On Scientific and Moral Integrity: Final Thoughts for 2006 ------ Rest of the Story will Return on Monday, January 8

Last Friday, sports broadcaster Jim Gray reported during a Philadelphia 76ers basketball telecast that he had spoken with (now former) 76ers star Allen Iverson on the phone and that Iverson told him he wanted to be traded to the Minnesota Timberwolves.

There was just one problem. Gray didn't talk to Iverson. It turns out it was an impostor. Iverson's agent immediately called the network to tell Gray that he didn't talk to Iverson and that the reported story was a mistake.

So what did Gray do?

He immediately "went on the air to say that Iverson's agent Leon Rose called to inform him that the reporter never spoke to Iverson. Gray said on the air that he had talked to an impostor." Gray immediately acknowledged the mistake, corrected his statement, and apologized.

At almost the same time as Gray's gaffe, Atlanta Falcons head coach Jim Mora stated on a Seattle radio interview that he was interested in coaching for the University of Washington football team, and that he would leave his job in the middle of the season if necessary to accept a job coaching the Huskies: "if that job's open, you'll find me at the head of the line with my resume in hand ready to take that job." Mora, being interviewed by KJR's Hugh Millen and Dave Mahler, was then asked, "If you're available?" Said Mora: "It doesn't even matter if I'm available. ... I don't care if we're in the middle of a playoff run. I'm packing my stuff and coming back to Seattle."

It turns out that Mora was joking; he was being sarcastic and merely trying to be funny. But the fans and the Atlanta media were non-plussed. He was heavily criticized for the comments.

So what did Mora do?

He immediately held a press conference and stated: "Clearly I made a mistake in the way I came across. My intent was sarcasm and wit with an old buddy I roomed with in college, Hugh Millen. I thought I was kidding but in listening to the replay it certainly didn't sound like that. So I apologize. I certainly didn't want to offend anyone in Atlanta here with the Falcons, Ty Willingham, or people in Seattle. It was just very poor judgment on my part and for that I apologize." Blank did not attend the news conference, but Mora had the appearance of a man who had been reprimanded by his boss. "I have talked with Arthur," Mora said. "He's disappointed in me and he should be. I'm more disappointed in myself than he ever could be with me. ... I opened my mouth and I let people down. "This is where I want to live. This is where I want to grow old, and boy, what a horrible job I did of expressing that, a horrible job. You'd think I'd learn. You think you get enough shots at this, you'd figure it out. But I never cease to amaze myself at some of the things that come flying out of my mouth before I can get them back."

Mora immediately acknowledged the mistake, corrected his statement, and apologized.

And at almost the same time as Gray's and Mora's guffaws, Massachusetts Senate President Robert Travaglini told a public audience that he would withhold support for incoming Governor Deval Patrick's legislative agenda because Patrick had blamed the legislature for wasteful spending. This public scolding was quite unexpected since Patrick has not even taken office yet and the two must work together if anything is to be accomplished in 2007.

So what did Travaglini do?

He immediately held a press conference at the State House, invited Patrick, and made a live, public apology to Patrick, an almost unprecedented occurrence for a politician:

"Travaglini appeared briefly with the governor-elect yesterday afternoon at a hastily called press conference at the State House, where Patrick accepted the apology and said he was not offended by the Senate president's remarks. ... "What I did was make public a conversation that was private, between the governor and I, and make public some of those details, and I don't think that was appropriate to do," Travaglini said. "We're going to have differences, but I think I've demonstrated in the four years I've been president that conflict isn't part of our arsenal. We like to compromise. . . . What happened yesterday does not fit in that mold." Travaglini said that the state Senate is "standing ready to partner with the new administration." The public appearance followed a private apology the day before. ... His appearance with Patrick was a rare event on Beacon Hill. Political figures at the State House almost never apologize for their sharp comments or attacks on their colleagues, let alone stand with them before the media to make their mea culpas."

Travaglini immediately acknowledged the mistake, corrected his statement, and apologized.

The Rest of the Story

In contrast to the behavior of Gray, Mora, and Travaglini, anti-smoking groups have refused to acknowledge that they have made mistakes in their communication of false health and medical information to the public, have refused to correct their statements, and have failed to apologize for the errant reporting of important health information.

When I checked the American Cancer Society's smoking ban strategy guide this morning, it was unchanged - it contained the same fallacious claims that I reported to the American Cancer Society and the Campaign for Tobacco-Free Kids earlier in the week, including the absurd claim that brief exposure to secondhand smoke can immediately cause atherosclerosis.

Americans for Nonsmokers' Rights (ANR) is still telling the public that 30 minutes of secondhand smoke exposure causes heart damage similar to that of active smokers, and that it reduces the ability of the heart to get life-giving blood. And we know that they have re-visited this "fact sheet." It is now dated "November 2006," and I originally reported the mistake to ANR in March.

So far as I can tell, the Association for Nonsmokers' - Minnesota has still never acknowledged its mistake in telling the public that 30 seconds of secondhand smoke exposure makes nonsmokers' coronary artery function indistinguishable from that of active smokers. Neither has it corrected the statement or apologized for the mistake.

As of this morning, SmokeFreeOhio is still telling the public that secondhand smoke causes debilitating pulmonary emphysema, even though the most comprehensive reviews of the subject - those by the U.S. Surgeon General and the California EPA - have failed to conclude that this is true.

So far as I can tell, the Office of the Surgeon General has yet to correct its claim that brief secondhand smoke exposure causes heart disease, nor has it even acknowledged that this was an error.

Physicians for a Smoke-Free Canada is still claiming that secondhand smoke causes reduced oxygen delivery to tissues comparable to that seen in children with cyanotic heart disease.

Action on Smoking and Health (ASH) is still telling the public that 30 seconds of secondhand smoke increases the risk of a fatal heart attack among nonsmokers to the same level as that of an active smoker.

And the one organization (ClearWay Minnesota) that did completely retract its fallacious claims about the acute cardiovascular health effects of secondhand smoke by deleting the relevant smoking ban manual from the internet has, so far as I can tell, failed to acknowledge the mistake, correct it, or apologize for it.

I have a hard time believing that these organizations actually believe the statements that they are making, and that the reason they are failing to respond is that they actually think these communications are accurate and are not misleading to the public.

Are you telling me that they really believe that the damage to the heart from active smoking is merely as bad as that from 30 minutes of secondhand smoke exposure? Are you telling me that they really believe that the risk of a fatal heart attack in a nonsmoker who is exposed to drifting tobacco smoke for 30 minutes is the same as the fatal heart attack risk of an active smoker? Are you telling me that they really believe that 30 minutes of secondhand smoke can cause hardening of the arteries? Are you telling me that they really believe that 30 seconds of secondhand smoke causes coronary artery dysfunction in nonsmokers which is the same as that in active smokers?

I think it's quite obvious that they don't actually believe that these claims are accurate and truthful and that they are not misleading to the public. If they do actually believe these things then the scientific integrity of the movement is completely shot, we have absolutely no scientific credibility, and we are incapable of, and should immediately stop providing any health and scientific information to the public.

Despite all the inaccuracies and the misleading information that has been communicated by anti-smoking groups to the public in 2006, I have still yet to witness, even once, an anti-smoking group acknowledging that it made a mistake, correcting the statement, and apologizing for the error.

I don't expect any anti-smoking group to be perfect and it is perfectly acceptable to make mistakes. However, the real sign of character and integrity is what you do after you make a mistake? Do you ignore it and fail to acknowledge it, or do you admit it, correct it, and apologize?

To me, that is the ultimately test of the scientific and moral integrity of the anti-smoking movement, and at least in 2006, the movement failed the test with flying colors.

I can only hope that 2007 will bring some major changes to the tobacco control movement.

What has been particularly disturbing to me has been the response of the movement to my pointing out these mistakes. Instead of responding, even once, in a substantive way (and addressing the actual science and the accuracy of the claims), I have been repeatedly attacked (publicly), insulted, accused of taking tobacco money and working for the industry, slandered, accused of being a scientific fraud, and generally lambasted and ex-communicated.

I would have loved, even once in 2006, to have actually been debated about the scientific merits of these statements by anti-smoking groups.

And do you know what I would have done if I were shown to have been wrong? Yes - I would have immediately acknowledged my mistake, corrected it, and apologized for misleading my readers.

I should add that while I have completely given the anti-smoking groups the benefit of the doubt in interpreting these fallacious health claims as merely being innocent mistakes, the failure to correct the claims seems to me to have a different interpretation. The intentional decision not to correct the mistakes seems to me to indicate a willful decision to mislead the public. And if true, that is unethical.

I'm going to need to see some real action in 2007 to prevent me from concluding that there is an intentional effort to deceive the public and that this effort is widespread among the tobacco control movement.

I am fighting for nothing less than the scientific and ethical integrity of the anti-smoking movement. These are basic values that were instilled upon me by my parents and I'm not going to let go of them simply because my colleagues are warning me to shut up because they are afraid I might be hurting the anti-smoking movement.

In the long run, what is hurting the anti-smoking movement the most is the fallacious claims themselves. Because these claims destroy the scientific integrity of the movement. And our scientific integrity is the one thing that truly, in the past, has separated us from the tobacco companies.

Take away that distinction and what are you left with? Not anything that I would want to be a part of. That's why I can't and won't relent in my effort to restore scientific integrity to the movement.

I do have to say that it has also been quite disappointing to me that there are really few individual advocates who have joined me in my effort to restore scientific integrity to the movement. But ultimately, I understand the reason why few others are willing to publicly speak out and simply acknowledge that these public claims are inaccurate or misleading and to call for the correction of these statements.

