovsky RN MSN. Comparison of dependence on electronic cigarettes and regular cigarettes in a large sample of e-cig users. Penn State University College of Medicine, Department of Public Health Sciences, Hershey, PA.)

Dr. Foulds and colleagues developed a 10-question scale to assess nicotine dependence and administered it to a sample of 2,368 current electronic cigarette users. Subjects were asked to fill out the scale to assess the level of their addiction while smoking, and then again to assess the level of their current addiction using electronic cigarettes.

The main results were as follows: "In the survey of e-cig users, dependence on e-cigs was significantly lower than it had been on cigarettes (8.6 v 14.9). ... Current e-cig users are significantly less dependent on e-cigs than they were on cigarettes prior to switching."

The Rest of the Story

While the study must be viewed as providing only preliminary evidence and further confirmation is necessary, this is important research because it suggests that contrary to the assertions of many anti-smoking advocates, switching from tobacco cigarettes to electronic cigarettes decreases rather than increases the level of addiction to nicotine. Smokers who make the switch are less addicted and feel better prepared and better able to quit completely.

Since Dr. Foulds' addiction scale correlates significantly with actual quitting behavior, one would expect that these results would eventually translate into higher rates of complete nicotine cessation in smokers who switch to electronic cigarettes.

These results, while preliminary, provide initial evidence that electronic cigarettes may serve not only as a means of helping smokers to quit, but also of helping them to eventually become free of nicotine addiction.

Hopefully, Dr. Foulds and his group will next repeat the study using a sample of dual users (electronic cigarettes and regular cigarettes) to determine whether or not dual users experience a similar reduction in their overall level of smoking addiction.

Tuesday, April 08, 2014

Americans for Nonsmokers' Rights Spreading False Information About Health Effects of Electronic Cigarettes

According to a "fact sheet" on the Americans for Nonsmokers Rights (ANR) web site, short-term use of electronic cigarettes impairs lung function and can cause difficulty breathing:

"Short term use of e-cigarettes has been shown to increase respiratory resistance and impair lung function, which may result in difficulty breathing."

The citation provided to back up this assertion is a study by Vardavas et al. (Vardavas, C.I.; Anagnostopoulos, N.; Kougias, M.; Evangelopoulou, V.; Connolly, G.N.; Behrakis, P.K., "Short-term pulmonary effects of using an electronic cigarette: impact on respiratory flow resistance, impedance, and exhaled nitric oxide," Chest 141(6): 1400-1406, June 2012.).

The Rest of the Story

The rest of the story is this study actually found no effect of electronic cigarette use on pulmonary function tests, indicating that there was no clinically significant observable effect of vaping on lung function. Specifically, the study found "no differences between basic pulmonary measurements" between the two groups, demonstrating that acute exposure to electronic cigarette vapor did not affect FEV1, FVC, PEF or MEF50 and MEF75."

In contrast to what ANR is stating, the study found no effect of e-cigarettes on lung function, as measured by spirometry. This is in contrast to tobacco smoking, which does have effects on lung function that can be measured using spirometric testing. While previous research indicates that active smoking and even secondhand smoke exposure can affect acute lung function as measured by spirometry, the study demonstrated that electronic cigarette use led to no impairment of lung function detectable via spirometric testing.

What the study did show was subclinical evidence of impaired lung function, meaning that the observed (measurable) lung function was unchanged, but that there was evidence of physiologic effects consistent with some bronchial inflammation. What is not known is whether this acute bronchial inflammation has any significance in the long-term. The presence of bronchial inflammation may be a result of propylene glycol having a respiratory irritant effect. But this does not necessarily mean that long-term exposure would lead to any adverse effect on lung function. More research is necessary to clarify that point.

The authors acknowledge this: "We must state though that while the differences within our study are of statistical significance, the clinical changes may be too small to be of major clinical importance."

Despite this, ANR tells the public not only that vaping impairs acute lung function, but that it can cause difficulty breathing. This is an outright lie. There is absolutely no evidence that vaping causes clinical respiratory impairment to an extent that leads to difficulty breathing. In fact, the available evidence overwhelmingly demonstrates that smokers who switch to electronic cigarettes experience a marked improvement in their respiratory symptoms.

Unfortunately, ANR is so determined to attack electronic cigarette use that it has abandoned scientific integrity and is spreading misinformation to the public. While ANR has every right to advocate against the use of electronic cigarettes, it should not do so based on false and misleading information.

The reason I resigned from the ANR Executive Board was that the organization told me that it placed a higher value on its political objectives than on scientific integrity. This story illustrates that ANR continues to operate on this unethical strategy.

Monday, April 07, 2014

Americans for Nonsmokers' Rights Disseminating Misleading and Potentially Defamatory Statements About Electronic Cigarette Groups

In a document entitled "Electronic Cigarettes: Advocacy and Research Updates," and an accompanying "fact" sheet, Americans for Nonsmokers' Rights (ANR) insinuates that all electronic cigarette companies are actually owned by Big Tobacco, that several e-cigarette trade associations/lobbying groups are actually tobacco industry front groups, and that Mistic E-Cigarettes specifically is owned by a tobacco company.

Here are the three claims, an analysis of what they insinuate to the public, and an explanation of why they are false, misleading, and potentially defamatory:

1. "E-cigarette companies ARE tobacco companies!" (capitalization and exclamation point are original to the document)

This statement insinuates that all electronic cigarette companies are tobacco companies. Had ANR wished to convey the assertion that some e-cigarette companies are tobacco companies, it could and should have stated: "Some e-cigarette companies are tobacco companies." The omission of the word "some," along with the capitaliation of the word ARE and the exclamation point at the end of the claim combine to construe to the reader that all e-cigarette companies are tobacco companies; that is, that they are one and the same.

This assertion is demonstrably false. While it is true that there are a total of about seven e-cigarette brands that are owned by Big Tobacco, the overwhelming majority of electronic cigarette companies have nothing to do with tobacco companies. There are estimated to be more than 250 e-cigarette brands on the market. Therefore, the overwhelming majority of electronic cigarette companies are completely independent from tobacco companies.

2. "Remember the National Smokers Alliance, Philip Morris' phony grassroots network? How about all those "studies" looking at public support for or economic impact of smokefree laws? They're back: There are three national e-cigarette "trade associations" one of which, Smoke Free Air Trade Association (SFATA), has several board members with ties to Big Tobacco. Also, two new statewide front groups, Oklahoma Vapors Advocacy League (OVAL) and Iowans for Alternatives to Smoking and Tobacco (IAST), have popped up and are providing testimony in favor of e-cigarette use. A lobbyist for IAST has also lobbied for Philip Morris."

