Tuesday, March 31, 2015

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

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

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

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

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

The Rest of the Story

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

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

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

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

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

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

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

Thursday, March 26, 2015

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

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

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

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

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

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

2. E-cigarettes turn kids into addicts.

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

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

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

4. Vaping causes asthma attacks.

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

5. E-cigarettes cause heart attacks.

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

6. Vaping causes as much lung inflammation as smoking.

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

7. Nicotine is as addictive as heroin.

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

The Rest of the Story

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

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

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

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

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

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

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

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

Wednesday, March 25, 2015

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

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

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

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

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

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

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

The Rest of the Story

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

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

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

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

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

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

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

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

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

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

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

Tuesday, March 24, 2015

Washington Governor and Legislature Seeking to Protect Cigarette Profits; Legislation Would Decimate Public Health by Increasing Cigarette Consumption

Under the guise of acting to "protect the children," the Washington State Governor and legislature are poised to protect cigarette profits at the expense of the public's health.

A new bill, introduced last week in the House, would impose the strictest regulations on e-cigarettes of any state in the country. In addition to banning the sale of e-cigarettes to minors, requiring labeling changes, and requiring child-proof packaging of e-liquids (which are reasonable), the bill would also: (1) ban flavorings - other than tobacco and menthol; (2) ban online e-cigarette sales; and (3) impose a 95% tax on e-cigarettes and all e-cigarette accessories (e.g., batteries); and (4) require the name and address of every purchaser of e-cigarettes to be recorded and saved for five years.

The Rest of the Story

This is one of the worst examples of window dressing that I've ever seen in tobacco control. The legislation makes it look like these politicians are deeply concerned about the health of Washington's children, but in reality, it shows a lack of courage to actually take on Big Tobacco and confront the real problem causing the prospects for early death and chronic disease among children in Washington state.

If the Washington governor and legislature were truly concerned about the health of the state's children, they would immediately impose a 95% tax on real cigarettes, require real cigarette purchasers' names and addresses to be recorded and saved for five years, and establish a cigarette tax revenue-funded comprehensive statewide tobacco prevention program accompanied by an aggressive anti-smoking media campaign.

Instead, these politicians are going after an easy target - the vaping industry - so that they can make it appear that they really care about children's health.

But I call baloney on them.

This legislation is a dream come true for cigarette companies, cigarette sales, and cigarette profits in the state of Washington. The fake cigarettes are being treated far more harshly than the real ones, which are the ones actually killing people in Washington and actually threatening the lives and health of Washington adolescents.

Why should the name of every e-cigarette purchaser need to be recorded, while anyone can just walk up to a counter at the local convenience store and purchase a pack of cigarettes without giving out their name or address?

Why should the tax on e-cigarettes be massively raised, while the tax on real cigarettes remain unchanged?

Let's be very clear. This bill is going to do very little good, but a lot of harm.

First of all, while e-cigarette use among youth is definitely concerning, there is no evidence that it is actually causing any significant harm. The bulk of the current evidence suggests that electronic cigarettes are deterring youth away from smoking real cigarettes, which in the long run may actually have a positive effect on their health. Moreover, there is no evidence that youth, even those who are "current" e-cigarette users, use them any more than occasionally. To be sure, some of the measures in the proposed legislation, such as its restrictions on the sale of e-cigarettes to minors and its requirements for child-proof packaging make sense. However, the rest of the legislation is dramatic overkill which is going to all but destroy the e-cigarette industry in Washington.

With the banning of flavors, most vape shops will be forced to go out of business. With the banning of internet sales, all vaping businesses without brick-and-mortar sales will be forced out of business. Not only will this legislation have a devastating financial impact on small businesses, but it will also significantly harm the public's health. 

Why? Because it will undoubtedly make it more difficult and less enticing for smokers to try to quit smoking. E-cigarettes have become one of the primary methods by which many smokers try to quit. By greatly limiting the availability of these products, greatly increasing their price, and taking away all the interesting flavors, the incentive for smokers to quit via electronic cigarettes will be all but completely destroyed. As a result, smoking in Washington will increase, as will the diseases and deaths that are associated with cigarette consumption. Many vapers will simply return to smoking once their favored products are taken off the market. The effects on the public's health will be stark and immediate.

