Two Halloween Posts That Should Scare Any Tobacco Control Advocate

Today's two posts should scare us as anti-smoking advocates, because they reveal the misrepresentation of science by an anti-smoking group to try to convince the public to support a policy proposal.

During a campaign season characterized by a number of misleading attacks on political candidates, it seems a shame that we in tobacco control are misleading the public in our own campaigns.

In the first post, I show how SmokeFreeOhio is misrepresenting scientific research to support its claims that secondhand smoke causes pulmonary emphysema and pancreatic cancer, conclusions that are not consistent with the U.S. Surgeon General's report or the California EPA report.

In the second post, I reveal another misleading campaign statement being made by SmokeFreeOhio: the claim that the effects of brief secondhand smoke exposure on atherosclerosis in nonsmokers are nearly as large as those of chronic active smoking.

SmokeFreeOhio Misrepresenting Scientific Research in Backing Up Unsubstantiated Health Claim

In support of its efforts to promote Issue 5, which would ban smoking in all Ohio workplaces, bars, and restaurants, SmokeFreeOhio is publicly claiming that secondhand smoke causes pulmonary emphysema.

According to its secondhand smoke fact sheet: "Secondhand smoke can cause the debilitating disease pulmonary emphysema, causing severe damage to the walls of the air sacs, with the lungs eventually losing their capacity to expand and contract."

To back up this claim, which is unsupported (and actually contradicted) by the U.S. Surgeon General's report on involuntary smoking and by the California EPA report, SmokeFreeOhio cites a single study: reference 14 on its fact sheet.

Citing this scientific reference - a study published in the American Journal of Physiology - makes it appear to the public as though the claim made by SmokeFreeOhio is documented in the scientific literature.

Curious to see the research that SmokeFreeOhio was using to substantiate its claim that secondhand smoke causes pulmonary emphysema, I examined the article.

It is also worth noting that when I corresponded with a representative of SmokeFreeOhio and expressed my concerns that the documentation to support a causal link between secondhand smoke and emphysema was inadequate, the representative responded by suggesting that if I had a problem, I should take it up with the authors of that paper.

So here's what the authors of that paper had to say in the article's abstract:

"Cigarette smoke is a mixture of chemicals having direct and/or indirect toxic effects on different lung cells. We investigated the effect of cigarette smoke on human lung fibroblasts (HFL-1) oxidation and apoptosis. Cells were exposed to various concentrations (1, 5, and 10%) of cigarette smoke extract (CSE) for 3 h, and oxidative stress and apoptosis were assessed by fluorescenceactivated cell sorting and confocal laser fluorescence microscopy. Both oxidative stress and apoptosis exhibited a doseresponse relationship with CSE concentrations. Lung fibroblasts also showed marked DNA fragmentation at the Comet assay after exposure to 10% CSE. Coincubation of HLF-1 cells with N-acetylcysteine (1 mM) during CSE exposure significantly reduced oxidative stress, apoptosis, and DNA fragmentation, whereas preincubation (3 h) with the glutathione- depleting agent buthionine sulfoximine (125 uM) produced a significant increase of oxidative stress. Cigarette smoke is a potent source of oxidative stress, DNA damage, and apoptosis for HFL-1 cells, and we speculate that this could contribute to the development of pulmonary emphysema in the lungs of smokers."

(Carnevali, S., Petruzzeli, S., Longoni, B., Vanacore, R., Barale, R., Cipollini, M., Scatena, F., Paggiaro, P., Celi, A., Giuntini, C. (2003, June). Cigarette smoke extract induces oxidative stress and apoptosis in human lung fibroblasts. American Journal of Physiology, 284, 955-964)

The Rest of the Story

There's just one minor problem with the use of this article to back up SmokeFreeOhio's claim: this article concludes that damage to fibroblasts can contribute to the development of pulmonary emphysema in the lungs of smokers, not nonsmokers. A minor technicality? Hardly.

The rest of the story is that SmokeFreeOhio is completely misrepresenting this scientific research to the public. They are presenting this research as supporting the conclusion that secondhand smoke causes pulmonary emphysema in nonsmokers. But what the article actually concludes is that tobacco smoke induces oxidative stress and apoptosis in fibroblasts in the lung, providing a potential mechanism by which active smoking contributes to the development of pulmonary emphysema.

In fact, nowhere in the paper does it even suggest that secondhand smoke can cause emphysema in nonsmokers.

This doesn't look good. Because it makes it appear that SmokeFreeOhio is intentionally misrepresenting the science in order to support its apparently untenable position.

I suppose one could argue that this was simply a mistake. But it seems hard to misread the clear conclusion of the paper. It concludes that the observed damage to lung fibroblasts could contribute to the development of pulmonary emphysema in the lungs of smokers. Even if one didn't read the rest of the article, one would still see that the article is referring to emphysema among smokers, not nonsmokers. It seems as clear as day to me. I don't think you even need to be a scientist to read the conclusion and understand that it is talking about smokers. After all, it says: smokers.

You can see why it is difficult for me to conclude anything other than that SmokeFreeOhio is intentionally misrepresenting this scientific research.

By the way, even if this article did postulate that tobacco smoke could contribute to the development of emphysema among nonsmokers, it is a far cry from being adequate documentation to support a conclusion that secondhand smoke causes emphysema. This is a study of the effect of tobacco smoke extract on human lung cells. The study does not involve actual people. It does not involve the identification of any actual cases of emphysema among nonsmokers. So it in no way provides support for a conclusion that secondhand smoke causes emphysema among nonsmokers.

To make matters worse, this is not the only misrepresentation of the science in SmokeFreeOhio's campaign. The group also claims that: "Secondhand smoke exposure increases your risk of developing pancreatic cancer." To back up this claim - which is unsupported by both the U.S. Surgeon General's report and the California EPA report - SmokeFreeOhio relies upon a single study: reference 15 on its fact sheet.

Curious about the evidence that would support SmokeFreeOhio making a claim, based on a single study, that is unsupported by the Surgeon General and the California EPA, I examined this study.

The basic conclusion of the study was as follows: "Among never smokers, those who were exposed to ETS both as a child and as an adult had an odds ratio of 1.21 (95% CI=0.60-2.44) relative to those with no exposure." (Villeneuve, P., Johnson, K., Mao, Y., Hanley, A. [2004, Jan.-Feb.] Environmental tobacco smoke and the risk of pancreatic cancer: Findings from a Canadian population-based case-control study. Canadian Journal of Public Health, 95(1), 32-7).

In other words, the study found no significant increase in the risk of pancreatic cancer among passive smokers.

For those unfamiliar with epidemiology, if the odds ratio for pancreatic cancer associated with passive smoking was 1.0, it would indicate no increased risk. If the 95% confidence interval around the study's estimate for the odds ratio includes 1.0, then the study is unable to conclude that there was a significant increase in pancreatic cancer risk among nonsmokers. In this study, the lower end of the confidence interval is 0.60. In other words, it is quite possible that nonsmokers exposed to secondhand smoke were only 0.6 times as likely to get pancreatic cancer. From this study, one cannot even conclude that secondhand smoke doesn't have a protective effect against pancreatic cancer.

Obviously, secondhand smoke doesn't have a protective effect. But the point is simply that the study found no significant elevation of risk among nonsmokers, and the results weren't even close to being statistically significant.

Does this mean that secondhand smoke does not cause a slight increase in pancreatic cancer risk? No. But it does mean that this single study cannot be used to back up the claim that secondhand smoke causes pancreatic cancer. In my opinion, SmokeFreeOhio is again misrepresenting the scientific research in order to create the appearance of their being scientific support for the claim that it is making.

This truly is deception. There's just no way around it any more. You can't put together this combination of misrepresented scientific findings to create the appearance for the support of claims which are not consistent with the conclusions of the Surgeon General and California EPA and convince me that these are just innocent mistakes. It has the clear appearance that SmokeFreeOhio is trying to mislead the public into thinking that there is strong scientific support for its claims when in fact, the science cited does not actually support these claims.

SmokeFreeOhio is running a campaign of deception, clear and simple. In my mind, this campaign of deception is irresponsible and unethical. I think that we in public health have a responsibility - an ethical responsibility - to accurately report the science to the public. SmokeFreeOhio is not only failing to do that, but they are misrepresenting the science in ways that are misleading the public.

As far as I'm concerned, the campaign battle over Issues 4 and 5 in Ohio is being fought with major deception on both sides.

If you want to see a battle in Ohio fought with any integrity, I'm afraid you'll have to wait until November 18, when the Wolverines head down to Columbus to take on Ohio State in a contest that will have national championship implications. And don't expect any trickery in that battle. Just in the trenches, hard-nosed, head-to-head football.

IN MY VIEW: Glaring Scientific Inconsistency in SmokeFreeOhio's Campaign and More Misleading Campaign Statements

SmokeFreeOhio is defending its public contention that breathing secondhand smoke for even a short time increases heart attack risk by insisting that since the Surgeon General made this statement, it must be correct.