The reason is that if you do so, your career in tobacco control will be destroyed. You will be attacked, people will be told to ignore you, people will be told that you don't know what you are talking about, and you'll be accused of taking tobacco money and being a tobacco stooge and a traitor. That's the reality of the groupthink mentality that has overtaken the movement and the McCarthyistic element that drives it.

Ultimately, I am willing to forgive anti-smoking groups for making these fallacious public claims. But for forgiveness, you have to be willing to first admit the mistake, correct it, and apologize. There has unfortunately been no sign of any of these in 2006.

Most importantly, this is not a game. We are supposed to be public health practitioners and we have an ethical responsibility to the public to communicate the science and represent the findings and implications of scientific studies as carefully and as accurately as possible. In other words, this is our job. This is ultimately what we go to work every day to do. It is not some sort of ancillary activity or frill.

I am having a lot of troubling waking up every morning to remember that my movement is widely misleading the public about important health information. It's an issue of conscience for me. This isn't about anything more salient and compelling than that.

My readers have stuck with me through my struggles, and often despite major differences of opinion have shown respect, something I have not received from many of my colleagues and certainly not from the list-serves from which I have been expelled because of my willingness to speak out for what I believe. For that respect, and for just listening, I thank each of you.

And I wish you all a happy holiday season and a happy and healthy New Year.


NOTE: The Rest of the Story will be back on Monday, January 8

Massachusetts Lawsuit Seeks to Force Philip Morris to Pay for Chest CT Scans for Smokers to Screen for Lung Cancer

According to an article in the Boston Globe, a federal class action lawsuit filed in Boston last week on behalf of all 50+ year-old smokers in Massachusetts who have smoked at least one pack per day of Marlboro cigarettes for at least 20 years seeks to force Philip Morris - the manufacturer of Marlboro - to pay for low-dose chest CT scans for this class of smokers in order to attempt to diagnose lung cancer at an early stage and therefore save lives.

According to the article: "Low-dose, noninvasive CT scans cost about $500, but they are rarely covered by health insurance. The complaint, filed in US District Court, requests that Philip Morris fund CT scans for people at least 50 years old who have smoked a pack of Marlboro cigarettes a day for at least 20 years -- the equivalent of at least 146,000 cigarettes -- and have not been diagnosed with lung cancer. It does not demand monetary damages. ... as many as 80,000 Massachusetts residents could become part of the class, an estimate based on public health data and Philip Morris's market share."

The lawsuit follows by about six weeks the publication of an article in the New England Journal of Medicine which reports that in a large multi-center, collaborative study of the use of low-dose CT scans for early detection of lung cancer (International Early Lung Cancer Action Program - ELCAP) among 27,456 high-risk patients, 85% of lung cancers detected were in the earliest stage (stage I) and the 10-year survival of these patients was 88%. The article concludes that "Annual spiral CT screening can detect lung cancer that is curable."

Without screening for lung cancer (when lung cancer is detected only when patients present with symptoms), the overwhelming majority of cases are detected in later stages (stages II and higher), which have a dismal prognosis. The stage I cancers have the best prognosis and are the only ones which are felt to have any substantial chance of being cured. By shifting the proportion of diagnosed lung cancers heavily towards stage I, it is thought that spiral CT scanning might result in earlier detection and treatment of tumors and therefore save lives.

The lawsuit apparently contends that Philip Morris produced a cigarette with many carcinogens in it that didn't have to be in there, that a safer alternative product was available but rejected by the company, and that because smokers in Massachusetts are at risk of lung cancer due to the presence of these carcinogens, Philip Morris ought to provide this screening procedure that could save the lives of many of these smokers.

The Rest of the Story

While this all may sound compelling, there is a rest of the story.

First of all, without a control group, the ELCAP study results do not necessarily prove that CT screening for lung cancer reduces mortality and saves lives. There are two potential biases that could be operating, which cannot really be evaluated in the absence of a control group.

Lead time bias is when screening detects cancer at an earlier time than it otherwise would have been diagnosed, but does not change the survival. It is possible that the survival of patients in the study was not altered - what was altered was merely the time of their diagnosis.

Overdiagnosis refers to the detection of indolent cancers that are slow-growing and unlikely to cause death.

Without a control group, it is difficult to assess whether or not the reported results are subject to lead time bias or to overdiagnosis, and therefore, it is difficult to conclude definitively that this screening procedure saves lives. A clinical trial is now underway in which patients are being randomized to either receive spiral CT screening or a conventional chest X-ray. This clinical trial will help to determine whether CT screening can indeed save lives. But until those results are in, it seems premature to be forcing Philip Morris to provide a screening program that has not yet been documented to save lives.

Another major problem is that spiral CT screening for lung cancer has not yet been shown to be an effective and appropriate screening tool. The specificity of the test is very low, and combined with a very low prevalence of lung cancer in the population, the positive predictive value of CT screening is dismally low. This means that the overwhelming majority of patients who have lung nodules detected on CT scan will not have lung cancer. But these patients will require follow-up monitoring, and some will even require further invasive procedures to obtain a definitive diagnosis. These procedures carry a morbidity and even a mortality risk themselves and a number of the diagnostic procedures will result in morbidity or possibly mortality unnecessarily (by which I mean morbidity or mortality in patients who do not have lung cancer).

Another important consideration is the anxiety that could be produced in a huge number of patients who have nodules detected on CT scan but who do not have lung cancer. The protocol calls on these patients to either have invasive diagnostic procedures, which can be physically damaging, or to simply wait for 3 months for a follow-up test, which can be psychologically damaging. Imagine the anxiety a patient would have if told that they have an abnormal nodule in their lung that could be cancerous and what the doctor wants them to do is sit around for 3 months and try not to think about it.

I don't know about you, but I'd be unable to do that without severe anxiety and severe interference with my ability to function. I'd want a definitive diagnosis right away. As a physician, I would feel very uncomfortable telling my patient: "We detected an abnormal nodule in your lung that is somewhat suspicious for lung cancer. We're not sure. Why don't you make a follow-up appointment for 3 months from now and we'll see how it's progressing. See you in a 3 months. Have a good one."

In the ELCAP study, 4186 patients were identified as having abnormal lung nodules at baseline CT screening. Of these patients, only 405 were found to have lung cancer. Thus, 3781 patients had false positive results. The positive predictive value of the test was therefore only 10%. This means that a positive test result (the finding of a lung nodule) only indicates lung cancer 10% of the time. Ninety percent of the time, the test is wrong. That's usually viewed as being unacceptable for a screening test.

In this case, having 90% of your patients with nodules worrying unnecessarily for 3 months hardly seems acceptable to me.

If there were some gold standard, definitive test that could be performed immediately following the baseline CT scan to determine whether or not a patient has lung cancer, then this initial screening test might be acceptable. But I find it quite troubling that patients are being told that they may have cancer - please come back in 3 months and we'll either tell you how much it's grown or we'll tell you never mind, false alarm.

Also concerning is the fact that in this study, 43 patients had some form of invasive or surgical procedure, presumably ranging from fine-needle aspiration to bronchoscopy to mediastinoscopy to open lung biopsy, but ended up having nothing wrong with them. Based on the number of participants in ELCAP and the number of potential smokers in the proposed class, we would expect to have about 120 of the class members end up needing an invasive diagnostic procedure when there is nothing wrong. Among these 120 people, we would expect to have a non-negligible number wind up with significant morbidity -- all for no reason and with no benefit to them.

In other words, what I'm trying to say is that without a doubt, instituting such a screening procedure is guaranteed to cause harm to some patients. It is likely to cause psychological harm to many, and physical harm to a smaller, but not negligible number of class members.

On the other hand, we cannot say with certainty that instituting this screening procedure will result in benefit to any of the class members. It has simply not yet been demonstrated definitively that spiral CT screening for lung cancer does save lives.

I'm not sure how you can ask a court to force Philip Morris to pay for a procedure that is guaranteed to cause some harm, but not definitively guaranteed to have any benefit.

Don't get me wrong. I'm not saying that spiral CT screening for lung cancer will never be an effective and appropriate screening test or that it won't ultimately be shown to save lives or that the benefits of this screening will not end up outweighing the risks and costs. I'm just saying that based on the evidence that is available right now, I don't think one can make a reasonable determination that the proposed screening program will produce a net benefit to this class of smokers.

Lander University Banning Smoking Everywhere on Campus - Indoors and Out; An Anti-Smoking Policy that Goes Too Far

Starting with the fall 2007 semester, smoking will be banned everywhere on the campus of Lander University, a public university in Greenwood, South Carolina, including all indoor and outdoor locations, according to a policy recently approved by the Lander Board of Trustees.

The purpose of the policy, according to articles (article 1; article 2) in the Greenville News, is to promote a healthy campus and take a stand on the tobacco issue: "When Lander's tobacco task force did its research about a year ago, university leaders could find no other university or college in the state with a complete ban on smoking indoors and out across the campus, said Lander spokeswoman Charlotte Cabri. Trustees' action came in support of Lander's wellness program, which has been formulated in accordance with the Healthy Campus 2010 guidelines established by the American College Health Association, Lander President Daniel W. Ball said. 'We will have smoking-cessation programs in place to help students, faculty and staff who will be trying to quit smoking,' Ball said. 'We already offer programs on such health issues as exercise, weight control, and stress management. In addition, we pride ourselves on providing a wide selection of healthy foods in our dining hall.' While the decision 'will not be popular with everyone,' Ball said, 'It is important that we as an institution take a stand on this vital health issue.'"