This statement insinutates that like the National Smokers Alliance, the Smoke Free Alternatives Trade Association (SFATA), Oklahoma Vapors Advocacy League (OVAL) and Iowans for Alternatives to Smoking and Tobacco (IAST) are actually Big Tobacco front groups. The statement emphasizes the ties of two of SFATA's Board members to Big Tobacco, as well as the fact that a lobbyist for IAST has lobbied for Philip Morris. Thus, the insinuation is that these are all Big Tobacco front groups and they are not being honest about their true funding from tobacco companies.

This assertion is very misleading, if not outright false. All of these groups readily acknowledge that they are trade associations whose members are electronic cigarette manufacturers or retailers. Moreover, none of these groups, to the best of my knowledge, is funded by Big Tobacco. They are independent trade associations that were organized by and are run by electronic cigarette companies or retailers, not by tobacco companies. 

3. "A recent survey conducted by Harris Decima, a Harris Interactive company, for Mistic e- cigarettes purports to document public support for use of e-cigarettes in in a variety of places, including airplanes, workplaces, sporting events, restaurants and bars, and more. But the survey should be looked at skeptically, inasmuch as, historically, research funded by the tobacco industry tends to yield results favorable to the industry's position. One only needs to refer to the landmark Department of Justice case against the tobacco companies to know their history of disseminating misinformation designed to protect industry profits."
This statement insinuates that Mistic is a tobacco company. The statement refers to the survey as "research funded by the tobacco industry" and reminds readers of the history of the dissemination of misinformation by "the tobacco companies." I read this as a clear assertion that Mistic is a tobacco company, or owned by a tobacco company.

To the best of my knowledge, this assertion is false. I do not believe that Mistic is a tobacco company. I believe that Mistic is an electronic cigarette company, and I do not believe that Mistic is owned by any tobacco company. Thus, I believe that this accusation is false.

Because ANR is falsely accusing Mistic of being part of Big Tobacco, I am afraid that ANR is making a potentially defamatory statement. The false accusation appears to be malicious, as it ties Mistic to the historical fraud and conspiracy for which the tobacco companies were found guilty in the Department of Justice lawsuit. The accusation also appears to represent a blatant disregard for the truth, since there is absolutely no reason to even think that Mistic is owned by Big Tobacco, and because ANR does not list Mistic in its list of e-cigarette brands that are owned by tobacco companies. Thus, it appears that ANR is aware that Mistic is just an independent e-cigarette company.

The Rest of the Story

I am very familiar with the tactics of ANR because I served on the ANR Executive Board for several years. The reason I resigned from the ANR Executive Board was that they told me they were more concerned with the political impact of their statements than worrying about whether their statements might be defamatory. Thus, the potentially defamatory statements that ANR is currently making about electronic cigarette companies and groups appear to be in line with its long-standing philosophy of using unethical tactics to smear, attack, and defame what it views to be its enemies.

Although I agree with most of the overall goals of ANR in terms of reducing the public's exposure to secondhand smoke, I denounce its tactics of disseminating false and misleading information to the public and especially, trying to smear its declared enemies with false, misleading, and defamatory attacks.

Thursday, April 03, 2014

As Calls to Poison Control Centers Increase, FDA Still Hasn't Released Electronic Cigarette Regulations

It seems as though we have been waiting for years for the FDA to finally release its proposed regulations for electronic cigarettes. It is not clear to me what has taken so long. But the need for these regulations is great.

The problems caused by the FDA's dragging its feet are highlighted by today's CDC report showing that calls to poison control centers related to exposure to nicotine contained in e-cigarette liquids have increased dramatically and have reached a level of 215 calls per month nationally.

According to CDC director Dr. Tom Frieden: "E-cigarette liquids as currently sold are a threat to small children because they are not required to be childproof, and they come in candy and fruit flavors that are appealing to children."

An earlier study noted that e-cigarette cartridges for some brands may leak, which may lead to nicotine exposure.

The CDC concludes that: "Health care providers, e-cigarette companies and distributors, and the general public need to be aware of this potential health risk from e-cigarettes."

The CDC also recommends that: "Developing strategies to monitor and prevent future poisonings is critical given the rapid increase in e-cigarette related poisonings."

The Rest of the Story

There is no magic in figuring out a way to prevent future poisonings. Basic quality control and child safety standards are necessary, and the FDA is the government agency with the ability to promulgate these regulations. The problem is that the FDA, for a reason that is not apparent to me, has still not released its proposed regulations.

Several quality control and child safety standards are critical:

1. All e-cigarette liquids should be packaged in childproof containers.
2. Quality control methods need to be put in place to ensure that e-liquid containers or cartridges do not leak.
3. E-cigarettes should have warning labels noting that they must be kept away from children and that care must be taken because of the presence of nicotine in the e-liquids, which could be harmful to children if touched, ingested, or inhaled.

No advanced engineering practices are necessary to accomplish this simple task. 

In addition, a very simple but critical step that the FDA needs to take is to regulate battery safety. There is no need for batteries that exploded. Overcharge protection does not take rocket science.

The rest of the story is that the FDA has spent so much time trying to take e-cigarettes off the market that it has delayed action on the most important measure it could take to protect the public's health: adopting basic quality control and manufacturing standards for e-cigarettes.

With more than 250 brands on the market, consumers need to know that any brand they purchase meets certain basic quality control and safety standards. They need to know that the amount of nicotine on the cartridge labels are accurate, that the battery will not explode, and that the e-liquids are in childproof containers that will not leak.

There is no political challenge in promulgating such regulations. No one opposes such safety and quality control standards.

So what is the FDA waiting for?

I recognize that the FDA was initially not well-equipped to deal with this issue and that there is a steep learning curve associated with becoming familiar with these products. However, organizations such as the American E-Liquid Manufacturing Standards Association (AEMSA) have developed standards that the FDA could easily adapt. These standards include childproof caps, tamper evident packaging, safety and health warnings, vendor age verification, nicotine quality standards, and nicotine level verification.

I also understand that the FDA is not comfortable commenting on the content of pending regulations or substantive issues such as why OMB failed to approve the draft regulations. However, I'm aware of no law or principle that would preclude the FDA from simply announcing the anticipated date on which the regulations will be released. I'd settle for the month. Or even the year.