At the same time, however, SmokeFreeOhio is ignoring the Surgeon General's conclusion that there is not adequate evidence to link secondhand smoke with emphysema, and telling the public nonetheless that: "Secondhand smoke can cause the debilitating disease pulmonary emphysema, causing severe damage to the walls of the air sacs, with the lungs eventually losing their capacity to expand and contract."

This certainly has the appearance of what might be called cherry-picking. When you like what the Surgeon General says, then repeat it. When you don't like what the Surgeon General says, then defy it.

If SmokeFreeOhio were presenting any scientific arguments of their own to back up their claims, then this wouldn't necessarily be a problem. One is entitled to agree selectively with elements of a scientific report. However, SmokeFreeOhio is not backing up its claims, and instead has relied on the shallow argument that it can claim that brief secondhand smoke exposure causes heart attacks because the Surgeon General said so.

This is perhaps not an unreasonable justification, except for the fact that the group is ignoring the Surgeon General's conclusions about the relationship between secondhand smoke and emphysema.

But I think SmokeFreeOhio has an obligation to go beyond this in backing up its claims. I think when you make a statement that the Surgeon General's report has concluded that a brief secondhand smoke exposure causes heart attacks, you need to at least verify that the report draws such a conclusion. In other words, you have to actually read the report.

Apparently, SmokeFreeOhio has not read the report, because if it had, it would have noted that nowhere in the report does it conclude that a brief exposure to secondhand smoke causes heart attacks.

This might be excusable because the organization just assumed that the report contained this conclusion. However, I informed them that the report did not contain such a conclusion, and by now they have had the time to realize this and correct their fact sheet, something they have not done.

One would think that with just 1 week until the election, when voters will be relying on their campaign statements in the voting booth, SmokeFreeOhio would want to be as accurate as possible with their campaign claims. This does not appear to be the case.

The Rest of the Story

To make matters worse, I am today revealing that SmokeFreeOhio is making yet another misleading public claim. The group is telling the public that the effects of a brief (minutes to hours) exposure to secondhand smoke on atherosclerosis among nonsmokers are nearly the same as those of chronic active smoking on smokers.

In its secondhand smoke "fact sheet," the group claims: "Evidence is rapidly accumulating that the cardiovascular system - —platelet and endothelial function, arterial stiffness, atherosclerosis, oxidative stress, inflammation, heart rate variability, energy metabolism and increased infarct size - —is exquisitely sensitive to toxins in secondhand smoke. The effects of even brief (minutes to hours) passive smoking are often nearly as large (averaging 80% to 90%) as chronic active smoking."

Clearly, one of the effects SmokeFreeOhio is referring to is atherosclerosis, since that is listed in the preceding sentence.

Is it true, then, that a brief exposure to secondhand smoke (minutes to hours) has nearly as large an effect on atherosclerosis as chronic active smoking?

The answer is a resounding NO. In fact, a brief exposure to secondhand smoke has NO effect on atherosclerosis among nonsmokers. You simply cannot develop atherosclerosis from a several-hour exposure. It's medically impossible.

In contrast, chronic active smoking can cause severe atherosclerosis. I have seen patients with greater than 95% stenosis (narrowing) of their coronary arteries due to chronic active smoking.

Is 0% nearly as large as 95%? I don't think so.

In my opinion, SmokeFreeOhio is misleading the public into thinking that the effects of a brief exposure to secondhand smoke on atherosclerosis are nearly the same as those of chronic active smoking. I don't think I'm stretching here since that's exactly what the "fact sheet" states. Yet this claim is untruthful. It's fallacious. The statement, then, is very misleading.

I should also point out that even if one were to accept that a brief exposure to secondhand smoke could cause a heart attack, this increased risk would only apply to persons with severe existing coronary artery disease. SmokeFreeOhio does not even take pains to clarify that its statement refers only to such individuals. Thus, it misleads the public into thinking that anyone exposed to secondhand smoke briefly could drop dead from a heart attack. I find that to be irresponsible.

I think it is really a shame that with just one week left before the election, SmokeFreeOhio continues to rely upon a campaign of deception, rather than on one of scientific accuracy.

I know that SmokeFreeOhio has made some attempt to correct their statements. They did delete several of the statements that I reported many months ago were misleading. But they are well aware that several misleading statements remain. It looks, however, like the misleading of voters is going to continue right up until the time they enter the polling booths.

This political season has been very disturbing to me. I've observed lots of national and regional campaigns that appear to me to be based more on deception than on sticking to the documented facts. All kinds of misleading insinuations have been made about particular candidates. It is very disappointing to me that we as anti-smoking groups are part of these tactics of misleading people to try to obtain their votes.

To me, the election is kind of tainted if people's votes are based on having been misled about the facts, rather than on educating people about the actual facts and letting them make a decision based on the whole truth.

In Ohio, both sides have been misleading the public. I don't know which side is worse, but from my perspective, I simply cannot imagine, with any integrity, telling people that a brief exposure to secondhand smoke has effects on atherosclerosis that are nearly the same as the effects of chronic active smoking.

That's just absurd.

In some ways, I think SmokeFreeOhio is probably misleading more people than Smoke Less Ohio. Because there has been a fair amount of publicity about the misleading tactics of the Smoke Less group. But there has not been much publicity about how SmokeFreeOhio is telling people that they can develop narrowing of their coronary arteries from a mere minutes to hours-long exposure to secondhand smoke, something that in reality takes about 15-20 years, at a minimum, to occur.

I could have written this off to just scientific sloppiness, if it weren't for the fact that SmokeFreeOhio has shown zero interest in considering my arguments and engaging in a dialogue that might actually result in correcting their so-called fact sheets so that they do not mislead the public. SmokeFreeOhio apparently has enough confidence in my scientific ability to rely upon my research and arguments to support a number of their public claims. But they don't want to listen when what I'm arguing runs against what they want to be able to claim.

It's one thing when you see politicians mislead the public in order to gain votes. But to see my fellow anti-smoking groups doing this is not something I'm used to. And it is very sad and disappointing to me.

I thought we were better than this.

Anti-Smoking Advocate Claims that Seconds of Tobacco Smoke Exposure Can Cause Heart Attacks in Nonsmokers

As I noted last Monday, the amount of time that it apparently takes for secondhand smoke to cause a heart attack has dropped from 30 minutes to 20 minutes to 5 minutes and ultimately, to 30 seconds.

Now, however, an anti-smoking advocate is claiming that mere seconds of exposure to secondhand smoke - the amount of time it would take to simply pass through a room with smokers - is enough to cause heart attacks among nonsmokers.

According to this advocate, who is a cardiologist in Minnesota and whose heart center is affiliated with a Minnesota anti-smoking organization, just passing through a smoke-filled room is enough to trigger a heart attack.

As he wrote in an opinion column in the October 22 edition of the St. Cloud Times:

"In the study of medicine and public health, every now and then a finding comes along that is so groundbreaking that the world is literally never the same. ... A recent, landmark study out of Pueblo, Colo., that links exposure to secondhand tobacco smoke to an increase in the rate of heart attacks is yet another. ... The study, which was published in Circulation: A Journal of the American Heart Association, found that hospitalizations for heart attacks declined significantly in that city after a comprehensive smoke-free workplace law, including restaurants and bars, was implemented on July 1, 2003. ... The study also appears to support the recent findings of the U.S. Surgeon General that there are no safe levels of exposure to secondhand tobacco smoke and that simply passing through a smoke-filled room can trigger heart attacks in nonsmokers."

The physician who makes this claim practices at the Central Minnesota Heart Center, which has representation on the Board of Directors of the St. Paul-based Minnesota Smoke Free Coalition. He also links to the Smoke Free Communities anti-smoking group in an earlier letter to the editor in the St. Cloud Times. This group is in fact coordinated out of the Central Minnesota Heart Center.

The Smoke Free Communities group itself claims that: "short term exposure to secondhand smoke while having lunch or a drink or two can trigger a heart attack in people who are at risk, particularly the elderly."

Smoke Free Communities also claims that: "In 30 minutes of secondhand smoke exposure, your arteries stiffen; your blood thickens and becomes more 'sticky,' and your body'’s ability to process cholesterol is diminished. This stress on your cardiovascular system can be the prelude to a heart attack."

The Rest of the Story

I can't tell you how many times I've witnessed this scenario. A guy tries to make it across a room where smoking is taking place, and before he can even make it to the other side of the room, he keels over and drops dead or unconscious from a heart attack.

I'm not sure why we need research and a cardiologist to tell us that mere seconds of secondhand smoke exposure causes people to have heart attacks, when common sense and general experience would tell us that people are dropping dead of heart attacks all the time when trying to pass through rooms where smoking is occurring.