The adoption of this policy seems to indicate a shift in college anti-smoking policies. Previously, the focus was on protecting the university community from secondhand smoke exposure by banning smoking in and around buildings. Now, an increasing number of campuses are considering policies that ban smoking completely on campus grounds.

The Rest of the Story

This policy goes too far.

While it makes sense to ban smoking in college buildings to protect people from secondhand smoke, banning smoking everywhere on campus is not about protecting people from tobacco smoke exposure. Clearly, it is not necessary to ban smoking completely - including all outdoors locations - in order to protect the college community from secondhand smoke. The purpose of such a policy appears, instead, to be to promote health by coercing smokers into not smoking. In other words, rather than protecting the health of people who might be affected by secondhand smoke, this policy is a paternalistic one which aims to protect smokers themselves from their own "poor" decisions.

A second possible purpose of the policy is to set a moral standard for the campus: to send a message that smoking is not a tolerable behavior on the campus.

Neither of these two purposes justifies banning smoking entirely on a college campus.

As I've argued before, the use of coercion to control people's behavior should be reserved for situations in which their behavior is unlawful, poses risks for others, or poses a risk so direct, severe, and immediate that a paternalistic approach is absolutely necessary.

As a public health policy, the Lander University policy is entirely inconsistent. While the university is coercing people into not smoking on campus, they are still free to drink alcohol and to eat as unhealthily as they like. If the university were to be consistent, it would have to ban alcohol use on campus and it would also have to force its dining halls to only serve healthy food.

The president's approach to promoting healthy eating behavior on campus is entirely appropriate: "we pride ourselves on providing a wide selection of healthy foods in our dining hall." In other words, the school provides a choice to students: it makes healthy food available and encourages students to make a healthy choice. That's appropriate.

In contrast, the school takes a different approach with smoking. It does not give students a choice, while encouraging them not to smoke. Instead, it coerces them to not smoke. There is no choice.

The vastly different treatment of different health behavior risks, such as smoking, alcohol use, and a healthy diet, makes the Lander policy inconsistent.

For this reason, it is difficult to accept that the true intention of the proposal is to protect and promote the public's health. If the university had a most sincere interest in protecting and promoting the health of the community, and was willing to use coercion to achieve this interest (which it apparently is), then it would also ban alcohol use and change the dining hall menu so that only healthy food is provided; it would not offer a choice.

To me, therefore, this has the appearance of being more about a moral prescription and a moral statement than anything else. The policy reeks of the second purpose listed above - to set a moral standard for the campus and send a message that smoking is not a tolerable behavior on campus.

The university is singling out smoking as a health behavior decision that is not to be tolerated, while all other unhealthy behavior choices are perfectly acceptable. Why single out one behavior? The answer, in my experience, is that there is something more going on than simply a concern for health promotion. The policy is making a judgment - a moral statement about what behavior choices are acceptable and which choices are not.

At Lander, you can choose to drink excessively and you can choose to eat unhealthy foods, but you cannot choose to smoke. Your choice of behaviors is being dictated to you, and in a completely inconsistent way.

The rest of the story is that the smoke-free movement has changed from a grassroots social movement that sought to protect nonsmokers from secondhand smoke exposure into an institutionalized, moral crusade that aims to send a message that smoking is an intolerable behavior choice.

This policy is not only unjustified and unreasonable, it is also dangerous. What it essentially says is that smokers are not welcome at Lander University. If a similar policy were to be enacted at many colleges and universities, it would essentially mean that kids who smoke would not be able to attend college; or at least, their choices of colleges would be severely limited. Combine this with the growing trend of policies by which smokers are not eligible for employment, and you'll soon have a society where smokers are not eligible for either an education or for employment. We'll be on our way to a two-tiered society, where education and employment is for nonsmokers only.

Isn't it already difficult enough for smokers? Do we need to limit the educational institutions that they can attend as well as the jobs for which they are eligible?

To see how dangerous this policy really is, consider that there is nothing qualitatively different about precluding smokers from attending a particular college than precluding fat people from attending a particular college because the school wants to promote a healthy lifestyle. A school wouldn't necessarily ban fat people from applying to college, but it would require them to lose weight before showing up on campus. Just as smokers aren't disallowed to apply, but they must quit smoking or at least refrain from smoking while on campus (which for resident students seems tantamount to quitting).

Educational institutions, especially public ones, should be open to all who are qualified to attend. Limiting them to nonsmokers or to those who agree to quit smoking is inappropriate.

Lander University: We adhere to an equal opportunity admissions policy, unless you're a smoker. Then, we dictate to you the personal behavior choices that you must make in order to attend our college.

Anti-smoking groups should speak out against this policy and others like it, making it clear that this is not what the smoke-free movement is all about. (Yeah right - like that will ever happen!)

IN MY VIEW: Anti-Smoking Movement Has Lost High Ground in Public Debate

By virtue of the widespread, coordinated, and intentional deceptive, misleading, and inaccurate statements being made by anti-smoking groups about the health effects of secondhand smoke, I believe that the tobacco control movement has unfortunately given up the scientific high ground that it previously could argue that it held above its opponents.

And this, I feel, is a great loss.

We used to be able to say, at the very least, that we had the science on our side. We used to be able to say that we had honesty, accuracy, and the truth on our side. We used to be able to say that while our opponents were cherry-picking data, misrepresenting or exaggerating the science, and misleading or deceiving the public by spinning scientific information in a favorable way, we were the carriers of the wholesome, unadulterated truth.

But in our zeal to impress upon the public the immediately deadly effects of secondhand smoke, we have ended up parting with our most prized, cherished, and essential possession: our scientific integrity.

It was one thing when I could say that tobacco control was telling the simple truth and communicating scientific facts accurately to the public while our opponents, including the tobacco companies, were misleading the public. But that is no longer true. Today, it is the case that both sides are playing the game of scientific spin, trying to sway public opinion to their side by distorting or misrepresenting the science as deemed necessary to yield what is perceived as a more effective and favorable public message.

Not everything is black and white, and I guess it doesn't have to be. But it's time to acknowledge that this is now the case with anti-smoking advocates and our opponents. We've borrowed a page from the tobacco industry playbook, and we're now playing on the same ball field, even if our end zone leads to a completely different goal than theirs.

To me, the shame of the whole thing is that we didn't need to play the game this way. We had the truth on our side. The truth could have been enough. But it wasn't good enough for us. We became enmeshed in a group-think mentality that disallowed anything but the continued expansion of our agenda and our public statements towards the extreme. And in a movement that does not tolerate dissent, there is no turning back from extremism.

This has uncomfortably put me in an awkward position. I have to argue that on the one hand, secondhand smoke is hazardous and that a lot of what the anti-smoking groups are telling the public is true. But I also have to argue, on the other hand, that secondhand smoke is not as hazardous as we are saying it is, and that a lot of what the anti-smoking groups are telling the public is not true.

In a world that is increasingly polarized and wants everything to be black and white, my message is a difficult one to deliver and an even more difficult one for people to understand. And importantly, it is also an extremely difficult one to communicate to the media (although I have been doing my best, and with at least some success).

My colleagues don't seem to understand the message, partly because some of them cannot accept the fact that we are indeed deceiving the public. But many of them find no flaws in my arguments and acknowledge that our messages have been misleading; what they cannot accept is not the fact that we are deceiving the public, but the fact that I would choose to write about that.

I have to honestly say that those who have been best able to understand where I am coming from are those who one might see as being on the "other side" of the issue. These are the people who are able to see the subtlety of my argument, to accept that the anti-smoking movement is deceiving the public about some aspects of the science, and to respect, although disagree with my view that the anti-smoking movement is telling the truth about other aspects of the science.

To anti-smoking advocates, there is no middle ground. By virtue of who we are, and by virtue of who the tobacco companies are, everything we say must be correct and everything they or their allies say must be wrong. To align oneself with a position that runs counter to the anti-smoking one, no matter how extreme, is tantamount to working for the tobacco industry. It automatically makes you a tobacco stooge, or at least a tobacco sympathizer. You have officially and irredeemably crossed over to the "dark side."

The rest of the story is that what separates anti-smoking groups from their opponents is not as great a divide as we think it is. The difference may be quantitative, but it is not any longer qualitative. The days when we were the ones with scientific integrity and the tobacco industry opposition was waging a campaign of deception are apparently over.

When we told the public that an acute exposure to secondhand smoke could cause atherosclerosis, we made it clear what we were. Now, we're just haggling over the amount of time that it takes.

American Cancer Society, UICC, and TFK Need to Follow ClearWay Minnesota's Lead and Retract Their False Health Claims

While ClearWay Minnesota has removed its inaccurate claim that secondhand smoke exposure reduces coronary blood flow in healthy young adults, there are still close to 100 anti-smoking groups making fallacious or misleading claims that I think need to be retracted or corrected.

But one which I think is the most problematic is the claim made by the American Cancer Society (ACS), International Union against Cancer (UICC), and Campaign for Tobacco-Free Kids (TFK) in their strategy guide, entitled "Building Public Awareness About Passive Smoking Hazards." This document is being disseminated worldwide through the GLOBALink website.

The document is attributed to the ACS and UICC, but TFK is apparently also one of the groups offering this guide to the global tobacco control community: "On behalf of the American Cancer Society, The International Union Against Cancer, the Campaign for Tobacco-Free Kids, and the many wise and experienced colleagues who contributed to this lengthy project, we are deeply pleased to offer this series of guides, Tobacco Control Strategy Planning to the global tobacco control community."