Tuesday, April 01, 2014

Policy Makers Respond to Concerns About Hazards of Touching Chairs in Restaurants

In response to the public warning issued recently by a prominent tobacco control researcher about the health hazards associated with touching chairs, city councils are beginning to take action to protect the health of the public.

According to Dr. Jonathan Samet, who is director of the USC Institute for Global Health and a member of TPSAC as well as a senior scientific editor of several U.S. Surgeon General's reports, touching a chair in a room where vaping has occurred could be a health hazard, as the nicotine in exhaled air from a vaper could contaminate the chair and the nicotine could then be absorbed through the skin if someone touches the chair.

According to an article in the Pasadena Star-News, Dr. Samet was quoted as stating: "There have been two reasons to handle e-cigs the same as combustible products. People would be exposed to the nicotine in the air, so the vapor could settle on people. It could contaminate the air that they breathe. It could contaminate a chair, and they could touch it and nicotine can go through the skin."

Alarmed by the danger to the public posed by finger or hand contact with chairs, the Farmville Town Council last night considered an ordinance which would require 75% of seating in all restaurants to be chair-free. As an initial attempt to protect the public from this newly recognized health hazard, town selectmen voted to exempt bars from the ordinance. However, all restaurants and other food service establishments that derive no more than 50% of their revenues from alcohol would be subject to the proposed law.

While the ordinance requires a second reading before it becomes law, the initial 8-1 vote of the council suggests that the chances of adoption are high.

The ordinance requires that 75% of the seating capacity of all restaurants be free of chairs that contain any type of upholstery that can absorb nicotine. Specifically, the proposed ordinance bans chairs covered with the following materials: cotton, cotton blend, wool, linen, silk, nylon, polyester, rayon, and olefin. Allowed chair coverings are: wood, leather, acrylic, and acetate. Wooden chairs, benches, and booths are fully allowed in the 75% restricted seating areas.

Reaction to the proposed ordinance was generally positive.

Joe Greene, the owner of the Emerald Valley Grille, was ecstatic about the proposal. "We are basically a pizza joint, and all of our existing seating consists of wooden benches," Greene said. "We wouldn't have to make any changes to comply with this law and if they decide to extend it in the future to a 100% ban, we are poised and ready to go. We won't have to spend a penny to be in full compliance."

All three Japanese restaurants in Farmville were pleased with the ordinance, as they offer traditional Japanese seating with no chairs. Customers sit on pillows on the floor, so no costs will be incurred by these establishments to comply with the ordinance.

One business owner who was not pleased with the proposal was Mary Redford of the Lighthouse Cove Steak House. She complained that "we just spent $30,000 to re-upholster all of our chairs and now we find out that it is all for nothing." Redford urged the council to consider a grandfather clause or an economic hardship exemption, but councilmembers did not appear to be sympathetic to her position.

"This is a serious public health issue," said Health Committee chair Dr. Joseph Timilty. "According to a most reputable source - a senior scientific editor of the esteemed Surgeon General's report on smoking - use of electronic cigarettes in restaurants contaminates the air with high levels of nicotine which settles on chair upholstery and then gets absorbed through the skin if someone touches the chair. It only takes 60 milligrams of nicotine to kill someone and even less for a child. We just can't take chances."

Dr. Timilty's views were shared by several other councilmembers, including Rose Schafer, a respiratory therapist at the Sweet Acres Hospital. Schafer stated that "nicotine on chair upholstery combines with chemicals in the air to form carcinogens and we know that there is no safe level of exposure to carcinogens." Schafer cited recent research out of UC Riverside showing that absorbing chemicals from upholstery can be more hazardous than smoking.

One Farmville resident who testified against the ordinance was Jonathan Schiff, owner of Home Farm Custom Upholstery, who expressed concern that he could go out of business if this ordinance is enacted. He was followed, however, by Joe Smith of Celestial Pastures Woodworking, who admitted that he stands to gain financially as restaurants re-outfit their seating to comply with the ordinance.

Susan Jefferson, president of a new group that calls itself "Citizens to Preserve our Freedom," argued that restaurant customers already have a choice. "Anyone who wants to avoid contact with an upholstered chair can easily do so. Why intrude upon the rights of the rest of us?" she asked the council.

Jefferson's testimony was attacked by councilmember Stu Peters, who claimed that "Citizens to Preserve our Freedom" is actually a front group funded almost entirely by the Upholstery Fabric Foundation, a trade association dominated by companies that produce chair fabrics, including brocade, chenille, chintz, cotton, crewel, damask, flame stitch, gingham, linen, mohare, silk, toile, velvet, and wool.

The second reading of the ordinance, and a final vote, will occur next Thursday at the Enchanted Glen Community Center.

Touching a Chair in a Restaurant Could Be Hazardous to Your Health if Vaping is Allowed, According to Tobacco Control Researcher

We've all heard of vaping. And most of us have heard of secondhand vaping (being exposed to air in a room where others are vaping). Now, a tobacco control researcher and member of TPSAC (the FDA's Tobacco Products Scientific Advisory Committee) is warning the public of the dangers of thirdhand vaping (touching a chair in a room where vaping has occurred).

According to Dr. Jonathan Samet, who is director of the USC Institute for Global Health and a member of TPSAC, touching a chair in a room where vaping has occurred could be a health hazard, as the nicotine in exhaled air from a vaper could contaminate the chair and the nicotine could then be absorbed through the skin if someone touches the chair.

According to an article in the Pasadena Star-News, Dr. Samet was quoted as stating: "There have been two reasons to handle e-cigs the same as combustible products. People would be exposed to the nicotine in the air, so the vapor could settle on people. It could contaminate the air that they breathe. It could contaminate a chair, and they could touch it and nicotine can go through the skin."

The Rest of the Story

This is the sort of hysterical nonsense that now passes for science in the tobacco control movement.

Dr. Samet was a senior editor of the Surgeon General's report. And now he is telling the public that they could be harmed by absorbing nicotine from a chair located in a room where vaping has occurred.

Based on the most conservative (i.e., the highest) existing estimates of the level of nicotine produced by vaping, the amount of nicotine inhaled by a bystander after 8 straight hours of exposure to a full room of vapers in a bar is only 0.08 cigarette equivalents. In order to inhale the equivalent amount of nicotine that would be inhaled by actively smoking one cigarette, a bystander would have to spend 12 days in a bar filled with e-cigarette vapor, at continuous exposure levels.