Seriously - this claim flies in the face of common sense and our collective experience. That doesn't mean the claim is wrong, but it does mean that in order to support such a claim, one would need to provide strong evidence or documentation of this risk. However, I am aware of no evidence or documentation that 10-15 seconds of secondhand smoke exposure (the time it would take to pass through a smoky room) causes heart attacks in nonsmokers. And to my knowledge, no such evidence has ever been presented.

But what makes this claim really inappropriate and unfortunate is the fact that it is not merely trying to portray one individual's opinion of the risk of acute secondhand smoke exposure, which the public might dismiss as being exaggerated. Instead, the claim being made is actually that the United States Surgeon General has concluded that merely passing through a smoky room causes heart attacks in nonsmokers.

If you re-read the opinion piece, you'll see that the writer is not simply offering his own opinion, but is communicating to the public that the Surgeon General drew such a conclusion.

This is untrue. If you read through the 727-page Surgeon General's report (you don't actually have to do it if you're pressed for time - I've read through the entire thing), you will not find any conclusion or finding that passing through a smoky room causes heart attacks in nonsmokers, or that very brief exposures (such as 15-30 seconds) in any setting cause heart attacks.

I suppose that if one only read the Surgeon General's propaganda statements, which do imply that a brief exposure to secondhand smoke can cause heart attacks and heart disease, but failed to actually read the report for oneself, one could perhaps be misled into thinking that the report concluded that brief exposure causes nonsmokers to have heart attacks. However, I think if you are going to publicly represent the conclusions of the Surgeon General to the public, you have a responsibility to read the report and understand the science. In addition, to take the vague term - "brief" - and translate that into the amount of time it takes to pass through a smoky room is an unwarranted exaggeration of even the misrepresented findings.

Importantly, this does not appear to merely be an errant claim of one particular anti-smoking advocate. The Smoke Free Communities group, which appears to be coordinated by the Central Minnesota Heart Center, is itself claiming that 30 minutes of secondhand smoke exposure causes heart attacks in nonsmokers.

Its first claim above - that exposure to tobacco smoke while having a drink or two can trigger a heart attack in people at risk - is an undocumented one. It is basically just speculation. Sure, there is evidence that 30 minutes of secondhand smoke exposure may cause platelet activation. But whether that increased platelet activation caused by a single, short-term exposure to secondhand smoke, if not prolonged or repeated, can actually trigger a heart attack, or whether it does so with any regularity, is speculation. There is no evidence or documentation I am aware of that would support such an extrapolation. Especially not to the point where it we can go around making this claim widely to the public with any scientific integrity.

Smoke Free Communities' second claim above is, at best, misleading because it implies that anyone exposed to 30 minutes of secondhand smoke exposure could potentially suffer a heart attack due to that exposure.

This is not true. Even if one extrapolates from the evidence of tobacco smoke's short-term effects on platelet aggregation and endothelial dysfunction and does not require any actual evidence that such short-term exposure could cause a heart attack, one could only speculate that a heart attack could be triggered in an individual with severe, pre-existing coronary artery disease.

However, this statement by Smoke Free Communities is not qualified in this way. It could easily be interpreted by the public as meaning that anyone exposed to secondhand smoke for 30 minutes is at risk of a heart attack. This is quite unfortunate, because for the overwhelming majority of the public, there is absolutely no concern that a short-term exposure to secondhand smoke could cause a heart attack. It is simply not plausible.

So why scare people unnecessarily?

The answer, it appears, is that anti-smoking groups are intentionally trying to increase the emotional appeal of their secondhand smoke messages, and they're not letting the actual science get in the way.

The Antithesis of Science: Blind Allegiance, Refusal to Discuss Issues, and Lack of Interest in Making Substantive Responses to Questioning

The shocking events of this week have woken me up to what the anti-smoking movement is really all about, at least right now. It was a jarring revelation, but one that substantially changed my view of what we are all about.

Shocking it was. Sure - I've known for a long time that anti-smoking groups have been unwilling to enter into a discussion of the scientific basis for their statements. I've known that the typical anti-smoking response to questioning is ad hominem attack, rather than substantive discussion of issues.

But it still has to shake you up a bit when you log onto your computer in the morning and find out that a message has been sent to literally thousands of your colleagues stating: "Please ignore Michael Siegel."

What a nice way to start your day, knowing that pretty much all of your colleagues have been instructed to completely ignore you.

But what an odd response that is. If I am wrong in what I'm arguing, then the last thing we'd want to do is ignore me. We would want to destroy my arguments, show why they are unfounded or not compelling.

If one of my colleagues made an argument about a scientific issue and sent it out to large numbers of tobacco control practitioners and scientists and I disagreed strongly with that argument and thought it might be damaging, then I would prepare a scientific response that presented the scientific reasons why that argument was flawed.

Telling people to simply ignore the person is essentially asking people to have blind allegiance to the dogma of the movement. No questioning of that dogma is allowed. It cannot be challenged. There are no replay officials in the tobacco control movement, and no red flags that can be thrown down to challenge the "official ruling" on the field.

This experience also highlighted the fact that the tobacco control movement almost never responds substantively to an argument challenging its statements, tactics, or actions. The only response in our arsenal is a personal attack against the challenger (even if it is someone within our movement), devoid of any substance.

This is the antithesis of science.

I don't see how we can claim to have scientific integrity in the face of the response to my questioning of the misleading (and in some cases fallacious and/or absurd) statements that we are making. And that's really a shame, because what is supposed to sharply distinguish us from the tobacco companies against whom we are fighting is our scientific integrity. Once you take that away, we completely lose the high ground.

Not only is it clear to me that the tobacco control movement is on the losing end of a scientific credibility crisis, but the events of this week have indicated something else to me. It is clear to me that many of these anti-smoking groups and advocates know that they are on the losing side of a scientific battle. If they were truly confident that their position was right, they would not have to resort to this. They could quickly and simply dismiss my arguments by demonstrating why I am wrong. The fact that they had to resort to tactics like this reveals that they realize, at least subconsciously, that they don't have a leg to stand on and that they have to go into attack mode to avoid their claims being exposed for what they are.

It seems that anti-smoking groups that have been challenged really do want people to ignore my arguments because they are rightfully afraid that if people really start to pay attention to what I'm arguing, the truth may be revealed and the movement's ability to make these alarming, but misleading claims about secondhand smoke will unravel.

One of the responses I received during the week was that I should stop expressing my opinions because this is a distraction from the important work that needs to be done. I guess I didn't realize that scientific honesty was merely a distraction, and that accurate and honest communication of science to the public was not the primary work that we are supposed to be doing.

You learn something every day, even if it does come at the expense of all your colleagues and friends being told to ignore you.

Anti-Smoking Advocates Told to Ignore the Science and Continue Making Absurd Health Claims; Rest of the Story Author Implored to Stop Speaking Out

In a message sent to thousands of anti-smoking advocates on a major list-serve, a prominent leader of the anti-smoking movement implored these tobacco control advocates to simply ignore the scientific arguments that I'm making about why a number of claims about the acute cardiovascular effects of secondhand smoke are misleading or fallacious.

The message, entitled "Please ignore Michael Siegel" stated: "Mike Siegel's statements below -- which he claims intimidated SmokeFree Ohio into changing their ads -- are just wrong. The increase in platelet aggregation after 20 minutes makes the platelets as 'sticky' as in a smoker. This DOES put [non]smokers at increased risk of a heart attack."

The message then included the text of the note I sent to a large list of anti-smoking groups, which is the same as my post from earlier today about the failure to respond to my concerns about the fallacious and misleading claims that are being made, such as the claim that 30 seconds of secondhand smoke exposure can cause coronary artery disease.

In further response to my post, anti-smoking advocates are imploring me to stop expressing my opinions. One advocate and researcher wrote: "I do not understand your position. All the anti-smoking information is medically correct. All information qualifiers cannot be added to every 30 second commercial. Your letters and blogging will only help big tobacco kill more folks. Please stop."

The Rest of the Story

I certainly understand the anger that many anti-smoking advocates and groups seem to have to my pointing out the misleading claims that are being made. We have all dedicated much of our lives and our careers to this cause, and it is not easy to be told that what anti-smoking groups are communicating is misleading. I also acknowledge the right of advocates to urge their fellow advocates to ignore my arguments. I don't criticize them for these actions. It would certainly be a lot easier for everyone if this problem simply went away and they are, in their own mind, trying to protect the movement from what they see as a threat. It is admirable to try to confront threats to the movement.

However, what I don't agree with is the scientific arguments that these advocates are relying upon.

1. First, in order to credibly argue that advocates should simply ignore my arguments, one would have to contend that it is indeed accurate to state that 30 seconds of secondhand smoke can cause severe coronary artery dysfunction as bad as that seen in a chronic, active smoker.