There are 4 reasons why I think the inaccuracies in this document are particularly important:

1. The claims in question are very deceptive, and in one case, the claim is so outrageous as to put the scientific credibility of the entire tobacco control movement at stake.

2. The claims are being made in the specific context of advising anti-smoking organizations worldwide specifically what to tell the public. So it isn't just that the ACS, UICC, and TFK are making these claims. They are encouraging other anti-smoking groups worldwide to make these same specific claims and they are even providing the specific wording. In other words, they are encouraging what amounts to a campaign of deception.

3. The claims are being suggested in the specific context of trying to increase the emotional appeal of the secondhand smoke message. It almost appears as if the strategy guide is first deciding what would be most sensational to tell the public, and then scrounging to try to find some science that will support such statements. The document readily admits that the purpose of these statements is to try to sensationalize and dramatize the effects of secondhand smoke.

4. The claims are in a prominent guide that has worldwide exposure. This is not just some isolated local anti-smoking group getting a little carried away.

Here are the specific claims and why they are false or deceptive:

A. "Immediate effects of secondhand smoke include cardiovascular problems such as damage to cell walls in the circulatory system, thickening of the blood and arteries, and arteriosclerosis (hardening of the arteries) or heart disease, increasing the chance of heart attack or stroke."

This is the statement that is absurd, in addition to merely being deceptive and inaccurate. While it may be reasonable to state the immediate effects of secondhand smoke include damaging cell walls (endothelial dysfunction) and thickening of the blood (platelet activation and aggregation), it is absolutely false to state that the immediate effects of secondhand smoke include arteriosclerosis - hardening of the arteries or heart disease.

Atherosclerosis is a process that takes many years to develop. Among active smokers, the process usually takes at least 20 years to develop, often even more. It is extremely rare to see a smoker in his or her 30's with coronary artery disease.

So if it takes 20 or more years for an active smoker to develop coronary artery disease, then how is it possible for a nonsmoker to develop atherosclerosis or heart disease in 30 minutes?

B. "Short-term exposure to tobacco smoke has a measurable effect on the heart in nonsmokers. Just 30 minutes of exposure is enough to reduce blood flow to the heart."

This statement is merely deceptive, not absurd. While it is true that short-term exposure to tobacco smoke has a measurable effect on the heart in nonsmokers, it is deceptive (if not inaccurate) to state that just 30 minutes of exposure reduces blood flow to the heart.

The truth is that 30 minutes of exposure reduces coronary flow velocity reserve, not blood flow to the heart. The coronary flow velocity reserve decrease is a sub-clinical effect, measurable only under experimental conditions, that is transient. The truth is that the same study being used to back up this claim actually found no reduction in baseline coronary blood flow, or blood flow to the heart.

The clear implication of the statement is that someone who is exposed briefly to secondhand smoke will experience reduced blood flow to the heart, which the public will generally (and correctly) associate with a heart attack. This implication is simply untrue. There is no risk of cardiac ischemia (inadequate blood flow to the heart) from a brief secondhand smoke exposure in a healthy person.

C. "Nonsmokers who are exposed to secondhand smoke in the home have a 25 percent increased risk of heart disease. As is the case with active smoking, much of the cardiovascular effect is due to acute poisoning."

This claim is "merely" misleading. Calling exposure to secondhand smoke "acute poisoning" implies that acute exposure causes clinical damage. But the effects of acute exposure on the cardiovascular system are transient and sub-clinical. There is no permanent impairment of function and any "damage" done is physiologic or sub-clinical.

In fact, the same claim could be made about eating a Big Mac. Eating a high-fat meal also causes endothelial dysfunction and platelet activation. But clearly, it would be misleading to state that eating a Big Mac represents "acute poisoning." So it is equally misleading to suggest that a brief exposure to secondhand smoke is "acute poisoning."

While I agree that the effect of chronic exposure to secondhand smoke, over many years, is to increase the risk of heart disease (and the 25% figure is consistent with the literature), it is very misleading to suggest that acute exposure represents "acute poisoning."

D. "People who are routinely exposed to secondhand smoke, such as workers in restaurants and bars, can expect their risk of lung cancer to triple."

This is classic cherry-picking, something we always accuse the tobacco industry of doing. The strategy guide chooses a single study to try to show that chronic secondhand smoke exposure triples the risk of lung cancer; however, the rest of the literature suggests a much smaller relative risk - something on the order of about 1.3, which is a 30% increased risk, not a tripling of risk. Even if one focuses on restaurant and bar workers, the evidence from a number of studies suggests an increased risk on the order of about 1.5 to 2 at the most.

So to pick one study which found a tripling of risk is very misleading. And in fact, if one wants to base one's claim on just one study, then one could just as easily pick a study that found no increased risk (there are plenty to choose from) and tell the public that they can expect no increased risk of lung cancer from routine secondhand smoke exposure.

Believe me, this is not a game that we want to start playing.

E. "There are immediate and substantial effects from secondhand smoke. For example, 30 minutes of breathing secondhand smoke makes blood platelets get as activated as in habitual pack-a-day smokers. These activated platelets damage the lining of arteries, which leads to heart disease. If they form a blood clot that lodges in a coronary artery, we call that a heart attack. If it lodges in the brain, we call it a stroke."

The first part of the statement is correct. There is, indeed, evidence that 30 minutes of secondhand smoke exposure does activate platelets as in habitual smokers and these activated platelets do damage the lining of arteries.

However, from here, the statement goes downhill. It is not true that the damaged lining of arteries (endothelial dysfunction and damage) that results from 30 minutes of exposure to secondhand smoke leads to heart disease. In fact, it does not lead to heart disease. It is transient and reversible and cannot lead to heart disease. As I emphasized above, it takes more than 20 years of platelet activation and endothelial damage from active smoking to cause heart disease, so how can the platelet and endothelial effects of 30 minutes of secondhand smoke cause heart disease?

It is also untrue that the activated platelets resulting from a 30-minute secondhand smoke exposure can form a blood clot that lodges in a coronary artery (causing heart disease) or in the brain (causing a stroke). This is extremely deceptive, because it implies that 30 minutes of secondhand smoke exposure puts individuals at risk of heart attacks and strokes.

But unless you already have severe coronary artery or carotid artery disease, you'd have to be exposed to secondhand smoke for a lot more than 30 minutes (try 30 years) before the effects on platelets and the endothelium would put you at risk of suffering a heart attack or stroke.

This is what I would call scare tactics. In my opinion, this is a clear example of misrepresenting and distorting the science in order to try to sensationalize the perceived effects of secondhand smoke. It is taking a transient, physiologic, sub-clinical effect and presenting it as a chronic, life-threatening effect that doesn't exist. All in an apparent effort to make the effects of secondhand smoke sound much more immediate than they actually are.

As much as we apparently want to tell people it in order to scare them, heart attacks and strokes resulting from the development of blood clots are not one of the established immediate effects of secondhand smoke. They are risks of chronic exposure, not effects that occur immediately.

Here is why I believe that the strategy guide is explicitly acknowledging that the claims which are provided are crafted specifically to dramatize the secondhand smoke message and create a more emotional appeal:

Speaking about the message that 30 minutes of secondhand smoke causes platelet activation which results in blood clots that may lodge in coronary arteries or in the brain, causing heart attacks and strokes, the document states:

"This message is effective because it provokes an emotional response in almost any listener. Effective messages are characterized by this combination of sound science and emotive language. An effective message has several key components:
• It equates the damage from passively breathing smoke to the damage from direct smoking. We know that the public is more aware of the dangers of smoking than of dangers from secondhand smoke.
• It conveys the fact that even short periods of exposure are harmful.
• It evokes an emotional reaction from the use of scientific terms.
• It utilizes startling and memorable imagery.
• It clearly states the risk of grave health conditions such as heart attacks and strokes."

It appears, then, that to be effective, a secondhand smoke message must convey the immediate effects of exposure, evoke an emotional reaction, use startling imagery, and state the risk of heart attacks and strokes. But what if the evidence does not support the combination of these elements? What if the evidence does not support a conclusion that heart attacks and strokes are an immediate effect of secondhand smoke exposure?

Apparently, the answer is simple: don't worry about it. Make the claim anyway.

The strategy guide makes an equally troubling statement about the need to emphasize to the public the immediate benefits of smoking bans in terms of heart attack reduction:

"Another message that may encourage the public to take action concerns a 2002 case study conducted in Helena, Montana (USA). Researchers found that, in the six months following the enactment of a new smoke-free workplace law, heart attack frequency declined significantly. This message is effective for several reasons.
• It offers a positive indication of what can happen to public health when people stop smoking and breathing secondhand smoke in public places.
• It indicates that a ban on smoking in public places can reduce the incidence of heart attacks for smokers and nonsmokers alike.
• It demonstrates that the health benefits of clean indoor air ordinances are virtually immediate.
• It provides more scientific evidence that smoke-free workplace policies improve health and save lives, which should encourage communities around the world to take action to protect the health of their citizens."

The problem is that the evidence does not support the elements that apparently make the message effective. As I have explained in detail, the study provides very weak evidence that there was a significant decline in heart attacks in the first place, that it was attributable to the smoking ban in the second place, and that it was due to reduced secondhand smoke exposure in the third place. In fact, the study did not even assess the smoking status of heart attack patients, making it impossible to conclude that "a ban on smoking in public places can reduce the incidence of heart attacks for smokers and nonsmokers alike."

But again, apparently the lack of scientific evidence is not enough to stop the strategy guide from recommending that this is the message that anti-smoking groups should communicate to the public. It is an effective message, so let's communicate it, even though there is insufficient evidence to support it.