The rest of the story is that Washington politicians pushing this legislation are essentially calling for a ban on all existing electronic cigarettes. Why? Because every electronic cigarette contains flavors. In fact, the presence of flavors is the only distinguishing characteristic of different brands of e-liquids or cartridges.

The ingredients of virtually every electronic cigarette liquid on the market are:

1. Nicotine
2. Propylene glycol and/or glycerin
3. Flavors

That's it! That's basically all there is.

For example, let's take a look at the ingredient list for some of the major e-cigarette brands on the market:

VUSE: nicotine, PG, VG, water, flavorings
Blu: nicotine, PG, VG, water, citric acid, flavorings
Mark Ten: nicotine, PG, VG, flavorings
V2: nicotine, PG, flavorings
LOGIC: nicotine, PG, water, flavorings
NJOY: nicotine, PG, VG, flavorings

Virtually every electronic cigarette consists of nicotine, PG and/or VG, and flavorings, plus or minus a little water and perhaps citric acid. It is the flavor that makes the brand. In most cases, even the "tobacco"-flavored electronic cigarettes contain flavorings.

It's easy to see that a ban on flavors is essentially a ban on electronic cigarettes. It would ban virtually every electronic cigarette currently on the market. Moreover, it would mean that there could only be one type of electronic cigarette liquid, which would have to contain just nicotine and propylene glycol and/or glycerine, and there would be no way for different liquids to distinguish themselves. The product would completely lose its appeal to smokers and the cigarette market would be protected forever. Menthol, mint, and wintergreen would be the only way to distinguish between e-cigarette brands. Thus, there would really be only four possible e-cigarette "brands" available. This would completely undermine the market and remove any competitive advantage over tobacco cigarettes.

Such a regulatory action would remove the ability of companies to market their products and would eliminate the taste and appeal of the product, handing the entire cigarette category over to Big Tobacco.

In my opinion, a ban on flavors in electronic cigarettes would completely destroy the electronic cigarette market. If the Washington legislature is going to ban the flavors in e-cigarettes, then it might as well just ban the product entirely.

Why would these public officials support an action that will end the great electronic cigarette experiment and permanently hand the entire cigarette market over to Big Tobacco?

If any of my readers can find out, please let me know because it is baffling to understand why public officials would want to protect cigarettes from the most serious competition they have ever faced. If this flavoring ban is enacted, the Washington legislature will have the rare role of being the hero of the cigarette promotion movement.

Monday, March 23, 2015

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

Today, I reveal the brackets and the regional finalists for the 2015 Rest of the Story Worst E-Cigarette Lie Championship. Those who have been following the Rest of the Story recently will recognize that there were a huge number of eligible contestants and that the work of the selection committee was difficult. The semifinalists and finalists will be revealed over the coming days. Criteria for selection included: (1) the extent of the misinformation provided to the public about e-cigarettes; and (2) the amount of probable damage to the public's health resulting by the misinformation.


University of California, San Francisco (UCSF) vs. California Department of Public Health

UCSF: In an article published in USA Today, Dr. Stanton Glantz stated definitively that electronic cigarettes are a gateway to smoking. He was quoted as stating: "There's no question that e-cigarettes are a gateway to smoking."

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


Centers for Disease Control and Prevention (CDC) vs. Greenville (SC) Health System

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

Greenville Health System: On the Greenville Health System blog, a respiratory therapist wrote: "I strongly oppose the use of e-cigarettes. It is unregulated and could potentially be more dangerous than a regular cigarette." Clearly, this claim that cigarette smoking might be healthier than vaping is a lie.


Mayo Clinic vs. University of Kentucky (Tobacco-Free UK)

Mayo Clinic: The Mayo Clinic stated that: "with nicotine inhalers you receive only nicotine." Even the arch-enemy of electronic cigarettes - Dr. Stanton Glantz - has acknowledged that nicotine inhalers deliver to users the following chemicals: Formaldehyde; Acetaldehyde; o-methylbenzene; Cadmium; Nickel; and Lead. In fact, I have shown that nicotine inhalers actually deliver higher amounts of six carcinogens than electronic cigarettes. The Mayo Clinic also stated that: "No studies have been done to examine the safety of e-cigarettes." However, there have been many studies that examined the safety of electronic cigarettes.