After all, that's one of the main points I make in my post. I point out, as an example of the misleading and inaccurate claims that are being made, the following statement from an anti-smoking group's press release: "Research studies have shown that even just thirty seconds of exposure to secondhand smoke can make coronary artery function of non-smokers indistinguishable from smokers."

I don't see any reason why anti-smoking advocates should ignore my concerns about this statement. The statement is not only misleading, it is downright wrong and it is downright ridiculous. There is not a shred of evidence that 30 seconds of secondhand smoke exposure causes damage to the coronary arteries that is the same as that from chronic active smoking.

In fact, anti-smoking advocates should be concerned about this statement not only because it is wrong, but because it undermines the public's appreciation of the dangers of active smoking. The statement implies that active smoking is no worse in terms of coronary artery dysfunction than merely breathing in drifting tobacco smoke for 30 seconds.

2. Second, in order to credibly argue that advocates should simply ignore my arguments, one would have to contend that it is indeed accurate to state that a brief exposure to secondhand smoke puts nonsmokers at the same risk of a fatal heart attack as chronic, active smokers.

After all, that's one of the main points I make in my post. I point out, as an example of the misleading and inaccurate claims that are being made, the following statement from an anti-smoking group's fact sheet: "breathing drifting tobacco smoke for as little as 30 minutes (less than the time one might be exposed outdoors on a beach, sitting on a park bench, listening to a concert in a park, etc.) can raise a nonsmoker's risk of suffering a fatal heart attack to that of a smoker."

I don't see any reason why anti-smoking advocates should ignore my concerns about this statement. The statement is not only misleading, it is downright wrong and it is downright ridiculous. There is not a shred of evidence that 30 minutes of secondhand smoke exposure causes the same risk of a fatal heart attack as that of someone who has smoked actively for 30-40 years.

In fact, anti-smoking advocates should be concerned about this statement not only because it is wrong, but because it undermines the public's appreciation of the dangers of active smoking. The statement implies that active smoking is no worse in terms of fatal heart attack risk than merely breathing in drifting tobacco smoke for 30 minutes.

3. Third, in order to credibly argue that advocates should simply ignore my arguments, one would have to contend that it is indeed accurate to state that eating in a smoky restaurant increases the risk of a fatal or non-fatal heart attack by 30%, which is the same amount by which a lifetime of secondhand smoke exposure increases heart attack risk.

After all, that's one of the main points I make in my post. I point out, as an example of the misleading and inaccurate claims that are being made, the following statement from an anti-smoking group's smoking ban manual: "Current scientific data suggest that eating in a smoky restaurant can precipitate myocardial infarctions in nonsmokers and increase the risk of fatal and non-fatal cardiac events in nonsmokers by about 30 percent."

I don't see any reason why anti-smoking advocates should ignore my concerns about this statement. The statement is not only misleading, it is downright wrong and it is downright ridiculous. There is not a shred of evidence that eating in a smoky restaurant, which would provide about 30-60 minutes of secondhand smoke exposure, increases the risk of a heart attack by the same amount as a lifetime of exposure to secondhand smoke.

In fact, anti-smoking advocates should be concerned about this statement not only because it is wrong, but because it undermines the public's appreciation of the dangers of secondhand smoke itself. The statement implies that the risks of lifetime exposure to secondhand smoke are no worse than those of merely eating in a smoky restaurant for an hour or so."

4. Fourth, in order to credibly argue that advocates should simply ignore my arguments, one would have to contend that it is indeed accurate to state that coronary blood flow is reduced in healthy young adults exposed to secondhand smoke.

After all, that's one of the main points I make in my post. I point out, as an example of the misleading and inaccurate claims that are being made, the following statement from an anti-smoking group's smoking ban manual: "Blood flow in the coronary arteries is decreased in healthy young adults exposed to secondhand smoke."

I don't see any reason why anti-smoking advocates should ignore my concerns about this statement. The statement is not only misleading, it can certainly be construed to be wrong. There is not only a lack of evidence that basal coronary artery blood flow is reduced in healthy young adults exposed to secondhand smoke, there is documentation that there is no impairment of basal coronary blood flow in these subjects.

In fact, the Otsuka et al. study which is being relied upon to support this statement actually found that 30 minutes of secondhand smoke did not impair basal coronary blood flow in healthy adults. What was impaired was the coronary flow velocity reserve, a measure of the coronary arteries' ability to dilate in response to artificially imposed stressors. This finding does not mean that someone exposed to secondhand smoke suffers decreased coronary blood flow.

Anti-smoking advocates should be concerned about this statement not only because it is wrong, but because it undermines the public's appreciation of the dangers of active smoking. If a brief exposure to secondhand smoke impairs coronary blood flow, then secondhand smoke is worse than active smoking. Because active smoking doesn't impair basal coronary blood flow until a person develops narrowing of the coronary arteries, which may take no less than 15-20 years to occur.

5. Fifth, in order to credibly argue that advocates should simply ignore my arguments, one would have to contend that it is indeed accurate to state that the heart damage suffered by active smokers is no worse than that suffered by nonsmokers exposed to secondhand smoke for a mere 30 minutes. Obviously, this is a preposterous assertion. How could the damage to the heart caused by active smoking for years be only as bad as that caused by breathing in drifting tobacco smoke for a half hour?

After all, that's one of the main points I make in my post. I point out, as an example of the misleading and inaccurate claims that are being made, the following statement from an anti-smoking group's fact sheet: "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."

I don't see any reason why anti-smoking advocates should ignore my concerns about this statement. The statement is not only misleading, it could reasonably be construed as being wrong. If you look at a bunch of long-time active smokers and a bunch of nonsmokers who just ate at a smoky restaurant for a half hour, you will most definitely find that the smokers have a much higher likelihood of, and severity of, damage to the heart than nonsmokers.

Many of the smokers will in fact have had heart attacks from smoking-induced coronary artery disease. These smokers may have severe heart damage. Some may have ejection fractions of only 30-40%, or even less. In contrast, unless the nonsmokers had coronary artery disease from some other cause, none of them will show evidence of heart damage.

Moreover, a decrease in coronary artery flow velocity reserve does not mean that the heart is unable to get life-giving blood. What it demonstrates is endothelial dysfunction, which is significant if the exposure continues or recurs. However, it has no clinical consequences for a mere 30 minute, one-time exposure. The person exposed does not have any problem with their heart not getting life-giving blood. This aspect of the statement is grossly misleading.

In fact, anti-smoking advocates should be concerned about this statement not only because it is wrong, but because it undermines the public's appreciation of active smoking. It implies that the damage to the heart caused by a lifetime of active smoking is no worse than that caused by a mere 30 minute exposure to secondhand smoke. Why should a smoker quit smoking if they are suffering no more damage to his heart than someone who breathes in drifting tobacco smoke for 30 minutes?

6. Sixth, in order to credibly argue that advocates should simply ignore my arguments, one would have to contend that it is indeed accurate and well-documented that secondhand smoke exposure causes debilitating pulmonary emphysema. It would have to be accurate to draw a conclusion that is not found in the Surgeon General's report or in the California EPA report. It would have to be accurate to draw a conclusion that in fact runs counter to what the Surgeon General concluded.

Remember, the Surgeon General concluded that there is not sufficient evidence to conclude that secondhand smoke causes emphysema: "The evidence is suggestive but not sufficient to infer a causal relationship between secondhand smoke exposure and risk for chronic obstructive pulmonary disease."

After all, the fact that many anti-smoking groups are claiming that secondhand smoke causes emphysema is one of the main points I make in my post. I point out, as an example of the misleading and inaccurate claims that are being made, the following statement from an anti-smoking group's fact sheet: "Secondhand smoke can cause the debilitating disease pulmonary emphysema, causing severe damage to the walls of the air sacs, with the lungs eventually losing their capacity to expand and contract."

I don't see any reason why anti-smoking advocates should ignore my concerns about this statement. The statement is not only unsupported by both the Surgeon General's report and the California EPA report, but by relying on cherry-picking the evidence to document this claim, and by ignoring the conclusions of two major reports, anti-smoking groups are undermining the scientific value of the careful consideration of the scientific evidence that the Surgeon General and California EPA provided. If we are going to conclude that secondhand smoke causes a particular disease just based on a few studies, but before the evidence is really solid, then why bother with the Surgeon General's report in the first place?

The idea that secondhand smoke could cause pulmonary emphysema is certainly scary, and definitely worthy of vigorous research. However, it's simply premature to be drawing such a definitive conclusion and disseminating it to the public. It hurts our credibility to be doing so. Anti-smoking advocates should be concerned about this.

All of these arguments are reasons why anti-smoking advocates should not, if they care about our scientific integrity, ignore the concerns that I have expressed. And we haven't even gotten to the issue of whether or not it is misleading to claim that 20 or 30 minutes of secondhand smoke exposure increases your risk of suffering a heart attack.