The Rest of the Story

It should be important to an organization like the American Cancer Society - which funds its own scientific research and depends on its scientific credibility to reach the public on a large number of cancer issues - to make sure that its public communications are accurate. To put out an absurd claim such as the statement that 30 minutes of secondhand smoke exposure causes atherosclerosis seems to me to undermine the scientific credibility of the organization, and you would think they would want to immediately correct this. Especially when they are telling hundreds of anti-smoking groups around the world to say the same thing to the public.

Not only do I think it hurts the scientific integrity and credibility of these organizations, but I think it hurts the scientific credibility and integrity of the entire tobacco control movement.

It is one thing to make a mistake, but the real measure of integrity is whether or not that mistake is corrected. We'll see how these organizations respond, but based on the lack of response from most of the groups in tobacco control which have made similar false statements, I would be surprised if these groups care enough about the truth to acknowledge a mistake and correct it.

Honestly, my impression is that the tobacco control movement doesn't really care about honesty and the truth; we are too concerned with scaring people about the exaggerated immediate effects of brief tobacco smoke exposure in order to generate a strong emotional appeal and garner support for the agenda - an agenda which I strongly support (at least as far as workplace smoking bans are concerned).

To me, the most concerning aspect of this story is that the strategy guide acknowledges that its express goal is to dramaticize and sensationalize the health effects of secondhand smoke by scaring people about the immediate, deadly impact that it can have. It is not that the document first reviews the research which supports these claims and then says, "Secondhand smoke really can cause heart disease in 30 minutes, so this is what we should tell the public." Instead, it appears that the document advises groups what claims would be the most sensational, and then scrounges around for evidence to support these claims, relying upon wild exaggerations and scientific misinterpretations and misrepresentations in order to accomplish this.

I will report here at week's end whether or not the inaccurate and deceptive claims in the strategy guide are retracted or corrected, or you can check the guide directly here.

Immediate effects of secondhand smoke include atherosclerosis???
Brief exposure to secondhand smoke causes acute poisoning???
Routine secondhand smoke exposure triples your risk of lung cancer???
Thirty minutes of secondhand smoke reduces blood flow to the heart???

If anti-smoking groups actually follow the advice of the American Cancer Society, International Union against Cancer, and Campaign for Tobacco-Free Kids and make these claims to the public, how can we expect anyone to believe us when we actually tell the truth?

IN MY VIEW: Anti-Smoking Groups' Claims are Making a Mockery of Secondhand Smoke Science; Years of My Own Research Being Thrown Down the Drain

In their zeal to scare people about acute cardiovascular effects of secondhand smoke that do not exist in order to promote public support for smoking bans, anti-smoking groups have engaged in what essentially amounts to a strategy of misrepresenting the science: taking evidence of minor, transient, physiologic effects and telling the public that this translates into major, permanent, clinically significant damage to healthy nonsmokers.

The claims have ranged from severe exaggerations to complete absurdity, but they all have one thing in common: they are distorting and misrepresenting the science.

The groups involved range from the smallest of anti-smoking organizations to the largest and most prominent figure in tobacco control - the Surgeon General himself.

Anti-smoking groups have told the public that 30 minutes of secondhand smoke is enough to cause hardening of the arteries. They have told the public that 30 minutes of exposure reduces coronary blood flow and deprives the heart of life-giving blood. They have told the public that brief secondhand smoke exposure causes reduced oxygen delivery that is comparable to that observed in cyanotic heart disease. They have even told the public that just 30 seconds of secondhand smoke is enough to make coronary artery function in nonsmokers indistinguishable from that in chronic active smokers.

The net effect of all of these deceptive and inaccurate claims is to undermine the true scientific basis for tobacco control policy, especially for the regulation of smoking in public places and workplaces. By virtually making up the science as they go along, these anti-smoking groups (or at least those feeding them the misleading information) are not only destroying the scientific credibility and integrity of the tobacco control movement, but they are also rendering as meaningless the years of research into the effects of secondhand smoke that scientists like myself have conducted.

What good is all the research that I've conducted on the actual hazards of secondhand smoke when anti-smoking groups are going to tell the public that a few whiffs of tobacco smoke can cause atherosclerosis? What value is there in my research when these groups are going to tell the public that brief exposure to secondhand smoke causes as much damage to the heart as years of active smoking?

What exactly is the purpose of conducting careful scientific research on the effects of secondhand smoke if anti-smoking groups are essentially just going to make things up, making whatever claims they want to the public in order to embellish the emotional appeal of the message?

Why am I needed anymore? If the groups are going to say that 30 minutes of tobacco smoke causes hardening of the arteries, then who needs to know exactly what the actual risk of chronic secondhand smoke exposure on heart disease is? If the groups are going to say that even a minor dose of secondhand smoke causes as much damage as a lifetime of active smoking, then why do we need to know what the actual levels of secondhand smoke exposure are for workers in different occupational settings?

In many ways, I feel that the nonsense that is going on in the tobacco control movement has made a mockery of my own career in tobacco control. Had I known 15 years ago that we were going to send a widespread message to the public that brief exposure to secondhand smoke can cause heart disease, then I would never have devoted the past 15 years of my career to researching the actual health effects of secondhand smoke.

What importance is there to knowing the actual health effects of secondhand smoke if we are going to deceive the public about what those health effects are?

One of the reasons that the events of the past several months sadden me so much is that it renders my research meaningless. What value did I add to the movement by carefully documenting the levels of exposure of restaurant workers and the health effects of chronic secondhand smoke exposure if these groups are simply going to tell people that 30 seconds of exposure is enough to kill anyone?

It makes me feel like all of my efforts were a waste, or at least, that my research is virtually worthless (at least irrelevant) at this point.

I remember being disturbed at a tobacco trial once when the tobacco industry attorneys kept standing up and objecting to my testimony on the grounds that it was "irrelevant and immaterial."

Well right now I feel as though my testimony about the health effects of secondhand smoke and what the evidence actually shows is "irrelevant and immaterial" because the anti-smoking groups are going to push their pre-ordained agenda regardless of what the evidence actually shows. They are going to make whatever claims they feel they need to in order to garner support for their increasingly draconian proposals, even if those claims defy the research, the science, and common sense.

So the tobacco company lawyers were right - my testimony, knowledge, and expertise in this area truly is irrelevant at this point. Once anti-smoking groups are telling the public that 30 minutes of exposure is enough to cause atherosclerosis, I don't really feel like I'm needed anymore.

And I think that's the truth: I'm not needed anymore.

More than that, I'm not wanted any more. When I was generating evidence that could be used to support the agenda, I was very much wanted in the movement. But now that I'm questioning the tactics and statements being used to promote the agenda (which I largely support) and questioning aspects of the agenda itself, I'm no longer wanted. There really isn't any room for someone like me in the tobacco control movement.

In fact, I'm a grave danger to the movement, because my parents instilled a value in me which I refuse to reqlinquish: something called the truth.

There really is not any room in the movement for someone who speaks the truth and refuses to shade the truth in order to follow the party line. There is simply no place for a person like me in this movement. When you speak the truth, you're forced out of the movement because you become a threat to it.

So now I join the tobacco company attorneys in standing to voice objection to the value of my own research and testimony: "Irrelevant and immaterial," I say.

California Medical Association Adds Support to Proposal that Will Increase Kids' Secondhand Smoke Exposure

The California Medical Association (CMA) on Saturday expressed its support for a proposed policy in Belmont that would ban smoking everywhere indoors and outdoors, with the exception of detached, single-family homes.

In a letter to the editor published in the San Jose Mercury News, the president of the California Medical Association wrote: "Plaudits to city officials in Belmont who are drafting a plan to ban smoking citywide (Page 3B, Dec. 5). The California Medical Association began opposing tobacco use even before the surgeon general issued his warning in the 1960s, and led the fight in banning smoking on planes, in bars and restaurants, and in all public places. Belmont's plan is more closely in line with our goal: to make California tobacco-free. It will happen, as long as cities like Belmont take a stand against the powerful tobacco industry, which continues to encourage people to smoke and fights anti-tobacco efforts in the face of clear scientific evidence that tobacco is deadly. The physicians of California see this as the right thing to do for the health of Californians. We hope other cities follow Belmont's lead."

The Rest of the Story

Do the physicians of California see forcing parents to smoke inside and expose their children to secondhand smoke, rather than being able to go outside to smoke, as the right thing to do for the health of Californians?

Yet that is precisely what the proposed policy in Belmont would do. By banning smoking outdoors, even on residential property, the policy would force parents who smoke to stay indoors in their homes to smoke rather than going outside where they will not expose their kids to secondhand smoke.

How could this possibly be the right thing for the health of California's children? Why would it be a good thing for other cities to follow this unhealthful lead?

The last thing in the world that public health practitioners and physicians should want is to ban smoking outdoors so that parents are forced to smoke inside where their kids will be exposed to high levels of secondhand smoke. I can't think of too many worse policies that could be proposed. Thus, I think it is a shame that the CMA is supporting this proposal.

It makes you wonder whether they have actually taken a look at the idea and thought about it or whether this is just knee-jerk support for another anti-smoking proposal. Do anti-smoking groups actually analyze public policy any more, or do they simply put their support behind anything that puts limits on smoking? Is public health really the driving force here, or is it more just a desire to punish smokers and keep them away from the public view?

A basic ethical principle of medical and public health practice is "First, to do no harm." The Belmont proposal would do harm. It would harm many children by increasing their exposure to secondhand smoke. Thus, how can the CMA, or any anti-smoking group, possibly justify supporting this proposal?