University of Kentucky Tobacco-Free Task Force: Tobacco-Free UK at the University of Kentucky warned the campus community that electronic cigarettes cause cancer. The text of its poster stated that "it causes cancer." The Tobacco-Free UK organization appears to be a UK Tobacco-Free Task Force, which is headed up by Ellen Hahn, a professor who has made misleading claims about electronic cigarettes.


Food and Drug Administration (FDA) vs. American Lung Association (ALA)

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

ALA: A CNN Opinion page featured an op-ed on electronic cigarettes from Harold Wimmer, the president and CEO of the American Lung Association. In the piece, Wimmer argued that Big Tobacco companies are using electronic cigarettes to create "new nicotine addicts" and that they are enticing youth with flavors such as bubble gum and cotton candy. According to the American Lung Association piece: "Big Tobacco desperately needs new nicotine addicts and is up to its old tricks to make sure it gets them. E-cigarettes are being aggressively marketed to children with flavors like Bazooka Bubble Gum, Cap'n Crunch and Cotton Candy. Joe Camel was killed in the 1990s, but cartoon characters are back promoting e-cigarettes." However, none of the three tobacco companies which market electronic cigarettes in the U.S. are selling electronic cigarettes with bubble gum, cap'n crunch, or cotton candy flavors. In fact, the disposable electronic cigarettes being sold by Big Tobacco companies (i.e., the ones most likely to be purchased by youth) are available solely in classic tobacco or menthol flavors.


West Regional: California Department of Health Services defeats UCSF

Since Dr. Glantz is recognized as an arch-enemy of electronic cigarettes, his lie about e-cigarettes being a gateway to smoking is less likely to cause damage. However, the California Department of Health Services, as a large and respected state health department, is likely to be causing public health damage with its false assertions that e-cigarettes are as addictive as tobacco cigarettes and that e-cigarettes do not help people quit smoking.

South Regional: CDC defeats Greenville Health System

The CDC simply carries too much weight. Its false claim that e-cigarettes are a gateway to smoking was picked up by media outlets throughout the country and is influencing state and local public health policy and causing substantial public health damage.

Midwest Regional: Mayo Clinic defeats University of Kentucky Tobacco-Free Task Force

The Mayo Clinic carries tremendous weight and thus its public misinformation about e-cigarettes is more damaging to the public's health.

East Regional:  FDA defeats American Lung Association

The FDA has perhaps the most influence on the electronic cigarette issue of any governmental organization. It defeated the ALA because its false and misleading pronouncements about electronic cigarettes have caused enormous public health damage.


1. California Department of Health Services vs. Mayo Clinic

2. CDC vs. FDA

Thursday, March 19, 2015

New Commentary Argues that Electronic Cigarette Use Can Improve Respiratory Health Among Smokers

In a commentary published yesterday in BMC Medicine, Dr. Riccardo Polosa of the University of Catania reviews existing evidence regarding the respiratory effects of electronic cigarette use. He concludes that switching to electronic cigarettes "can reverse harm from tobacco smoking."

The key findings were as follows:

 "Long-term changes in lung function have been monitored for up to 1 year in a large group of ‘healthy’ smokers who were invited to quit or reduce their tobacco consumption by switching to a first generation EC. Significant early positive changes from baseline of a sensitive measure of obstruction in the more peripheral airways (i.e., forced expiratory flow measured between 25% and 75% of FVC) were already detected at 3 months after switching in those who completely gave up tobacco smoking, with steady progressive improvements being observed also at 6 and 12 months (Polosa R, unpublished observation)." ... 

"In the only clinical study conducted to ascertain efficacy and safety of EC use in asthma, substantial improvements in respiratory physiology and subjective asthma outcomes have been reported [20]. Exposure to e-vapor in this vulnerable population did not trigger any asthma attacks." ...

"The reported improvements of respiratory patients who have become regular ECs users are consistent with findings from a large internet survey of regular EC users diagnosed with asthma and COPD [2]. An improvement in symptoms of asthma and COPD after switching was reported in 65.4% and 75.7% of the respondents, respectively."

Dr. Polosa concludes that: "Taken together, these findings provide emerging evidence that EC use can reverse harm from tobacco smoking."

The Rest of the Story

It is important to note that among the asthmatic smokers that Dr. Polosa studied, improvement in respiratory symptoms and lung function were observed even among dual users. This finding demonstrates that contrary to the claims of many anti-smoking advocates, the substantial reduction in cigarette consumption that often results from e-cigarette trial is associated with health improvement.