Despite these data, Dr. Samet would have us believe that nicotine exposure levels due to secondhand vaping are high enough to cause substantial enough contamination of chairs so that a mere human touch of the chair could result in hazardous nicotine absorption.

This is ludicrous. There is simply no way that touching a chair in a room where vaping is occurring poses a substantial health risk.

But here's the problem: if we can't trust someone like Dr. Samet to make credible statements regarding the health risks of thirdhand vaping, how can we trust statements he makes about other important tobacco-related health risks? How can we trust the Surgeon General's reports that he oversees? How can we trust the scientific judgment of the Tobacco Products Scientific Advisory Committee?

While as a scientist, I can discriminate carefully between this hysterical and ludicrous pronouncement by Dr. Samet about the danger of touching a chair and the well-established conclusions that he put out in the 2006 Surgeon General's report, it is much less straightforward for the general public to make such judgments. This example of shoddy science unfortunately contaminates all of our scientific pronouncements and risks undermining our credibility.

With more than 400,000 Americans dying each year from smoking, Dr. Samet is actually worrying about the possibility that some Americans might touch a chair? Is this what the science in the tobacco control movement has come to?

Monday, March 31, 2014

Laboratory Study Shows No Detectable Carcinogens or Metals in High-Technology Electronic Cigarette Brand, Suggests that Minimal Risk E-Cigarette is Technologically Feasible

A laboratory study presented last week at the annual meeting of the Society of Toxicology provides important new evidence that electronic cigarettes have the potential to deliver nicotine with a high degree of relative safety. Specifically, the study reports that a high-technology brand of electronic cigarette (VUSE) delivers an aerosol that has no detectable carcinogens or metals - compounds that were of concern in a number of other e-cigarette brands.

(See: Theophilus EH, et al. VUSE electronic cigarette aerosol characterization (poster). Presented at the Annual Meeting of the Society of Toxicology, March 24-27, 2014.)

In the study, researchers from R.J. Reynolds Tobacco Company and the Eurofins-Lancaster Laboratories in Winston-Salem examined the constituents in the aerosol produced by VUSE electronic cigarettes. Of particular concern were a number of carcinogens, metals, and volatile compounds found in previous studies of different electronic cigarette brands. The study chromatigraphically profiled the chemical constituents of VUSE aerosol.

Among the compounds specifically examined were the following:

Tobacco-specific nitrosamines



Volatile Organic Compounds
Propylene oxide
Vinyl chloride

Poly-aromatic amines

Poly-aromatic hydrocarbons


The study reported that none of the above chemicals were detected: all were below the limit of detection or limit of quantification of the laboratory methods used. In contrast, most of these compounds were detected in tobacco cigarettes.

The study concluded that the composition of VUSE aerosol is much less complex than that of tobacco smoke, that the main compounds detected are those predicted to be present (i.e., those present in the e-liquid), and that none of the toxicants of specific concern were detectable in the electronic cigarette aerosol.

The Rest of the Story

This research is important because it suggests that it is technologically possible to produce an electronic cigarette that delivers nicotine with an excipient, but essentially without any other toxic or carcinogenic chemicals. How R.J. Reynolds is able to avoid the hydrolysis products of propylene glycol is not clear. Perhaps it is related to the quality of the heating mechanism and/or the temperature regulation. The avoidance of metal contamination may have to do simply with the quality of the manufacturing process. At any rate, this is an important study because it suggests the great promise of the electronic cigarette as perhaps the most important smoking cessation product of the future.

Of course, this is only a study of one brand of electronic cigarette. But it shows what is technologically possible. I believe that one of the FDA's priorities in regulating these products should be to discover and articulate the specific manufacturing processes or features that allow nicotine to be delivered in as clean a fashion as VUSE appears to deliver it. Quality assurance and quality control standards should be the centerpiece, I believe, of the FDA's regulation of electronic cigarettes, rather than strict regulation of these devices in a manner similar to that of tobacco cigarettes.

While we still don't know the effects of long-term inhalation of propylene glycol, this study suggests that outside of the nicotine, VUSE poses minimal health risks. Obviously, this research helps to confirm that VUSE is much safer than tobacco cigarettes.

It is also important to note that this study also suggests that "secondhand" exposure to VUSE e-cigarettes is unlikely to pose any substantial health risks.

This research should cause tobacco control practitioners to embrace electronic cigarettes as a promising device that could permanently alter the nature of the combustible tobacco product space, potentially saving more lives than any previous smoking cessation product. We have a long way to go, but embracing the promise of these products and committing to use our public resources and policies to maximize the benefits while minimizing the risks of these products is the first step.

Monday, March 24, 2014

New Study on Electronic Cigarettes by UCSF Researchers is Not Only Bogus Science, But is Also Dishonest

Researchers from the Center for Tobacco Control Research and Education at UCSF have published a research letter in JAMA Internal Medicine which purports to show that electronic cigarettes are ineffective for smoking cessation.

(See: Grana RA, Popova L, Ling PM. A longitudinal analysis of electronic cigarettes use and smoking cessation. JAMA Internal Medicine. Published online March 24, 2014. doi:10.1001/jamainternmed.2014.187.)

The study involves a survey of 949 adult smokers who were interviewed at baseline in 2011 and followed up one year later. Of these smokers, at baseline, 88 had tried electronic cigarettes in the past month (that is, they had used electronic cigarettes at least once).

The study reports that at one year follow-up, the rate of smoking cessation among the baseline non-e-cigarette users was 13.8%, compared to 10.2% for the 88 electronic cigarette users, a difference that was not statistically significant. On this basis, the study concludes that electronic cigarettes are not effective for smoking cessation.

The authors write: "Consistent with the only other longitudinal population-level study with 1-year follow-up that we are aware of, we found that e-cigarette use by smokers was not followed by greater rates of quitting or by reduction in cigarette consumption 1 year later."

They conclude that "our data add to the current evidence that e-cigarettes may not increase rates of smoking cessation."

The Rest of the Story

I'm sad to say that this is complete garbage.

It is truly an example of bogus, or junk science.

Why? Because the study does not examine the rate of successful smoking cessation among electronic cigarette users who want to quit smoking or cut down substantially on the amount that they smoke and who are using e-cigarettes in an attempt to accomplish this.