I'll deal with that issue in more detail in a subsequent post, but for now, let's just stipulate, for the sake of argument, that it is indeed accurate and well-documented that a 20 or 30 minute exposure to secondhand smoke does cause heart attacks in nonsmokers with severe existing coronary artery disease. It is plausible that this is the case, although I personally don't believe there is enough evidence to make such a claim. But forget that - let's just assume that there is plentiful evidence.

My argument, then, is that it is still misleading to make an unqualified claim that brief secondhand smoke exposure increases heart attack risk. To avoid misleading the public, one would have to qualify the claim by making it clear that you are referring to people who already have severe coronary artery stenosis. After all, they are the only ones at risk. A brief secondhand smoke exposure is not going to cause you to develop heart disease if you don't have it already, and it's not going to turn moderate heart disease into severe disease.

So I maintain that I am on solid ground suggesting that many members of the public will be misled by telling them that brief secondhand smoke exposure may cause them to keel over from a heart attack. I contend that people will assume this puts them at risk, even if they don't have severe existing coronary artery disease.

What possible damage could there be from simply stating clearly that: "For people with severe existing heart disease, even a brief secondhand smoke exposure could be the trigger that causes them to have a heart attack."

It is troubling to me that the way the tobacco control movement is responding to these concerns is by trying to simply ignore them. And even worse, by imploring me to keep quiet about the science.

The appearance is that we cannot discuss the science. We must accept as truth everything that is being stated by our anti-smoking groups. If they say it, it must be true. It is not subject to discussion, and any meaningful scientific discussion of the issues must be quelled. We simply cannot allow the science to even possibly get in the way of the statements that we want to make in support of our position.

The advocate who complained that we cannot add qualifiers to every 30-second commercial seems to be agreeing that qualifiers are appropriate and that if we only had the space and time, we should add them. Yet I'm not talking about 30-second commercials. I'm talking about web sites, fact sheets, and manuals, where there is plenty of room to add qualifiers and to present the science accurately and completely, so as not to deceive people.

Of course, the ad hominem approach (telling me that I'm helping Big Tobacco to kill people) is merely a technique (it has been used repeatedly on me) to try to quell dissent from within our troops.

But the bottom line truth is that I'm trying to save the credibility of the movement, because I'm afraid that if we continue to make misleading, inaccurate, and absurd claims, we're going to destroy our scientific reputation. That will "help Big Tobacco to kill people."

Anti-Smoking Groups Fail to Correct Misleading Statements about Effects of Secondhand Smoke

Despite being informed that they were making misleading statements about the health effects of secondhand smoke, not a single one of the anti-smoking groups which received my letter has corrected its misleading claims.

One group - SmokeFreeOhio - did apparently delete from its "fact sheet" one of its misleading statements, but it retained two other ones.

SmokeFreeOhio did eliminate the following statement: "After twenty minutes of exposure to secondhand smoke, a nonsmoker'’s blood platelets become as sticky as a smoker’s, reducing the ability of the heart to pump and putting a nonsmoker at an elevated risk of heart attack."

However, it retained the statement: "Secondhand smoke can cause the debilitating disease pulmonary emphysema, causing severe damage to the walls of the air sacs, with the lungs eventually losing their capacity to expand and contract."

And it also retained the statement: "Breathing secondhand smoke for even a short time can have immediate adverse effects on the cardiovascular system and interferes with the normal functioning of the heart, blood, and vascular systems in ways that increase the risk of a heart attack."

None of the other groups challenged to correct or clarify their misleading claims made any changes in them.

The statement that SmokeFreeOhio chose to retain is even less well-supported than the one it apparently chose to delete. Neither the Surgeon General nor the California EPA concluded that secondhand smoke is a cause of emphysema, and the Surgeon General in fact concluded that there is not adequate evidence to make such a statement.

So SmokeFreeOhio has decided to retain a health claim that conflicts with the conclusions of the Surgeon General and the California EPA.

How does the group defend this decision? According to the individual with whom I corresponded, the conclusion that secondhand smoke causes emphysema was made in one study, and if I have a problem with that, I should contact the authors of that study.

By that criterion, smokers' rights groups are perfectly justified in telling the public that secondhand smoke does not cause heart disease and lung cancer. Because one could simply pick a study that didn't find such a result and base one's overall conclusion on that one study.

In other words, what SmokeFreeOhio is doing is cherrypicking, plain and simple. They found one study they liked, which happened to report an association between secondhand smoke and emphysema. Never mind the studies which failed to find an association. Never mind the conclusion of the Surgeon General that there is not adequate evidence to conclude that secondhand smoke causes emphysema.

Conveniently, when it came to the other retained statement - that even brief secondhand smoke exposure causes heart attacks - the representative of SmokeFreeOhio with whom I corresponded defended the statement solely based on the fact that the Surgeon General made this claim.

This is cherrypicking: when it comes to a statement you want to make, you simply pick out something that is in the Surgeon General's summary of his report. When it comes to a statement that you don't want to admit to (i.e., that secondhand smoke has not been found to cause emphysema), you simply ignore what is in the same Surgeon General's report.

This doesn't say a lot for the quality of the science in the tobacco control movement today, but it does show how things work in the movement nowadays.

The Rest of the Story

I can now say that the misleading statements being made by a large number of anti-smoking groups do not appear to be simple mistakes. Instead, they appear to be reflect intentional decisions to try to hype up the health effects of secondhand smoke to create more dramatic sound bites for the public.

Each of these organizations had the opportunity to correct or even just clarify their statements. They also had the opportunity to defend their statements, but failed to do so. The bottom line is that they have now chosen to retain these misleading statements on their web sites. These misleading and/or fallacious claims can no longer be attributed to innocent mistakes. This is an intentional effort to hype up the health effects of secondhand smoke, regardless of what the science actually supports.

At a minimum, each of these groups could simply have chosen to put a qualifying clause in their statements, noting that the alleged increased risk of a heart attack from a brief secondhand smoke exposure pertains only to people with severe existing coronary artery disease. Instead, they chose to keep their statements general, so that people might reasonably infer that anyone exposed to secondhand smoke even briefly might keel over from a heart attack.

Surely, it wouldn't have hurt anything to qualify these claims. What damage could possibly be done by trying to prevent the public from being misled?

Of course when you make a blanket statement that brief exposure to secondhand smoke causes heart attacks, the public is going to reasonably infer that this could happen to anyone. There is no way that any lay person (or even many scientists) would figure out that the claim only refers to people with severe existing coronary artery disease.

Thus, it is my opinion that each of these anti-smoking groups has intentionally chosen to retain what could easily be viewed as a claim that is very misleading to the public. There was no necessity to do this. These statements could have been clarified (at very least, qualified).

It is now clear to me that anti-smoking groups are quite comfortable with the notion that their communications might mislead the public into thinking that secondhand smoke is more hazardous than it actually is.

It is also clear to me that anti-smoking groups are severely biased in their appraisal of the scientific evidence. They are cherrypicking the studies which support the conclusions they would like to make, and ignoring the evidence that runs counter to their favored statements. This is not objective science. It is partisan science, and we are now no different from many of the groups and individuals who we criticize.

It is, honestly, very sad to me that the once-clear distinction between the scientific integrity of the tobacco control movement and that of the tobacco industry has been blurred. We have now adopted the tactic - once belonging to the tobacco companies - of cherrypicking evidence to support our position. We have adopted the tactic of misleading the public in order to support our agenda.

I guess it makes sense that it is the acute cardiovascular effects of secondhand smoke that seems to be the focal point for our misrepresentation of the science. After all, it is very alarming to the public to be told that even a brief secondhand smoke exposure may cause them to drop dead from a heart attack. Sudden death is a scary thing, and apparently, if we can tell people that secondhand smoke can cause it, we will. All we need is a shred of remote, indirect evidence and apparently that is enough to back up our claim. The days of substantiated claims in tobacco control are gone.

It is particularly disappointing for me because I no longer see a need for my own research on secondhand smoke. If anti-smoking groups are going to claim that brief secondhand smoke exposure increases the risk of a heart attack in a nonsmoker to the same level as a smoker, then what point is there for me to produce data that could be used to make accurate statements about secondhand smoke?

Perhaps the most troubling aspect of the lack of response to my letter is that not even the preposterous claim that 30 seconds of secondhand smoke exposure impairs coronary function to the same degree as chronic active smoking was corrected.

Let's face it: even if my arguments why it is not sound to conclude that 30 minutes of secondhand smoke exposure causes heart attacks are faulty, no one actually believes that 30 seconds of exposure has the same effect on coronary function as a lifetime of active smoking. The Association of Nonsmokers - Minnesota, has to (it seems to me) recognize that their statement was wrong.