This should dispel the myth being propagated by the anti-smoking community that dual use is a negative outcome of electronic cigarette use among smokers. On the contrary, cigarette smokers who become vapers appear to experience substantial improvement in their respiratory health, even if they are unable to quit smoking completely.

This research also provides important evidence that electronic cigarettes are beneficial for the public's health, a key criterion that has to be met in order for these products to be approved as "new tobacco products" under the proposed FDA deeming regulations.

Tuesday, March 17, 2015

Anti-Smoking Group and Advocate Want Conflicted Scientists to Sit on FDA Tobacco Advisory Panel

Recently, the FDA announced that in compliance with a court ruling, it would re-constitute its Tobacco Products Scientific Advisory Committee (TPSAC) by eliminating members with significant conflicts of interest by virtue of their previous financial relationships with pharmaceutical companies.

Apparently, the four TPSAC members who were removed from the Committee (or who had already left the Committee) were Jonathan Samet, Claudia Barone, Joanna Cohen, and Suchitra Krishnan-Sarin.

In response, the Campaign for Tobacco-Free Kids and Dr. Stan Glantz blasted the FDA for complying with the court decision. Apparently, they would like to see scientists with Big Pharma conflicts of interest sitting on a federal advisory panel that makes policy regarding the very drugs produced by these companies.

The Campaign for Tobacco-Free Kids wrote: "It is deeply troubling that the FDA today removed several extraordinarily qualified members of its Tobacco Products Scientific Advisory Committee (TPSAC) based on a misguided and overreaching court ruling that is under appeal. The FDA’s action demonstrates that the court decision and FDA’s overly cautious interpretation of that decision will deprive the agency of advice from many of the nation’s foremost and most credible scientific experts and undermine the FDA’s ability to do its job. It is essential that the FDA both aggressively pursue its appeal of the court decision in question and, in the interim, apply that ruling in a way that does not impair its tobacco advisory committee."

Glantz wrote: "Last week the FDA fired or forced the resignations of several highly qualified and respected scientists from its Tobacco Products Scientific Advisory Committee because of an overly cautious reaction to a misguided court decision  Like its decision to discount the health benefits of reduced smoking by the "lost pleasure" smokers experience when they stop or do not start smoking, this action sets a terrible precedent not only for tobacco control but public health in general."

The Rest of the Story

Both the Campaign for Tobacco-Free Kids and Dr. Glantz appear to have a misunderstanding of federal law. According to the Federal Advisory Committee Act, all federal advisory panels (including TPSAC) must be "fairly balanced in terms of the points of view represented and the functions to be performed," and its members cannot have severe financial conflicts of interest such that the committee's assessments, reports, or recommendations and decisions will be "inappropriately influenced . . . by any special interest."

Following this law, a D.C. district court ruled that the presence of the above members of TPSAC violated federal law because these members had significant financial conflicts of interest with Big Pharma.

It is essential that federal expert and advisory panels not contain members with significant conflicts of interest with corporations such as pharmaceutical companies because these conflicts of interest may influence, or have the appearance of influencing the recommendations and decisions of these panels. Do we really want a scientist who worked for Pfizer to make decisions about the use of a drug produced by Pfizer? Do we want a researcher who received grant funding from GlaxoSmithKline to make recommendations regarding whether a drug manufactured by that very company should be approved?

Both the Campaign for Tobacco-Free Kids and Dr. Glantz appear to misunderstand the importance of eliminating these conflicts of interest. Their arguments are based on the contention that the scientists in question were of the highest integrity and that they could contribute significantly to the panel. But it is not the integrity nor the potential contributions of these scientists that is in question. The only thing in question is whether they have conflicts of interest that, according to federal law, should preclude them from serving on a federal panel that will likely make decisions that affect the financial status of the very companies with whom these scientists have had financial relationships.

Here is a brief summary of the apparent financial conflicts of interest we are talking about:

Dr. Samet: According to the original complaint filed by Lorillard and R.J. Reynolds: "During the last decade, Dr. Samet has received grant support for research and writing from GSK on at least six occasions, including in 2010. In addition, he formerly led the Institute for Global Tobacco Control, which is [was] funded by GSK and Pfizer. Moreover, until 2009, Dr. Samet received regular honoraria from Pfizer for his service on the Pfizer Global Tobacco Advisory Board."