Instead, the study examines the percentage of quitting among all smokers who have ever tried electronic cigarettes - for any reason - in the past month.

A large proportion of the 88 smokers who had tried an e-cigarette may have simply been trying these products to see what they are like. It is plausible, in fact probable, that many of these 88 smokers were not actually interested in quitting or trying to quit with electronic cigarettes. These products have become very popular and have gained widespread media attention and it is entirely possible that many of these smokers simply wanted to see what the big fuss is all about.

It is easy to see how this fatal flaw in the research destroys the validity of the authors' conclusion.

But that isn't the end of the story. If this were simply a bogus conclusion, then we could simply evaluate the article as being junk science, dismiss it as bogus, and leave it there. But unfortunately, it doesn't end there.

Why? Because it is quite apparent from the study itself that the authors knew that the overwhelming majority of the 88 electronic cigarettes "users" in their study had little or no interest in quitting and were not using these products as part of a quit attempt.

How do we know this? Because the authors tell us!

In the Table, the authors report that of the 88 e-cigarette "users," only 8.0% reported that they were trying to quit at that time (that is, within the next 30 days). And only 39.8% of the e-cigarette users had any intention of quitting in the next six months. This means that we actually know for a fact that the majority of e-cigarette users in this study were not using these products as part of a quit attempt.

What this indicates is that this is not simply junk science. Rather, it is a deliberate attempt on the part of the investigators to misuse data. They are using these data to draw a conclusion about whether electronic cigarettes are effective in helping smokers quit, yet they are knowingly drawing upon data from smokers who are using e-cigarettes for other reasons, who may have simply tried an electronic cigarette once, and who most definitely were not using these products as part of a current quit attempt.

In other words, 92% of the e-cigarette users in the study were not trying to quit. We know for a fact that 92% of the e-cigarette users were not making a quit attempt. And yet the study authors interpret the data as if these smokers were trying to quit using e-cigarettes, but failed!

This is dishonesty in research.

Unfortunately, it does not appear that these investigators are truly interested in whether e-cigarettes help many smokers quit or not. Instead, I believe that these researchers have a pre-determined conclusion that e-cigarettes are ineffective and that they are trying to manufacture results that support their pre-determined conclusion.

It would be a tragedy if policy makers use the conclusions of this "study" to draw conclusions about the effectiveness of electronic cigarettes for smoking cessation purposes.

Another Tobacco Control Practitioner Tells Public that Smoking May Be No More Harmful than Vaping

Adding to the long list of tobacco control practitioners who have publicly declared that smoking may be no more harmful than vaping - which involves no tobacco and no combustion - a South Carolina respiratory therapist is telling patients that they should not quit smoking using electronic cigarettes because these devices may be more dangerous than tobacco cigarettes, which kills more than 400,000 Americans each year.

On the Greenville Health System blog, a respiratory therapist writes: "I strongly oppose the use of e-cigarettes. It is unregulated and could potentially be more dangerous than a regular cigarette."

This respiratory therapist misleadingly reports that: "emergency rooms across the United States have been reporting visits from patients that use e-cigarettes, with a variety of complaints, including blood clots, difficulty breathing, coughing, headaches and chest pain." But he fails to also mention that emergency rooms across the nation have also been reporting visits from patients who use NRT, with a variety of complaints that include blood clots, difficulty breathing, coughing, headaches and chest pain.

Moreover, he fails to report that emergency rooms across the nation have also been reporting suicides and attempted suicides from the use of Chantix.

The Rest of the Story

This irresponsible advice, supported by a fraudulent lie - that smoking may be safer than vaping - represents public health malpractice, in my opinion. In fact, as it may convince some smokers to continue smoking rather than switch to a non-tobacco product that has helped thousands quit smoking, it could actually constitute medical malpractice, as this negligent information and advice could actually lead to medical harm.

Why is it negligent? Because it deviates from a well-accepted standard of care in medical and respiratory therapy practice, which is telling the truth. By disseminating false information - that smoking may be no more hazardous than vaping - to patients, this could lead to medical harm by convincing smokers not to quit via electronic cigarettes, but based on false information.

It is certainly not medical malpractice to advise patients not to use electronic cigarettes, because these products are not yet the standard of care in medical treatment for smoking dependence. However, to tell patients not to use electronic cigarettes because they may be more dangerous than cigarettes is clearly negligent, and in my opinion it rises to the level of malpractice if it ends up causing medical harm (i.e., a smoker who is misled by this advice and decides not to quit smoking because of the advice).

But beyond the issue of medical or public health malpractice, I am most concerned about the simple principle of honesty. As medical and health professionals, our very first obligation is to be truthful with our patients and with the public. The information being provided by this respiratory therapist is untruthful. It is simply not the case that smoking may be less hazardous than vaping. There is no credible scientific debate about that issue in the year 2014.

Thursday, March 20, 2014

Exactly 44% of Kids Who Start Smoking Do So Because of Smoking in Movies

Not that our science allows us to be precise to the percentage point, but the American Legacy Foundation has publicly claimed that exactly 44% of kids who start smoking do so because of having seen smoking in the movies.

The claim is made in a press release entitled "44 Percent of Adolescents Who Start Smoking Do So Because Of Smoking Images They Have Seen In The Movies."

According to the press release: "As viewers around the world prepare to tune in for Sunday's 86th annual Academy Awards honoring achievements in the film industry, the public health community is drawing attention to new data concluding that by eliminating tobacco imagery in youth-rated movies, youth smoking rates could decline by an estimated 18 percent. Incidents of smoking in youth-rated films have doubled between 2010 and 2012, returning to levels of a decade ago. In fact, according to Thumbs Up! Thumbs Down! two of the three PG-13 movies (Captain Phillips, Philomena) that are nominated for Best Picture this year include smoking. Large-scale studies have demonstrated that movies with smoking cause youth to start smoking, and this rebound represents a set-back for national youth tobacco prevention goals. According to research funded by Legacy, in 2013 youth-rated movies delivered an estimated 14.8 billion tobacco impressions to theater audiences, a 169 percent increase from 2010."

The Rest of the Story

The major problem with this claim is that exposure to smoking in movies is likely to represent a proxy measure for a wider constellation of media-related exposures to smoking that likely all contribute to the smoking initiation process. These include magazine advertising, outdoor advertising (especially on the exterior of stores and point-of-sale advertising within stores), exposure to smoking on television, in music videos, video games, the internet, etc.