If it were me, I would correct it the moment I realized the mistake. But it does not appear that the group has done that. I don't understand this failure to respond. To me, the impression I get is that this is an intentional decision to let the misleading (and absurd) statement stand. Why would you do this? It makes it appear that you couldn't care less about the public's perception of your scientific integrity.

The rest of the story is that it is now clear to me that the widespread dissemination of misleading and in many cases fallacious health claims by anti-smoking groups is not just a simple mistake. It appears to be an intentional decision to try to hype up the perceived effects of secondhand smoke.

By making the public think that even a brief exposure to secondhand smoke can make anyone keel over from a heart attack, I believe anti-smoking groups think they can create stronger public support for their agenda: promoting smoking bans.

While I support the agenda, I condemn the means being used to achieve this end.

Not only do I think it is unethical and does a severe disservice to the public, but I also think that our loss of scientific integrity will end up harming our credibility and reputation with the public, the media, and policy makers. Ultimately, this will set back efforts to protect the public from the hazards of secondhand smoke, negating any fleeting gains from making people think that 30 minutes in a restaurant with smoking present is enough to make a healthy young person drop dead of a heart attack.

Surgeon General Misrepresented Conclusions of His Report Even in Summary of Report Conclusions

Previously, I reported that the Surgeon General misrepresented the conclusions of his 2006 report on the health consequences of involuntary smoking in his press release and ancillary press materials that accompanied the report. Here, I reveal that the Surgeon General misrepresents the conclusions of the report in his summary of the conclusions of the report itself.

In his summary of the 6 major conclusions of the report, the Surgeon General makes the following statements:

1. "Breathing secondhand smoke for even a short time can have immediate adverse effects on the cardiovascular system and interferes with the normal functioning of the heart, blood, and vascular systems in ways that increase the risk of a heart attack."

2. "Short exposures to secondhand smoke can cause blood platelets to become stickier, damage the lining of blood vessels, decrease coronary flow velocity reserves, and reduce heart rate variability, potentially increasing the risk of a heart attack."

The Rest of the Story

Here is why each of these statements is misleading and mis-representative of the actual conclusions of the Surgeon General's report.

1. "Breathing secondhand smoke for even a short time can have immediate adverse effects on the cardiovascular system and interferes with the normal functioning of the heart, blood, and vascular systems in ways that increase the risk of a heart attack."

It is true that breathing secondhand smoke for a short time can have immediate adverse effects on the cardiovascular system and one could reasonably state that these effects represent something other than normal functioning of the heart, blood, and vascular systems. However, there is not evidence that these effects, which have been shown to be transient, increase the risk of a heart attack.

The statement is misleading, then, because it suggests that the adverse acute effects of a brief exposure to secondhand smoke have been shown to increase the risk of a heart attack. This is simply not the case.

Moreover, even if the statement were accurate, it misrepresents the conclusions of the actual Surgeon General's report, which is devoid of any conclusion that short-term exposure to secondhand smoke increases heart attack risk.

If you read through or search the entire 727-page report, you will not find any conclusion that a brief exposure to secondhand smoke increases heart attack risk. And for good reason: there is no such evidence. The report itself is very carefully reviewed science and it is cautious in drawing causal conclusions. Not so the summary of the conclusions of the report provided by the Surgeon General.

It is as if the Surgeon General didn't even read his own report. It is as if he simply decided in advance the claims he wanted to make, and made them, regardless of whether there was evidence in the report to support them, or whether the report had drawn those conclusions.

It is important to add that even the speculation about the potential effects of a brief secondhand smoke exposure on heart attack risk apply only to people with severe existing coronary artery disease, who are essentially so fragile that virtually any insult (even eating a hamburger) could cause a heart attack. Without qualifying the claim to make it clear that it is referring only to people with severe coronary artery disease, the claim is very misleading.

2. "Short exposures to secondhand smoke can cause blood platelets to become stickier, damage the lining of blood vessels, decrease coronary flow velocity reserves, and reduce heart rate variability, potentially increasing the risk of a heart attack."

It is true that short exposure to secondhand smoke can increase platelet aggregation, cause endothelial dysfunction (damage to the lining of blood vessels), decrease coronary velocity reserves, and reduce heart rate variability. However, there is not evidence that these effects, which have been shown to be transient, increase the risk of a heart attack.

The statement is misleading, then, because it suggests that the adverse acute effects of a brief exposure to secondhand smoke have been shown to increase the risk of a heart attack. This is simply not the case.

Moreover, even if the statement were accurate, it misrepresents the conclusions of the actual Surgeon General's report, which is devoid of any conclusion that short-term exposure to secondhand smoke increases heart attack risk.

If you read through or search the entire 727-page report, you will not find any conclusion that a brief exposure to secondhand smoke increases heart attack risk. And for good reason: there is no such evidence. The report itself is very carefully reviewed science and it is cautious in drawing causal conclusions. Not so the summary of the conclusions of the report provided by the Surgeon General.

Once again, it is as if the Surgeon General didn't even read his own report. It is as if he simply decided in advance the claims he wanted to make, and made them, regardless of whether there was evidence in the report to support them, or whether the report had drawn those conclusions.

It is important to add, again, that even the speculation about the potential effects of a brief secondhand smoke exposure on heart attack risk apply only to people with severe existing coronary artery disease, who are essentially so fragile that virtually any insult (even eating a hamburger) could cause a heart attack. Without qualifying the claim to make it clear that it is referring only to people with severe coronary artery disease, the claim is very misleading.

What This All Means

What this means is that there really wasn't much of a need for a 727-page report. If the Surgeon General was just going to communicate alarmist claims to the public that weren't in the report itself, why waste the effort preparing the 727 pages?

Well it occurs to me that there is a potential reason: to make it appear that the conclusions being communicated were carefully reviewed and scrutinized and that they are therefore not subject to questioning. There is no way that the public, or even most anti-smoking advocates or groups, are going to read through the entire 727-page report to figure out what claims made by the Surgeon General are well-documented and supported by the evidence and conclusions drawn in the report and which are not. By attaching what basically amounts to a propaganda statement along with the report, it makes it appear to all that these conclusions are documented, when in fact they are not.

Whether this is simply a serious mistake or an intentional attempt to deceive is not clear to me. But the effect is that anti-smoking groups across the country have ended up misrepresenting the science to the public, themselves deceived into thinking that these particular conclusions are rock solid.

For example, SmokeFreeOhio has repeated one of these two "conclusions" in its own fact sheet. When I mentioned this to the group, it responded by noting that the Surgeon General had drawn this conclusion, so it must be true. I pointed out that the conclusion was nowhere to be found in the report itself, but when someone as high up as the Surgeon General makes a statement, it is going to be very difficult to convince people that it is flawed. This is what makes it particularly problematic that the Surgeon General has misrepresented the actual conclusions of the report. There is almost no way to repair the damage.

If we are ready, based on the available evidence, to conclude that brief exposure to secondhand smoke causes heart attacks among nonsmokers, then I submit that we no longer need 727-page reports, or any Surgeon General's reports, for that matter. What is the point of preparing a 727-page report that does not conclude that brief secondhand smoke exposure causes heart attacks if the Surgeon General, followed by hundreds of anti-smoking groups, are going to claim to the public that brief exposures do cause heart attacks? To me, this undermines the need for, and importance, of having sound science to support anti-smoking groups' statements and actions.

Frankly, we might as well just make up the statements we'd like. If we're not going to require solid documentation for our claims, then why work under the pretense that our claims are well-documented by the evidence? Why not just drop the pretense altogether and just state whatever we feel like?

It is unfortunate, but we have reached a point where anti-smoking groups need to actually read the full 727-page report if they want to be sure that any claims they make are accurate and well-supported by the report. It is simply not enough to take the Surgeon General's summary of the conclusions of the report and repeat them to the public. They need to be independently verified, because apparently, even at the highest levels of the tobacco control movement, the desire to produce dramatic claims about the health effects of secondhand smoke has superceded the desire to be careful, cautious, and solidly supported by science.

Moment of Truth for Anti-Smoking Groups Has Arrived

While the letter I sent out to my secondhand smoke mailing list went out to a large number of anti-smoking groups which have misleading or inaccurate health claims about secondhand smoke on their web sites, there are several sentinel groups that I will be watching with special interest. Each of these groups has been directly contacted and has been sent my letter, so their misleading claims have been brought directly to their attention.

In this post, I list these groups, their fallacious claims, and the reasons why I consider these particular groups' actions to be important in indicating the direction that the movement is going and in assessing whether or not these are simply innocent mistakes or whether there is an intentional effort to deceive people by hiding information and not telling the complete story or considering all the evidence.

First, let me say that this has been going on now for nine months. It was January 30 that I first brought this issue to the attention of the tobacco control community. My initial post on this issue, which pointed out the fallacious claim being made by Action on Smoking and Health (ASH) - that 30 minutes of secondhand smoke raises a nonsmoker's risk of suffering a fatal heart attack to that of a smoker's - was widely circulated on tobacco control list-serves and discussion forums, including GLOBALink. ASH apparently was aware of my post, which was what presumably prompted them to defend their misleading claims.