New Study Shows that Coronary Blood Flow is Not Impaired in Active Smokers, Much Less Passive Smokers; Statements of 38+ Anti-Smoking Groups are False

A new study published in this month's issue of The Journal of Nuclear Medicine reports that coronary blood flow is not reduced in young smokers, throwing into severe doubt the claim by 38+ anti-smoking groups that passive smoking reduces coronary blood flow (see: Morita K, Tsukamoto T, Naya M, et al. Smoking cessation normalizes coronary endothelial vasomotor response assessed with 15O-water and PET in healthy young smokers. The Journal of Nuclear Medicine 2006; 47:1914-1920).

The study used PET scans to measure myocardial blood flow in 14 young smokers with no evidence of heart disease and 12 age-matched nonsmokers. Active smoking was found not to affect coronary blood flow, as there were no significant differences in the measured myocardial blood flow between smokers and nonsmokers. The researchers did find a reduction in endothelium-mediated vasodilation, as blood flow in response to a cold pressor test was reduced in the smokers, which the authors conclude indicates endothelial dysfunction. Of note, this endothelial dysfunction was reversed within one month of smoking cessation.

According to the study: "There were no significant differences in myocardial blood flow at rest and during ATP infusion between smokers and nonsmokers."

The authors concluded that: "young healthy smokers have impaired coronary endothelial vasomotor dysfunction, which is reversible within 1 month after smoking cessation, and the improvement is preserved at 6 months after cessation. ... These findings indicate that coronary endothelial dysfunction may be reversible within 1 month after smoking cessation in healthy young smokers."

The Rest of the Story

This study demonstrates that the statements being made to the public by 38+ anti-smoking groups, indicating that secondhand smoke exposure reduces coronary blood flow, are not just deceptive - they are just plain wrong.

To suggest, as Americans for Nonsmokers' Rights (ANR) does, that 30 minutes of secondhand smoke impairs the ability of healthy young nonsmokers' hearts to get life-giving blood, seems to be inaccurate in light of the evidence presented in this paper. Even active smokers did not have a problem with myocardial blood flow in this study.

The numerous other claims made by anti-smoking groups, indicating that secondhand smoke reduces blood flow to the heart, are also inaccurate. The truth is that even active smoking, in the absence of heart disease, does not reduce blood flow to the heart. It is only endothelial function that is affected by tobacco smoke, not baseline coronary blood flow.

In light of this new research, it is now inexcusable for these anti-smoking groups to fail to retract these claims and apologize for misleading the public.

ClearWay Minnesota has apparently responded by removing from the internet its smoking ban manual which contained the fallacious statement that secondhand smoke reduces coronary blood flow in healthy young adults (although I'm aware of no acknowledgment of the mistake nor an apology for it). But at least it's a step in the right direction - getting the false health claim off its website and preventing the public from being misled any further.

There are now well over 30 anti-smoking groups that need to follow ClearWay's lead.

One other aspect of the study deserves mention. This research found that endothelial dysfunction induced by active smoking is reversible within one month following smoking cessation. If this is true, then certainly endothelial dysfunction induced by a 30-minute exposure to secondhand smoke is reversible.

This confirms that the statements being made by a number of health and anti-smoking groups, including the Office of the Surgeon General, that brief secondhand smoke exposure causes atherosclerosis, narrowing or hardening of the arteries, or heart disease are false.

If endothelial dysfunction in active smokers is quickly reversible, then it is also reversible in passive smokers, and thus a brief exposure cannot possibly lead to hardening of the arteries (atherosclerosis) and heart disease, despite what the Surgeon General told the public.

Because of the high-profile nature of the communication from the Surgeon General's report, the heavy reliance of the tobacco control movement on the Surgeon General for public education, and the intense publicity surrounding the report and high media response to the press release containing the untruthful statement, a correction and apology for that misrepresentation of the science is particularly important for the credibility of the tobacco control movement.

Articles Cited to Defend Anti-Smoking Groups' Claims Show No Evidence of Increased Heart Attack Risk Among Healthy Nonsmokers Exposed to Tobacco Smoke

In his response to my commentary on the deception of the public by anti-smoking groups, Dr. Glantz cites several articles which he implies rebut my argument that anti-smoking groups are deceiving the public when they suggest that secondhand smoke exposure can cause heart attacks in healthy nonsmokers. These articles, he suggests, show that I don't know what I'm talking about when I argue that it is inaccurate to tell the public that acute secondhand smoke exposure can put healthy nonsmokers at risk of a heart attack.

The most important article - a comprehensive review of the acute cardiovascular effects of secondhand smoke - was published this year in the European Heart Journal (see: Raupach T, Schafer K, Konstantinides S, Andreas S. Secondhand smoke as an acute threat for the cardiovascular system: a change in paradigm. European Heart Journal 2006; 27:386-392).

I recently re-reviewed this article, thinking that possibly I might have missed some evidence presented by the authors to support the contention that secondhand smoke may pose an increased risk of acute coronary events (heart attacks) among healthy nonsmokers.

The Rest of the Story

Raupach et al. present 4 lines of evidence - 4 different types of acute cardiovascular effects of secondhand smoke: (1) impairment of endothelial function; (2) effects on platelet activation; (3) oxidative stress, lipoprotein modification, and inflammation; (4) stimulation of sympathetic nervous system activity; and (5) effects on oxygen-carrying capacity.

Here is a summary of what they have to say about each of these effects. I focus here on their conclusions regarding the clinically meaningful effects of each.

1. Impairment of endothelial function

Brief secondhand smoke exposure impairs the ability of the endothelial cells (those which line the coronary arteries) to regulate vascular tone. Normally, in response to certain stresses, these cells release substances such as nitric oxide which relax the smooth muscle in the artery wall, leading to vasodilation and increased blood flow through the vessel. This response is impaired by secondhand smoke, as well as by a high-fat meal, diabetes, and high cholesterol. In addition, secondhand smoke has a direct adverse effect on the viability of endothelial cells.

These effects "result in the migration of monocytes into the vessel wall, their transformation into lipid-laden macrophages, and the subsequent growth and destabilization of lesions due to local inflammatory activity."

In summary, "impairment of endothelial function predicts the initiation and progression of atherosclerosis [hardening of the arteries]."

In other words, the effects of secondhand smoke on the endothelium have 2 clinically meaningful implications: (1) these effects may promote atherosclerosis; and (2) in an individual with severe existing coronary artery disease, it is possible that these effects could trigger a heart attack.

In order to develop atherosclerosis, years and years of exposure are necessary. In order to trigger a heart attack, the individual in question would have to be severely compromised to begin with. He or she would need severely narrowed coronary arteries with existing artery lesions. In other words, he or she would have to have severe existing coronary artery disease.

2. Effects on platelet activation

Secondhand smoke exposure increases platelet activity, leading to platelet aggregation and enhanced coagulability (clotting ability) of the blood. The clinically significant meaning of this effect, as summarized by the study authors, is that: "Platelet activation and thrombosis [clot formation] at sites of vascular injury or atheromatous plaque disruption play a crucial role in the pathophysiology of acute coronary events."

In other words, this effect of secondhand smoke exposure could potentially trigger a heart attack in someone with severe pre-existing coronary artery disease.

3. Oxidative stress, lipoprotein modification, and inflammation

Secondhand smoke exposure causes oxidative stress and impairs anti-oxidant functions in nonsmokers. It also enhances lipid [fat] accumulation in the artery wall and if repeated over time, causes a persistent inflammatory state. The long-term consequence of these effects (if exposure is sustained) is the development of atherosclerotic plaques.

The clinical meaning of these effects is that if "passive smoking occurs on a regular basis...it is very likely to contribute to a persistent inflammatory response which promotes atherothrombosis."

Once again, the evidence for an increased risk of heart attack applies only to, and specifically to, individuals with chronic exposure or with severe existing coronary artery disease.

4. Stimulation of sympathetic nervous system activity

Secondhand smoke exposure increases sympathetic nervous system activity. One manifestation of this is increased cardiac autonomic tone, which leads to decreased heart rate variability. The clinical significance of this effect is that "autonomic dysfunction is linked to higher mortality rates in patients with chronic heart failure."

Thus, this effect would not have clinical meaning for healthy individuals. It would be potentially significant only for individuals with severe existing heart disease and chronic heart failure.

5. Reduced oxygen-carrying capacity

Secondhand smoke, because it contains carbon monoxide which binds to hemoglobin, can impair the ability of red blood cells to carry oxygen. At the cellular level, the decreased oxygen delivery can be significant. Specifically, it "lowers the threshold for cardiac arrhythmias in patients with coronary artery disease. Moreover, exposure to SHS shortens the symptom-free interval in patients with stable angina."

Thus, any effect on the risk of an acute coronary event is restricted to individuals with severe existing coronary artery disease.

In summary, this article (which is consistent with the overall literature) provides evidence that secondhand smoke exposure has a number of physiologic effects which could potentially trigger an acute coronary event (heart attack or arrhythmia) in an individual with severe existing coronary artery disease.

But importantly, the article presents no evidence that there is any acute heart attack, arrhythmia, decreased coronary blood flow, or other adverse clinical event risk in a healthy individual. It also presents no evidence that brief secondhand smoke exposure can cause atherosclerosis.

The rest of the story, then, is that this article strongly supports, rather than refutes, my argument that a large number of anti-smoking groups are deceiving the public by stating that brief exposure to secondhand smoke reduces coronary blood flow in healthy adults, increases heart attack risk in nonsmokers in general, presents clinically meaningful effects that are equivalent to that observed in active smokers, and/or causes hardening of the arteries.

I stand by all of my previous commentaries.