The studies upon which the 44% figure is derived did not produce a comprehensive picture of each youth's exposure to smoking in all media and then isolate the impact of smoking in movies. In fact, these studies simply compared smoking initiation between youth with differing levels of exposure to smoking in movies.

Therefore, I don't think it is valid to isolate the specific impact of exposure to smoking in movies and claim that this exposure alone is the cause of youth smoking in these 44% of youth smoking cases. It is likely that a much wider array of exposures is contributing to the initiation process. Exposure to smoking in movies may certainly be one of them, but it is not the only one, and I do not believe that from the underlying studies, which didn't measure any of these other exposures, one can tease out the smoking in movies and claim that it is the precise (and sufficient) cause of the observed smoking behavior.

Why is this important? After all, couldn't one argue that since the ultimate effect of this research and any resulting policy action will be to reduce exposure to smoking and decrease smoking (albeit by a lower amount than 44%), it is ultimately not a problem?

I think it is a problem, however, for two reasons.

First, I think that despite all this scientific work being for a great cause, it ultimately hurts the science base for tobacco control in general to have specific claims being made from studies that do not support those claims. It is only an observation, but it certainly seems to me that the rigor required before we start making these kinds of precise quantitative claims has decreased over the years in which I have been doing research in this field. Ultimately, I guess that I am concerned somewhat about the credibility of tobacco control research findings among the public if they are continually exposed to these types of quantitative claims being made from research designs that are simply not "designed" to produce such claims.

Second, if, for the reasons I have outlined above, the claim is an overestimate, then we will fail to see the expected decline in youth smoking if we do address the problem definitively. So even if we were to ban all smoking in movies tomorrow, I very much doubt that we would subsequently see a 44% reduction in youth smoking initiation.

In fact, there is evidence to support this contention. After all, the Legacy press release claims that there was a doubling of youth exposure to smoking in youth-rated movies between 2010 and 2012. Further, there was a 169% increase in tobacco impressions in youth-rated movies between 2010 and 2013.

If it were true that smoking in movies is responsible for 44% of youth smoking initiation, then certainly we would have expected to see an increase in smoking initiation over the past three years, concurrent with this drastic increase in smoking in movies. However, the opposite is the case. Smoking among youth is now at an all-time low. It has declined significantly, rather than increased drastically, during the past three years.

These data hardly seem consistent with the claim that smoking in movies - alone - is responsible for 44% of youth smoking initiation.

An even more significant problem is that of confounding. Youths do not randomly choose to watch or not watch films that are likely to show lots of smoking. Some of the factors that predict what movies a youth is likely to view are also likely to predict their risk of smoking initiation. It is difficult to identify, much less quantify and measure these variables, and the existing studies have controlled for a few potential confounders, but not for many of them.

For these reasons, I think it is scientifically unsupportable for the American Legacy Foundation to claim that 44% of all smoking initiation is caused by exposure to smoking in movies.

Does smoking in movies contribute towards media exposure that influences youth smoking?


Should we take efforts to reduce youth exposure to smoking in movies and other media?


But I don't think we do ourselves any favors when we go beyond the science and make sweeping, yet quantitatively precise claims like this one from Legacy. Ultimately, it hurts our scientific credibility and undermines the integrity of our work.

Wednesday, March 19, 2014

New Hampshire Public Radio - The Exchange Segment on Electronic Cigarettes and Smoking

Yesterday, The Exchange segment on New Hampshire Public Radio featured a detailed discussion of electronic cigarettes and smoking. If you listen, you'll hear a great example of the typical public health perspective on this issue, along with my arguments against that perspective.

Tuesday, March 18, 2014

Tobacco Control Science Deteriorating to an All-Time Low

Just days after Stan Glantz told the public that his cross-sectional study, which was unable to determine whether youths who use e-cigarettes go on to start smoking or whether smokers are more likely to try e-cigarettes, proves that e-cigarettes are a gateway to a lifetime of smoking addiction, researchers from elsewhere at the University of California are telling the public, based solely on mouse studies, that thirdhand smoke is as harmful as active smoking.

According to an article at Liberty Voice, thirdhand smoke is as deadly as smoking. In other words, if you sit in a room where people have smoked, you might as well be a smoker yourself.

This conclusion comes, by the way, purely from mouse studies in which mice treated with thirdhand smoke in controlled experiments experienced impaired wound healing and other forms of cell damage. Not a single human, clinical study was performed by these researchers to support their conclusion that thirdhand smoke exposure is every bit as bad as active smoking.

According to the article: "Studies are now showing the dangers of smoking, not just that of first and second-hand smoke, but the dangers presented by third-hand smoke. It is that sticky substance that is left behind on the walls, furniture, toys and surfaces after someone smokes indoors. ... The latest research, funded by the Tobacco-Related Disease Research Program, was published by the American Chemical Society on March 16. It states that young children are at high risk when they put toys in their mouth that have been exposed to third-hand smoke. It actually causes DNA damage and poses a risk for developing cancer." ...

"In another recent study, conducted by the University of California and published in PLOS ONE, researchers found that third-hand smoke is dangerous to the lungs and liver, possibly due to inflammation. They also found that it leads to type II diabetes, even when patients are not overweight or obese. Furthermore, they discovered that, while studying mice in a controlled environment, wounds on the skin did not heal as quickly. They determined that the collagen had been damaged. The study claims that third-hand smoke is as big a danger and just as deadly as smoking itself."

The Rest of the Story

The rest of the story is that this is complete garbage.

It is truly depressing to me to watch this - day in and day out.

When the tobacco industry decided - sometime back around 2000 or so - to stop monitoring tobacco control science and to just let us say anything we wanted to - I thought they had made a poor decision. But in retrospect, I think it may have been brilliant. They apparently knew that before long, without the restraints of having to answer to Big Tobacco's public questioning, our science would deteriorate and we would just start saying anything we wanted to. Unrestrained, the tobacco control movement's scientific rigor would fall to such a low level that we would end up discrediting ourselves and undermining our own credibility.

Well, we're there. We're officially there.

I'm sure I'll have more to say about this later. But for now, I'm just too damn depressed.

Monday, March 17, 2014

Daly City Mayor Wants to Shut Down Shops that Sell E-Cigarettes, Keep those that Sell Real Cigarettes

In a move that could not be more favorable to the cigarette industry in Daly City, California, the city's mayor wants to ban vape shops that sell electronic cigarettes which are being used by many Daly City smokers to quit smoking or cut down substantially on the amount they smoke, while allowing the city's 85 cigarette stores to continue selling those deadly products.