A highly visible and very contentious series of attacks against me on GLOBALink ensued, ending in my expulsion from GLOBALink for not agreeing to stop criticizing anti-smoking groups for misleading the public.

As more and more fallacious claims were uncovered, I publicized them as well, noting that the amount of time that it apparently takes for secondhand smoke to cause heart disease kept dropping from 30 minutes to 20 minutes to 5 minutes and ultimately, to 30 seconds.

Here are the key groups, their claims that I believe are misleading, the reasons why the claims are deceptive, and why I consider the particular group's response to be critical. It is important to note that each of these groups has been contacted directly about these claims, so they cannot claim that they were not aware that they might be communicating inaccurate or misleading information to the public.

The Rest of the Story

1. Action on Smoking and Health

The Claim: "Even for people without such respiratory conditions, breathing drifting tobacco smoke for even brief periods can be deadly. For example, the Centers for Disease Control [CDC] has warned that breathing drifting tobacco smoke for as little as 30 minutes (less than the time one might be exposed outdoors on a beach, sitting on a park bench, listening to a concert in a park, etc.) can raise a nonsmoker'’s risk of suffering a fatal heart attack to that of a smoker."

Why It is Misleading: First of all, the CDC never warned that 30 minutes of secondhand smoke exposure raises a nonsmoker's risk of a fatal heart attack to that of a smoker. Such a claim is absurd on its face. How could a nonsmoker possibly be at equal heart attack risk as that of a smoker after only 30 minutes of exposure? This would mean that chronic active smoking is no more dangerous to the heart than breathing in drifting smoke for 30 minutes.

Why the Response is Critical: ASH is one of the most important national anti-smoking organizations and has been at the center of the movement for decades.

2. SmokeFreeOhio

The Claim: "After twenty minutes of exposure to secondhand smoke, a nonsmoker'’s blood platelets become as sticky as a smoker'’s, reducing the ability of the heart to pump and putting a nonsmoker at an elevated risk of heart attack."

Why It is Misleading: There is no evidence that the increase in platelet activity caused by 20 minutes of secondhand smoke exposure reduces the ability of the heart to pump. Brief exposure to secondhand smoke actually increases cardiac output. There is no evidence that this platelet activation can cause a heart attack, and it certainly cannot cause a heart attack in an individual without severe existing coronary artery stenosis.

The Claim: "Secondhand smoke can cause the debilitating disease pulmonary emphysema, causing severe damage to the walls of the air sacs, with the lungs eventually losing their capacity to expand and contract."

Why It is Misleading: It doesn't appear to be true. There is considerable debate over the extent to which long-term exposure to secondhand smoke causes significant decrements in lung function in non-asthmatic nonsmokers, much less pulmonary emphysema. The two most recent and most comprehensive reports on the health effects of secondhand smoke (those of the Surgeon General and the California EPA) failed to conclude that secondhand smoke causes emphysema. The Surgeon General concluded that there was not sufficient evidence to draw such a conclusion.

The Claim: "Other Conclusions of the Surgeon General's Report: Breathing secondhand smoke for even a short time can have immediate adverse effects on the cardiovascular system and interferes with the normal functioning of the heart, blood, and vascular systems in ways that increase the risk of a heart attack."

Why It is Misleading: The Surgeon General's report did not conclude that breathing secondhand smoke for even a short time increases the risk of a heart attack. Such a claim is simply nowhere to be found in the report.

Why the Response is Critical: SmokeFreeOhio is trying to win a very contentious ballot initiative battle against Smoke Less Ohio by convincing voters that the opposition is misleading the public. If SmokeFreeOhio is also misleading the public, then they lose all credibility and don't have a leg to stand on in making this public appeal. Discontinuing its own deception is a prerequisite to asking the public to reject the pleas of the opposition because of its deception.

3. Americans for Nonsmokers' Rights

The Claim: "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."

Why It is Misleading: It is absurd to claim that the damage caused to the heart by chronic active smoking is no worse than that caused by a mere 30 minutes of passive exposure. While the coronary arteries are impaired in their ability to dilate, this is an experimental finding and has no clinical significance in terms of decreasing the flow of life-giving blood to the heart. In fact, the study being used to support this claim documented that there was no decline in basal coronary blood flow among the subjects exposed to 30 minutes of secondhand smoke.

Why the Response is Critical: ANR is the leading national organization promoting smoking bans and providing technical assistance and scientific information to anti-smoking groups throughout the country. If they don't have their facts straight, then the entire tobacco control movement will end up misleading the public. In addition, ANR has been vocal in criticizing others for junk science claims. It must have some scientific integrity of its own if it is going to maintain any credibility in issuing these attacks.

4. Association for Nonsmokers - Minnesota

The Claim: "Research studies have shown that even just thirty seconds of exposure to secondhand smoke can make coronary artery function of non-smokers indistinguishable from smokers."

Why It is Misleading: First of all, it is absurd to claim that just 30 seconds of exposure is enough to cause coronary artery dysfunction. There is no evidence at all to support such a claim. It is also absurd to claim that 30 minutes of exposure makes coronary artery function of nonsmokers indistinguishable from that of chronic active smokers. If this were the case, then the coronary disease risks of lifetime, chronic active smoking would only be as dangerous as a mere 30 minutes of passive smoking. In fact, active smoking often causes coronary artery stenosis in smokers, which is easily distinguishable from the coronary arteries of an individual nonsmoker exposed for only 30 minutes, which would show no stenosis.

Why the Response is Critical: This claim is so fallacious and so damaging to public health goals (it undermines the public's appreciation of the dangers of active smoking) that it requires an immediate correction.

5. ClearWay Minnesota

The Claim: "Blood flow in the coronary arteries is decreased in healthy young adults exposed to secondhand smoke."

Why It is Misleading: In fact, the study that is being used as the basis for this claim revealed that coronary blood flow in healthy young adults exposed to secondhand smoke was not decreased. What was decreased was the coronary flow velocity reserve, which has no clinical meaning for these young adults in the absence of sustained or repeated exposure. The clear impression of the statement is that a healthy young person exposed to secondhand smoke for 30 minutes will suffer a reduction in coronary artery blood flow. This is untrue.

The Claim: "Current scientific data suggest that eating in a smoky restaurant can precipitate myocardial infarctions in nonsmokers and increase the risk of fatal and non-fatal cardiac events in nonsmokers by about 30 percent."

Why It is Misleading: There are no scientific data which show that eating in a smoky restaurant can cause a heart attack. It is impossible that eating in a smoky restaurant could increase the risk of cardiac events by 30%, since being exposed to secondhand smoke for a lifetime only increase the risk of cardiac events by about 30%.

Why the Response is Critical: These inaccurate claims appear in a toolkit that is designed to be used by many local anti-smoking groups to promote smoking bans. Failure to correct these "facts" will result in the widespread dissemination of false health claims by anti-smoking groups. These claims are particularly fallacious, especially the suggestion that a mere 30 minutes of exposure can increase heart disease risk by 30%.

6. Smoke Free Wisconsin

The Claim: "Accumulating evidence suggests that even short-term exposure to secondhand smoke can trigger a heart attack."

Why It is Misleading: There is actually no direct evidence that short-term exposure to secondhand smoke can trigger a heart attack. Moreover, it is implausible that short-term exposure could trigger a heart attack in a person without severe existing coronary artery disease. Thus, this statement is not only unsupported by the evidence, but it is misleading by virtue of not specifying that it is referring only to individuals with severe coronary artery stenosis.

Why the Response is Critical: I think Smoke Free Wisconsin's response is critical because it was this group that made perhaps the most absurd public claim about secondhand smoke: that 5 minutes of exposure causes the body to start closing off arteries.

Action on Smoking and Health Promoting Street and Sidewalk Smoking Bans and Completely Misrepresenting the Science

NOTE: In recognition of the challenge I have issued to anti-smoking groups to correct their misleading claims (a letter has been sent to a large number of these groups), I am re-publishing my first post about the misleading claims that anti-smoking groups are making about the acute cardiovascular health effects of secondhand smoke, which appeared on January 30, 2006. Here it is:

In a press release issued Saturday, Action on Smoking and Health (ASH) became the first anti-smoking organization to officially promote the adoption of laws broadly banning smoking outdoors, including on streets and sidewalks. ASH backed up its support for these smoking bans by offering to assist local governments in defending the legality of these laws.

According to the press release: "The formal designation of secondhand tobacco smoke as a 'toxic air contaminant' opens the door to many additional restrictions on smoking, both in cars where children are present and even on public sidewalks... One city has already asked its staff to submit a report on the legality and feasibility of prohibiting smoking on city streets and sidewalks -- the legality of which has already been upheld in a law suit in which ASH's Executive Director ... participated. The designation follows on the heels of findings that even small amounts of tobacco smoke outdoors can be dangerous. ... ASH also says it will help to defend the legality of bans on smoking on streets, sidewalks, and in other public places as it did successfully in the past."