The only aspect of my previous commentaries which I am having some trouble with is my belief that the deception of the public may be inadvertent, due to simple, innocent mistakes. I no longer feel that is a viable explanation for what is going on. My opinion now is that this is basically a deliberate attempt to mislead the public into thinking that secondhand smoke is far more dangerous, on an acute level, than it actually is.

While I share the concern about educating people about the hazards of secondhand smoke and promoting policies to protect them from these hazards, I do not share the conviction that the ends justify the means and that misleading people is acceptable as long as the ultimate goal is a noble one. Deceiving people, with the intention of promoting a favored policy, is wrong. What we are observing is unethical behavior within the anti-smoking movement.

At Least 38 Health and Anti-Smoking Groups are Misleading the Public by Conflating Coronary Blood Flow and Coronary Flow Velocity Reserve

On Friday, I explained why I think that ClearWay Minnesota's statement that secondhand smoke decreases coronary blood flow in healthy young adults is deceptive. As I explained, the group seems to be conflating coronary flow velocity reserve, which is decreased by acute secondhand smoke exposure, and coronary blood flow, which is not impaired at all.

However, the implications of the difference are immense. A decline in coronary flow velocity reserve merely indicates that physiological damage is taking place - the function of the endothelial cells has been impaired. In contrast, a decline in coronary blood flow would indicate clinical damage; reduced blood flow to the heart puts an individual at risk of a heart attack and death.

Today, I reveal that no less than 38 anti-smoking groups are making similar claims about the acute effects of secondhand smoke - claims which are deceptive because they conflate coronary blood flow and coronary flow velocity reserve.

The Rest of the Story

Here they are:

Americans for Nonsmokers' Rights: "Even a half hour of secondhand smoke exposure causes heart damage similar to that of habitual smokers. Nonsmokers' heart arteries showed a reduced ability to dilate, diminishing the ability of the heart to get life-giving blood."

American Cancer Society and Campaign for Tobacco-Free Kids: "Short-term exposure to tobacco smoke has a measurable effect on the heart in nonsmokers. Just 30 minutes of exposure is enough to reduce blood flow to the heart."

ClearWay Minnesota: "Blood flow in the coronary arteries is decreased in healthy young adults exposed to secondhand smoke." (Note: Document has been removed from site in response to my post.)

Minnesota Smoke-Free Coalition: "Non-smokers are harmed by even brief exposures to passive smoke, according to a study published recently in the Journal of the American Medical Association. ... The study showed that after only short periods of exposure, secondhand smoke contributed to narrowing of blood vessels, restricted flow of blood and hardening of the arteries."

Asthma Initiative of Michigan: "...in as little as 30 minutes of exposure to secondhand smoke, the nonsmokers’ blood flow dropped to the same level as people who had smoked a pack of cigarettes.

American Heart Association, Heritage Affiliate: "Even 30 minutes of exposure to secondhand smoke reduces blood circulation and increases your risk for a heart attack."

SmokeFreeColorado: "Just thirty minutes of exposure to secondhand smoke can compromise the cardiovascular system of nonsmokers by reducing blood flow to the heart."

British Heart Foundation: "Just 30 minutes exposure to tobacco smoke can affect the cells lining the coronary arteries and this can contribute to the development of atheroma narrowing the coronary arteries and reducing blood flow to the heart."

Action on Smoking and Health (London): "Short term exposure to tobacco smoke also has a measurable effect on the heart in non-smokers. Just 30 minutes exposure is enough to reduce coronary blood flow."

Clearing the Air Scotland: "30 minutes exposure to second hand smoke is sufficient to reduce coronary blood flow in otherwise healthy adults."

American Lung Association of Oregon: "As few as 30 minutes of secondhand smoke exposure can impair coronary circulation in a non-smoker."

SmokeFreeOhio: "Only 30 minutes of secondhand smoke exposure can cause narrowing of blood vessels, restricting the flow of blood and contributing to hardening of the arteries." (Note: Claim was removed from fact sheet in response to my post).

Citizens Against Unhealthy Smoke-Filled Environments: "Just 30 minutes exposure to secondhand smoke can compromise the cardiovascular system of nonsmokers by reducing blood flow to the heart." (Note: Page is no longer active).

Smokefree Islington (UK): "A study published in the Journal Of The American Medical Association found that just 30 minutes' exposure is enough to reduce coronary blood flow."

Smoke-free Bristol (UK): "Short-term exposure to second-hand smoke has a measurable effect on the heart in non-smokers -– 30 minutes exposure is enough to reduce blood flow to the heart muscle."

Texas Department of State Health Services: "Just 30 minutes'’ exposure to secondhand smoke can constrict arteries and damage the body'’s ability to supply blood to the heart."

Smoke Free North West: "Short term exposure to tobacco smoke also has a measurable effect on the heart in non-smokers. Just 30 minutes exposure is enough to reduce coronary blood flow."

East Cambridgeshire and Fenland PCT: "Being exposed to 30 minutes cigarette smoke can significantly reduce the coronary blood flow in a fit healthy adult."

Smokefree Wyoming: "Within 30 minutes, your blood becomes stickier, damaging artery linings and restricting flow."

Oregon Department of Human Services: "Experts have found that just 30 minutes of secondhand smoke exposure can impair blood flow to and from the heart in non-smokers."

American Lung Association of Metropolitan Chicago: "People who spend just 30 minutes in a smoke-filled room have a measurable decrease in oxygen delivered to their heart."

Hong Kong Medical Association: "Just 30 minutes exposure is enough to reduce coronary blood flow."

Share Air: "Just 30 minutes' exposure to secondhand smoke can constrict arteries and damage the body's ability to supply blood to the heart."

Illinois Coalition Against Tobacco: "Even as little as 30 minutes of exposure to secondhand smoke has a negative effect on arteries and oxygen's flow to the heart is decreased."

Smoke Free North East: "Just 30 minutes exposure is enough to reduce coronary blood flow."

Smokefree England: "Just 30 minutes exposure is enough to reduce coronary blood flow."

Smokefree Mecklenberg: "Only 30 minutes of secondhand smoke exposure can cause narrowing of blood vessels, restricting the flow of blood and contributing to hardening of the arteries."

Smoke Free Wirral: "Short-term exposure to tobacco smoke also has a measurable effect on the heart in non-smokers. Just 30 minutes exposure is enough to reduce coronary blood flow."

Pueblo City-County Health Department: "Breathing secondhand smoke for just a few minutes increases arterial stiffness, promotes the tendency of blot to clot, reduces blood flow to the heart, and makes arteries more prone to damage."

Smoke Free Solihull: "Just 30 minutes exposure is enough to reduce coronary blood flow."

British Medical Association: "Just 30 minutes in a smoky room can reduce the flow of blood to the heart."

British Medical Association, Tobacco Control Resource Centre: "Just 30 minutes in a smoky room can reduce the flow of blood to the heart."

Smoke Free Liverpool: "Just 30 minutes exposure to other people’s tobacco smoke can be enough to reduce blood flow through the heart."

Royal College of General Practitioners: "Just 30 minutes exposure is enough to reduce coronary blood flow in a non-smoker."

Scottish Executive: "Short-term exposure to tobacco smoke also has a measurable effect on the heart of non-smokers: just 30 minutes' exposure is enough to reduce coronary blood flow."

Oregon Department of Health Services: "Experts have found that just 30 minutes of secondhand smoke exposure can impair blood flow to and from the heart in non-smokers."

British Heart Foundation: "Furthermore, exposure to cigarette smoke does not have to be particularly prolonged for it to damage your heart. One study has shown that just 30 minutes exposure is enough to reduce coronary blood flow to the heart."

State Tobacco Education & Prevention Partnership (Colorado): "Just thirty minutes of exposure to secondhand smoke can compromise the cardiovascular system of nonsmokers by reducing blood flow to the heart."

Just to make it clear, there is no evidence that acute exposure to secondhand smoke reduces coronary blood flow. It does not decrease blood flow to the heart.

What it does is decrease coronary flow velocity reserve, which is an experimental measure of reduced ability of the arteries to dilate in response to certain induced stressors. It is important to note that this is a physiological effect, not a clinical one. When it occurs in a healthy young adult, it has essentially no clinical significance. Of course, if the exposure is repeated over and over again over many years, then it could have clinical significance as atherosclerosis could develop.

What the anti-smoking groups have been doing is conflating the observed physiological change with a clinically significant effect.

To give you an idea of why this is inappropriate, consider the fact that simply eating a hamburger, fries, and milk shake at McDonalds decreases coronary flow velocity reserve. But it would obviously be misleading to put out messages to the public telling them that eating a meal at McDonalds can decrease their coronary blood flow, reducing blood flow to the heart!

The importance of today's revelation is that it demonstrates that the deception of the public about the acute cardiovascular effects of secondhand smoke, especially in relation to the effects on coronary blood flow, is not just limited to a few errant statements by a few anti-smoking groups. The deception is a widespread phenomenon that pervades the tobacco control movement.

I can't yet completely figure out how exactly this occurred. Was there simply just a very bad mistake in interpreting the clinical significance of these findings that was spread widely among the groups, or was there an intentional decision made to mislead people into thinking that the clinical significance of these findings for healthy people is more than it really is?

To me, it hardly matters, because at this point, I believe that these groups - especially the major ones and the ones with which I have communicated directly - should be aware of the mistakes and should have had plenty of time to correct them. The continued presence of these fallacious claims, in my view, does at this point represent an intentional effort to deceive, even if the original cause was simply a mistake.