Ironically, Mayor Canepa wants to close up shop for stores which are arguably selling a product that deters consumers from using toxic tobacco cigarettes, while at the same time, protecting existing stores from this competition and allowing them to continue selling their deadly cigarettes to Daly City smokers, which according to recent data, include children, who were able to buy cigarettes at one out of every four Daly City cigarette stores.

In fact, 96% of residents of Daly City believe that it is far too easy for kids in Daly City to purchase cigarettes. Thus, the logical action taken by the Mayor was which of the following:

A. Crack down on the sale of cigarettes to minors in Daly City
B. Eliminate the sale of cigarettes in Daly City
C. Decrease the number of stores allowed to sell cigarettes in Daly City
D. Ban vape shops which sell cigarettes to zero youths in Daly City.

The answer, sadly, is D - ban vape shops which sell cigarettes to zero youth in Daly City. Moreover, youths are not even allowed in these vape shops and it would be quite easy to adopt rules to ensure that youths do not have access to these stores.

Congratulations to Mayor Canepa, for making an early bid for the 2014 Colonel Benjamin Church Anti-Smoking Hypocrisy Award.

Friday, March 14, 2014

Cease and Desist: Clive Bates Tells Glantz to Stop Misrepresenting His Research on E-Cigarettes

On his wonderful science and advocacy blog, tobacco control practitioner and former director of Action on Smoking and Health (ASH-UK) Clive Bates issues a cease and desist order: an open letter to Stan Glantz urging him to discontinue the misrepresentation of his research to spread false and unsupported information about electronic cigarettes being a gateway to cigarette smoking.

The letter picks up on many of the precise points that I have been arguing during the past few weeks: post 1; post 2; post 3.

Clive's letter begins as follows:

"Dear Professor Glantz, Dr. Dutra:

Misleading use of survey data has no place in professional public health practice
I had intended to blog about your recent paper, but decided instead to write an open letter and to put these concerns to you directly. So, I write to express dismay at the false, misleading and damaging conclusions you have drawn from your recent paper in JAMA Pediatrics and related media communications. The errors of reasoning are elementary, but have been used to draw conclusions that are relentlessly hostile to e-cigarettes and the important public health concept of ‘tobacco harm reduction’.  

It should be stressed that misleading information in this arena can cause actual harm to real people if they react to misplaced concerns in ways that cause them to continue to smoke. Further dangers arise as physicians and other trusted professionals give bad advice based on false information. Finally, there is the danger that policy-makers and legislators will be misled into making excessively restrictive regulations that protect cigarette sales from competition from much safer and better alternatives.  I believe your study and the subsequent media work owe more to misguided activism than to responsible academic investigation, and as such they have no place in professional public health practice or a reputable university."

Clive goes on to cite two specific examples of conclusions that Glantz disseminated to the public which were not supported by his own research.

First, he cites the JAMA Pediatrics article in which Glantz and Dutra conclude that electronic cigarettes are exaggerating, rather than ameliorating smoking among youth. Clive writes: "somehow you have managed to position this study as showing there is a gateway from e-cigarette use to smoking. NOTHING in the study or the underlying data suggests this.  You would need information on how smoking, e-cigarette use and abstinence evolved over time to test these hypotheses, but your study does not have that."

Second, he cites the press release from that study, which opened with the admonition that electronic cigarettes are a gateway to smoking. Clive writes: "There is no basis for drawing this unequivocal ‘gateway’ conclusion from the data presented in the study.  None whatsoever – and the published study even makes this clear. In fact the data are consistent with the opposite hypothesis – that e-cigarettes are primarily used by smokers interested in quitting or cutting down. Indeed the observation  that users have a higher intention to quit smoking lends support to that hypothesis more than to your preferred explanation."

Clive further shows how the misguided headlines created by Glantz have already led to public policy makers being misled by this misrepresentation of the science.

The letter concludes: "I really hope you will reconsider your approach – it does not serve public health or the public interest. It is wrong simply to assume that e-cigarettes will play no part in reducing the expected one billion 21st Century deaths from smoking. The evidence that there is, taken as a whole, is actually very encouraging, and certainly not a reason to mount a ‘dirty tricks campaign’ against these products. In any event, there is never a case to mislead the public, policy-makers and legislators even if you are convinced the end justifies the means, which in this case it does not."

Like Clive, I do not criticize Stan for having a different opinion on the issue of electronic cigarettes. Having a diversity of opinions is a healthy thing and in the long run, it will help ensure that the best possible public policies result. However, misrepresenting scientific evidence, deceiving the public about the science and what it shows, and lying to the media and the public about the science are simply not acceptable. They serve no positive purpose and in the long run, they end up undermining the credibility of the entire tobacco control movement.

Thursday, March 13, 2014

UC Researcher: Vaping May Be More Hazardous than Smoking

According to an article in the UC Riverside campus newspaper, a UC Riverside researcher has discovered that electronic cigarettes are more hazardous than tobacco cigarettes.

According to the article: "UCR professor of cell biology Dr. Prue Talbot and her team discovered the chemicals used to refill electronic vapor cigarettes (e-cigarettes) may be more harmful than tobacco cigarettes. Her team discovered that electronic vapor requires a consumer to take deeper breaths which may potentially draw in harmful chemicals to fragile parts of the lungs, as opposed to a tobacco cigarette that burns on the other end, allowing the consumer less inhalation. “Our earlier studies with electronic cigarette refill fluids showed that some of these products were toxic to both mouse neural stem cells, (and) human embryonic stem cells as well as to adult lung cells,” she said in a UC press release."

The Rest of the Story

You've got to be kidding me! Based on some non-human studies of the toxicity of electronic cigarette chemicals in cell culture and based on the fact that her researchers believe vapers may have to take deeper breaths when vaping than smoking, Professor Talbot has concluded that vaping may be more harmful than smoking?

This is what we call science in tobacco control today?

Even if e-cigarette vapor shows some toxicity in cell culture studies, how does that demonstrate that vaping is more harmful than smoking?

And even if vaping involved deeper inhalation than smoking, how would that demonstrate that vaping is more dangerous than smoking, especially since the vaper is inhaling far fewer carcinogenic chemicals - and at far lower levels - than the smoker?