To support its recommendation that smoking be banned on streets and sidewalks, ASH presented scientific data on the health hazards associated with brief exposure to secondhand smoke, stating that: "Even for people without such respiratory conditions, breathing drifting tobacco smoke for even brief periods can be deadly. For example, the Centers for Disease Controls [CDC] has warned that breathing drifting tobacco smoke for as little as 30 minutes (less than the time one might be exposed outdoors on a beach, sitting on a park bench, listening to a concert in a park, etc.) can raise a nonsmoker'’s risk of suffering a fatal heart attack to that of a smoker. The danger is even greater for those who are already at an elevated risk for coronary problems: e.g., men over 40 and postmenopausal women, anyone who is obese, has diabetes, a personal or family history of heart or circulatory conditions, gets insufficient exercise, has high blood pressure, cholesterol, etc."

ASH also stated that: "A 2004 study by the Centers for Disease Control and Prevention found that as little as 30 minutes of exposure to drifting secondhand smoke can have a serious or even lethal health impact by rapidly increasing the tendency of blood to clot."

Finally, ASH stated: "In cases where drifting tobacco smoke was present and a nonsmoker suffered a heart attack, asthmatic attack, or other similar problems, the municipality which owns and operates the beach, park, playground, etc. could be liable since it was on notice of the known health dangers but failed to take the 'reasonable' step of banning smoking as taken by many other outdoor areas."

The Rest of the Story

I am quite serious when I suggest that this action by ASH, if unchecked by the rest of the tobacco control community (and especially if supported by other anti-smoking groups), is going to cause the whole smoke-free movement to implode, resulting not only in no bans on smoking on sidewalks and streets, but in a severe dent in what I see as legitimate efforts to regulate smoking indoors, in workplaces.

There is, in my opinion, simply no justification for invoking the state's police powers to regulate smoking on streets and sidewalks, places where people are free to move about and where, in most situations, people can simply avoid substantial exposure to secondhand smoke. And I am aware of no scientific evidence that secondhand smoke exposure on streets and sidewalks is a significant public health problem.

And I think the public is going to view smoke-free advocates as complete fanatics because of this type of action that ASH is taking.

Nevertheless, the saddest part of the story is not ASH's promotion of banning smoking on streets and sidewalks. Instead, the saddest part of the story is the completely misleading, inaccurate, and irresponsible public representation of the science which ASH alleges supports the need to ban smoking on streets and sidewalks.

It is simply not the case that breathing drifting tobacco smoke for as little as 30 minutes can raise a nonsmoker'’s risk of suffering a fatal heart attack to that of a smoker, and in my view, it is not the case that CDC made such a claim.

The truth is that an otherwise healthy nonsmoker cannot suffer a heart attack as a result of 30 minutes of exposure to secondhand smoke. A nonsmoker's risk of a heart attack from breathing tobacco smoke for 30 minutes is not the same as that of a smoker. It is actually ZERO.

You are not going to have a heart attack if you don't have coronary artery disease; and 30 minutes of exposure to secondhand smoke is not going to clog your coronary arteries.

I cannot over-emphasize the fact that ASH's claim is completely fallacious. It's not like ASH is distorting the truth here. In my opinion, they are just completely making this up, or at least, misinterpreting the data so badly that it has the appearance of coming out of nowhere. You simply aren't going to get atherosclerosis and clogged coronary arteries in 30 minutes!!!

It is not just inaccurate and misleading to make a public statement like this. It is also, in my opinion, irresponsible. This could scare nonsmokers into thinking that they are going to keel over and drop dead from a heart attack if they walk down a street and breathe in secondhand smoke for 30 minutes.

And I think it is also irresponsible to try to intimidate city officials by suggesting to them that if they don't ban smoking in a beach, park, or playground, they are putting nonsmokers at risk of dropping dead of a heart attack. There is simply no evidence that acute exposure to secondhand smoke can cause a heart attack in a healthy nonsmoker, and it is completely implausible that any such evidence could exist in the first place. You can't develop coronary artery disease in 30 minutes.

What the CDC did say, and what the relevant research does say, is that 30 minutes of exposure to secondhand smoke can cause endothelial dysfunction, as measured by coronary flow velocity reserve (CFVR), in nonsmokers to the same degree as seen in smokers (see Otsuka R, Watanabe H, Hirata K, et al. Acute effects of passive smoking on the coronary circulation in healthy young adults. JAMA 2001; 286:436-441 and Pechacek TF, Babb S. How acute and reversible are the cardiovascular risks of secondhand smoke. BMJ 2004; 328:980-983).

But endothelial dysfunction is a far cry from a heart attack!!!

In fact, what endothelial dysfunction measures is the early process of atherosclerosis. As the authors (Otsuka et al.) concluded: "The present findings suggest that reduction of CFVR after passive smoking may be caused by endothelial dysfunction of the coronary circulation, an early process of atherosclerosis, and that this change may be one reason why passive smoking is a risk factor for cardiac disease morbidity and mortality in nonsmokers."

What this means is that acute exposure to secondhand smoke can result in endothelial dysfunction in nonsmokers that if prolonged and repeated over a long time, could eventually result in atherosclerosis and heart disease.

In other words, this study provides a potential mechanism for the observed increase in heart disease risk among passive smokers. It provides biologic plausibility for a causal relationship between exposure to secondhand smoke and heart disease. But it does not suggest that an otherwise healthy nonsmoker could suffer a heart attack as a result of a 30 minute exposure to secondhand smoke, and it certainly does not mean that a nonsmoker's risk of a heart attack approaches that of a smoker's after 30 minutes of exposure to secondhand smoke.

The only possible acute risk of secondhand smoke exposure in terms of heart attack risk is the slight possibility that in people with existing severe coronary artery disease, the endothelial dysfunction triggered by acute exposure to secondhand smoke might be enough to trigger a coronary event (i.e., a heart attack). There is very little evidence that this is the case, but it is possible, and I wouldn't argue with recommending that nonsmokers with coronary artery disease should try to minimize or eliminate their exposure to secondhand smoke.

It is also worth noting that one piece of evidence ASH relied upon to support its contention that small amounts of acute exposure to secondhand smoke causes heart attacks is what Jacob Sullum aptly called "The Vanishing Miracle of Helena and Pueblo."

The fact that heart attack admissions fluctuated downwards in these two small cities in association with a smoking ban was apparently enough for ASH to conclude not only that the downward fluctuation was due to the smoking ban, but that the observed effect was due to a reduction in secondhand smoke exposure (even though it is completely implausible that the observed reductions could be due to reduced secondhand smoke exposure even if they were due to the smoking ban in the first place and even though there is no evidence that a reduction in secondhand smoke exposure explains the decline [smoking status was not measured in either study]).

The rest of the story is two-fold:

First, the rest of the story is that the anti-smoking movement is now on record as supporting and promoting a wide ban on smoking in non-enclosed outdoor areas where people can move about freely, including on public streets and sidewalks. Unless this is contested by other anti-smoking groups, I believe it is a big step towards making ourselves perceived by the public as a bunch of fanatics.

And I believe it is a big step towards what I fear will be the eventual implosion of the smoke-free movement. After all, public opinion is critical to enable even legitimate legislation, and if we risk losing that, we risk losing everything. That is why I am bringing this to the tobacco control community's attention and speaking out against it.

Second, the rest of the story is that the misuse and misrepresentation of science by anti-smoking groups has risen to a new and unprecedented level. An anti-smoking group has claimed that 30 minutes of secondhand smoke exposure raises a nonsmoker's risk of a heart attack to the level of a smoker. This is not just a stretch of the science, it is completely fallacious and it seems to come out of nowhere.

I'm not claiming that it is an intentional fabrication. Perhaps it is just a very errant interpretation of the scientific evidence. But either way, the bottom line is that it is a public misrepresentation of the scientific evidence that is misleading, inaccurate, and irresponsible.

This is the lowest I have observed the anti-smoking movement sinking in terms of misleading the public, because there is simply no basis whatsoever for the claim that a nonsmoker's risk of a heart attack after 30 minutes of secondhand smoke exposure is the same as that of a smoker's. In fact, after 30 minutes of secondhand smoke exposure, an otherwise healthy nonsmoker's risk of a heart attack is basically ZERO. Now you can see why I don't view this as merely a gross over-estimate (like the Helena and Pueblo claims, where at least there is some plausibility to the idea that a smoking ban could reduce heart attacks to some small degree), but as a "fact" that has the appearance of coming out of nowhere.

It should go without saying that I think ASH needs to publicly retract or correct this communication and apologize for misleading the public so severely.