At least one group - ClearWay Minnesota - has apparently responded appropriately to my pointing out its misleading statements by removing the web page containing those statements. But as today's post shows, we have a long way to go before the anti-smoking movement can regain any semblance of scientific credibility.

Leading Tobacco Control Scientist Tells Thousands of Advocates that Rest of the Story Author Has No Idea What He's Talking About

In an email sent to his announcement list of thousands of tobacco control advocates worldwide, a prominent tobacco control scientist tells advocates that I do not know what I am talking about and do not understand the scientific issues involved in communicating the acute cardiovascular health effects of secondhand smoke. In the message, he suggests that I am in no position to comment on the statements being made by anti-smoking groups about the acute cardiovascular effects of secondhand smoke and further, that it is irresponsible of me to do so because I have no understanding of the issues upon which I am commenting.

The message sent to an undetermined number of worldwide advocates, believed to be in at least the thousands, states:

"Michael Siegel simply does not know what he is talking about. I am attaching several peer reviewed academic reviews that show how all these things link together. Coronary flow velocity reserve is an important measure of the ability of the heart to respond to increases in demand and is closely related to endothelial and platelet function, both of which relate to both the chronic and acute risk of heart attack. It is well established that increased platelet activation causes platelets to stick to the vascular lining (the endothelium) and cause physical damage, which is important for the development of atherosclerosis. The acute effects can also trigger a heart attack in people at risk. No one is saying that one whiff of smoke causes a heart attack in everyone who breathes it. What the evidence shows is that there are substantial immediate effects that compromise the cardiovascular system and that, in some people, these changes are the same kinds of things that can trigger an acute event.

Journalists following Siegel's commentary should be aware that he is fond of quoting himself (his blog), not the peer reviewed scientific literature. In addition, while Dr. Siegel has published papers on other topics, he is not published in cardiovascular research.

A responsible scientist talks about things he or she actually understands."

The message included the text of my post, entitled "Conflating Coronary Blood Flow and Coronary Flow Velocity Reserve: The Basis for Anti-Smoking Groups' Misleading Health Claims" which I sent out to my own email list of tobacco control groups and reporters.

The Rest of the Story

Despite the derogatory and nasty statements made about me and sent to thousands of my friends and colleagues, and to prominent members of the media, and the suggestion that I am a complete fraud who talks about things of which I have no understanding, the ironic part of the rest of the story is that I wholeheartedly agree with everything Dr. Glantz states.

He is correct, I believe, in noting that the research literature documents that secondhand smoke causes platelet activation and platelet aggregation as well as endothelial damage, which are important in the development of atherosclerosis and which may also be involved in triggering acute coronary events among those with existing coronary artery disease. There are substantial immediate effects that cause compromise to the circulatory system and which, in some people (those with severe coronary artery stenosis) may possibly trigger an acute event (i.e., a heart attack).

Nothing that Dr. Glantz states is in any way inconsistent with my post.

So how could this be? How could it be that Dr. Glantz is basically condemning me and maligning my character (intimating that I am a complete fraud) in front of thousands of our colleagues and yet there is essentially no disagreement between us on the scientific issues?

The answer, I believe, is that Dr. Glantz is ignoring (or has not taken the time to read) my actual argument. I was not arguing in the commentary that brief exposure to secondhand smoke does not cause heart attacks in people with severe existing coronary artery disease. Nor was I criticizing any anti-smoking groups who are making such a statement to the public.

Instead, I was criticizing two specific statements made by two specific anti-smoking groups (although mirrored by similar statements made by a large number of other groups) that imply that brief secondhand smoke exposure can cause heart attacks in healthy young adults.

In fact, the statement by ClearWay Minnesota that I was criticizing stated explicitly that 30 minutes of secondhand smoke exposure decreases coronary artery blood flow in healthy young adults.

And the statement by the Association for Nonsmokers - Minnesota that I was criticizing implied that 30 seconds of secondhand smoke causes as much damage to coronary artery function as chronic active smoking. It mentioned nothing about people with existing coronary artery stenosis. It clearly represents itself as a statement about the general public exposed to secondhand smoke.

Moreover, the statement by the American Cancer Society and the Campaign for Tobacco-Free Kids stated that atherosclerosis (hardening of the arteries) is an "immediate effect" of secondhand smoke exposure. Again, this is not even remotely related to triggering of coronary events in people with high-risk heart disease; it is about whether a process that in smokers takes 20-30 years to develop can occur among nonsmokers in just minutes.

So as much as I respect Dr. Glantz and his scientific expertise, I do not believe his statement has any relevance to the discussion at hand, which is not about whether brief exposure to secondhand smoke can trigger an acute coronary event in someone who is at high risk for such an event. The discussion at hand is about: (1) whether or not it is accurate to tell the public that 30 seconds of secondhand smoke exposure is as bad as chronic active smoking in terms of damage to the coronary arteries; (2) whether or not it is accurate to tell the public that brief exposure to secondhand smoke decreases coronary artery blood flow in healthy young adults; and (3) whether or not it is accurate to tell the public that secondhand smoke can immediately result in hardening of the arteries, a process that takes 20-30 years to develop among active smokers.

It honestly appears to me that Dr. Glantz did not actually read my commentary, because it would seem that if he did, he would have understood that I was not in any way suggesting that there is no evidence that acute exposure to secondhand smoke could potentially trigger an acute coronary event in an individual with severe heart disease. If he did actually read my commentary, then it is beyond me why he would misread it so badly, but I suppose it's always possible that I did not explain myself clearly enough.

When I stated that I was criticizing public health groups for implying that "a healthy young person exposed to secondhand smoke is at risk of death due to that exposure," what I meant was that public health groups should not be implying that brief secondhand smoke exposure poses a risk of death from a heart attack in a healthy young person. I certainly apologize if I failed to make that clear.

I don't exactly see how someone could misread what I wrote as criticizing these anti-smoking groups for stating that secondhand smoke exposure can precipitate an acute coronary event in people with severe existing heart disease, but if I wasn't clear, it is my fault and I apologize for the lack of clarity in my writing.

Just to make sure that it is clear now, what I intended to say when I stated that ANR, for example, is implying that "a half hour of secondhand smoke exposure impairs the body's ability to get life-giving blood to the heart, putting even a healthy young individual at risk of a heart attack and therefore of death," is that I am criticizing ANR not for stating that secondhand smoke can trigger a heart attack in someone with severe narrowing of the coronary arteries and a pre-existing atherosclerotic plaque, but for implying that a half hour of secondhand smoke exposure impairs the body's ability to get life-giving blood to the heart, putting even a healthy young individual at risk of heart attack and therefore of death.

I have so much respect for Dr. Glantz and I know that thousands of tobacco control advocates also do, so I am quite sure that there are thousands of advocates out there now who believe Dr. Glantz when he tells them that I am a complete scientific fraud who talks about things without really understanding what he is talking about. Obviously, any possibility of a career in tobacco control has been completely shot by this email announcement.

And the shame of the whole thing is that the email was completely irrelevant to the actual discussion. If I am going to be discredited and my career ruined, then I would love to be discredited and to have my career ruined based on something I actually said, rather than on something that I never said. If I had my druthers, I would choose to have a derogatory statement about me sent to thousands of colleagues address one of my many actual flaws.

While I have a lot of flaws, being a complete scientific fraud who talks out of my ear and pretends to be familiar with the science when I actually don't have a clue what I am talking about is not one of them.

I agree that a responsible scientist should only talk about things he or she actually understands. But I think this also applies to public health groups. Tobacco control groups should only present themselves as sources of accurate scientific information if they actually understand the medical issues about which they are communicating. And I would humbly and respectfully suggest that a group which tells the public that secondhand smoke can cause, as an immediate effect, hardening of the arteries, does not truly understand the pathophysiology of heart disease.

As a physician, I not only studied the pathophysiology of heart disease in medical school, but I also treated hundreds of patients with heart disease and acute coronary events (heart attacks). I took part in surgery on blocked coronary arteries (thank goodness I wasn't the one sewing in the bypass grafts). I followed a multitude of patients with severe coronary artery stenosis, which I measured directly by participating in the coronary angiography of those patients, and observed their progression or lack of progression to acute coronary events. I treated many patients with tissue plasminogen activator and aspirin in order to directly interfere with the platelet activation process, so as to decrease the likelihood of the triggering of an acute coronary event in these patients.

I think I know a little bit about this topic.

But frankly, I'm not sure that it even takes a physician to be able to suspect that something is fishy when an anti-smoking manual tells groups to inform the public that nonsmokers can develop atherosclerosis immediately after exposure to secondhand smoke. I don't think it would be unreasonable for a lay person to suspect that she had been misled by a statement that it takes only minutes for secondhand smoke to cause hardening of the arteries, when that person is aware that among active smokers, the same process takes many years.

I don't think it takes a physician to challenge the statement that 30 seconds of secondhand smoke exposure is as bad as a lifetime of chronic active smoking when it comes to coronary artery function. And I don't think it even takes a physician to read the statement in the Otsuka et al. paper which states clearly that there was no decrease in coronary blood flow in the study subjects, and to then question why anti-smoking groups are stating that secondhand smoke reduces coronary blood flow in healthy young adults.

As my readers hopefully know, I don't think that you have to be published in cardiovascular research to enter into this discussion intelligently. In fact, perhaps those who are furthest removed from the science and the agenda of tobacco control are in the best position to shed light on the implications of the statements being made by anti-smoking groups that I have cited and on whether or not those statements seem to be accurate and responsible communications based on even just the evidence that Dr. Glantz provides in his commentary, or based even on stipulating that everything Dr. Glantz states in his commentary is correct.