Furthermore, it is well known that electronic cigarette users do not inhale more deeply than smokers. While smoke does enter the distal airways - which is why adenocarcinoma rates have increased so dramatically - vaping involves aerosol inhalation and the aerosol is mostly absorbed in the upper, not the lower airways. As with a nicotine inhaler, most of the nicotine absorption occurs in the upper airways.

So not only are these researchers lying by making false extrapolations, they are lying even in the assumptions they are making prior to making those extrapolations. Worst of all, they are trying to make determinations of risk based on only one small slice of the total information that is necessary to judge the relative safety of electronic cigarettes compared to tobacco cigarettes.

I don't understand why electronic cigarette researchers who oppose electronic cigarettes have to go to such extremes to deceive, mislead, and lie to the public. Why are we acting like the tobacco industry used to? Where is the error in simply being honest and truthful to American consumers?

Wednesday, March 12, 2014

President Obama Wants to Make Early Childhood Education Dependent Upon High Rates of Cigarette Sales; Campaign for Tobacco-Free Kids Applauds

Hopefully, we can all agree that funding early childhood education should be a national priority. The question is: where do we get those funds?

Last week, President Obama announced his answer: from smokers. The President proposed a 94 cent per pack increase in the federal cigarette tax, with revenue going to support a much needed expansion of early childhood education.

And predictably, the Campaign for Tobacco-Free Kids (CTFK) applauded.

The Rest of the Story

But here is why that knee-jerk reflex that CTFK exhibits any time a tax increase is discussed is short-sighted and premature.

In funding early childhood education from cigarette sales revenues, the President is forever tying the financial solvency of early childhood education on continuing high sales of cigarettes. If cigarette consumption were to drastically fall (as we should all hope it will), then the revenues for early childhood education would drastically fall as well, and the program would lose its fiscal solvency.

This creates a huge incentive for Congress, and the President, not to take any action that would substantially reduce cigarette consumption. For example, it would create an incentive to bury electronic cigarettes somewhere under the Beltway so they cannot compete with the traditional cigarette products.

Moreover, the scheme is regressive and unfair because it balances the budget on the most needy, rather than most well-off, members of society. If we have a budget shortfall and need to find revenues to fund a much-needed early childhood education program, shouldn't that money come from the wealthiest 1% and from corporations, rather than from individuals who tend to be at the lower end of the income spectrum?

Sure, I understand that it is a lot more politically advantageous to go after smokers than it is to go after corporations and the wealthiest citizens. But it is also uncourageous. And it is certainly not leadership. Nor does it show vision.

What it does, sadly, is continue to exaggerate the income disparity between the richest and the poorest in our society. And saddest of all, it forces the poorest in our society to pay for their own benefit programs - programs that should be provided by the government to all citizens.

Unfortunately, the Campaign for Tobacco-Free Kids is just all too ready to buy into this political propaganda and to jump on the train being conducted by communities of privilege that runs ramshod through poorer communities.

Should early childhood education be funded?


Should it be funded by smokers?


Who should fund it?

The wealthiest 1% of Americans, along with corporations that are enjoying inappropriate tax breaks.

Should the cigarette tax be raised?

Sure, but only if the revenue is used to directly benefit those who are bearing its burden. Raise the cigarette tax and use the money to fund anti-smoking programs and services, research, and treatment for smokers, especially in poorer communities and communities of color, and the policy is no longer regressive but progressive. It could reduce, rather than exacerbate existing income and health inequities.

Why is it that the Campaign for Tobacco-Free Kids always acts as if everyone is white, everyone is middle- or higher-income, and everyone is living in communities of privilege?

Tuesday, March 11, 2014

E-Cigarettes are a Gateway to Cigarette Use and Inhibit Quitting? Then Why is the Decline in Cigarette Consumption Accelerating?

According to Stan Glantz and a number of anti-smoking groups and agencies, including the CDC, electronic cigarettes have been shown to be a gateway to youth smoking. In addition, Glantz maintains that electronic cigarettes inhibit quitting among current smokers. Thus, in the opinions of these groups, the use of electronic cigarettes is exacerbating, rather than ameliorating the cigarette smoking epidemic.

Well, the 2013 numbers are in and they simply do not support the Glantz/CDC conclusions.

The Rest of the Story

According to figures from Reynolds American, domestic cigarette volume declined by 4.6% in 2013, compared to just 2.3% in 2012. In other words, the rate of decline in total cigarette consumption doubled in 2013. Because of the growing population, this means that per capita cigarette consumption declined even more strikingly in 2013.

According to the Reynolds American summary: "Cigarette industry volume was down 6.2 percent in the fourth quarter, and down 4.6 percent for the year. This was a challenging comparison as industry volume declines were below trend in the prior-year periods -- industry volumes were down 0.8 percent in the quarter and down 2.3 percent in 2012. ... When looking at industry volume declines over the past several years, they are about 3.5 percent."

Thus, even accounting for market volatility, it appears that there was a substantial decline in expected cigarette consumption in 2013. This hardly seems consistent with the drastic proliferation of electronic cigarettes that are supposedly driving youth to start smoking and smokers to continue smoking rather than quit.

Philip Morris also reported that its own figures show a decline in domestic cigarette units sold in 2013 compared to 2012:

"PM USA’s 2013 fourth-quarter and full-year reported domestic cigarettes shipment volume decreased 5.8% and 4.1%, respectively, primarily due to the industry’s rate of decline, changes in trade inventories and other factors, partially offset by retail share gains. When adjusted for trade inventories and other factors, PM USA estimates that its domestic cigarettes shipment volume was down approximately 4% for both the fourth quarter and the full year, which is consistent with the estimated category decline."

Again, these declines reinforce the finding that domestic cigarette unit sales were substantially lower in 2013 compared to 2012, despite the tremendous proliferation of electronic cigarettes and the dramatic rise in electronic cigarette use among youths. Again, this hardly seems consistent with the hypothesis that the proliferation of electronic cigarettes is driving youth to start smoking and smokers to continue smoking rather than quit.

As I've already noted, however, it is quite clear that Glantz, the CDC, and most anti-smoking groups are no longer driven by data and science. Ideology has pretty much taken over. And that ideology is an abstinence-only philosophy. If you're still inhaling nicotine and you are still using a device that looks like a cigarette, you are still a smoker in their book. Even if you have just saved your life.

(Thanks to Bill Godshall for the tip.)