Dr. Barone: According to her C.V., Dr. Barone and two of her colleagues received a $400,000 educational grant from Pfizer, covering the period 2010-2013.

Dr. Cohen: According to her C.V., Dr. Cohen works for the Institute for Global Tobacco Control. She is now the director. The problem is that the Institute for Global Tobacco Control apparently received funding from GlaxoSmithKline and Pfizer. However, that funding appears to have been received before Dr. Cohen came to the Institute. Thus, I cannot understand in this case why Dr. Cohen should be precluded from serving on TPSAC.

Dr. Suchitra Krishnan-Sarin: According to a 2011 C.V., Dr. Krishnan-Sarin received a GRAND award from Pfizer covering the years 2011-2013. Also listed is Pfizer funding for a clinical trial conducted in 2003-2004.

While Glantz and the Campaign for Tobacco-Free Kids argue that the removal of conflicted members will impede the work of the FDA, the assurance that federal expert panels and advisory boards be free from financial conflicts of interest actually enhances the work of these bodies by eliminating a major potential source of bias and by ensuring that there is no appearance of a conflicted panel.

In summary, I see no reason that Dr. Cohen should not be able to serve on the TPSAC panel. However, the other three members do have significant financial conflicts of interest that should preclude them from serving on TPSAC.

Finally, this has nothing to do with the integrity, character, or potential value to the committee of the conflicted scientists. The only issue here is the conflicts of interest.

Monday, March 16, 2015

Disingenuous As Can Be: Campaign for Tobacco-Free Kids Urges States to Raise Tobacco Sales Age to 21

In a press release issued last week, the Campaign for Tobacco-Free Kids has called on state and local governments throughout the country to raise the legal purchase age for cigarettes from age 18 to age 21. This recommendation comes on the heels of an Institute of Medicine report which concluded that raising the legal age to 21 nationally would reduce smoking prevalence by 12% and smoking-related deaths by 10%.

In urging states and localities to raise the legal purchase age to 21, the Campaign cited a 1986 Philip Morris document which "made it clear decades ago that the industry knew a higher age of sale would hurt the peddling of its deadly products. “Raising the legal minimum age for cigarette purchaser to 21 could gut our key young adult market (17-20),” that report noted."

The Campaign for Tobacco-Free Kids writes: "The ages of 18 to 21 are a critical period when many smokers move from experimental smoking to regular, daily use. While half of adult smokers become daily smokers before 18, four out of five do so before they turn 21. Increasing the tobacco sale age to 21 will help prevent these young people from ever starting to smoke."

The Rest of the Story

So how is the Campaign for Tobacco-Free Kids being disingenuous?

What they fail to tell you in this press release is that the Campaign for Tobacco-Free Kids actively prevented the FDA from raising the age of cigarette sales nationally to anything above 18! The Campaign agreed to this restriction - which completely ties the FDA's hands - in order to appease Philip Morris when it was negotiating the Family Smoking Prevention and Tobacco Control Act.

So the rest of the story is that it is thanks to the Campaign for Tobacco-Free Kids that the FDA does not have the authority to raise the legal sales age for cigarettes. And this is the reason why the Campaign is calling for action at the state and local level, rather than at the national level. Given that the FDA supposedly has regulatory jurisdiction over cigarettes, that agency should obviously have the authority to regulate the age of sale for tobacco products. But the Campaign for Tobacco-Free Kids took away that authority in order to appease Philip Morris, the very company whose document the Campaign cites in its press release as opposing such a move because it would significantly hurt its sales.

The truth of the matter is that in appeasing Philip Morris and tying the hands of the FDA, the Campaign for Tobacco-Free Kids did more to protect cigarette sales than anything Big Tobacco could have dreamed for. Now, instead of the FDA being able to respond to the IOM report by increasing the legal age to 21, the Campaign has to try to go state-by-state and city-by-city to convince hundreds of localities to enact such a measure. Obviously, a measure like this is only going to be feasible and effective if it is enacted at the federal level. It was the Campaign for Tobacco-Free Kids which made that an impossibility.

More than any other group (with the exception of Philip Morris), the Campaign for Tobacco-Free Kids has helped to protect cigarette sales and make sure that the next generation will not be tobacco-free. Yet they have the gall to pretend to be a great protector of children's health, while hiding from the public the fact that they were the ones who actually prevented the next generation from being tobacco-free by ensuring that the age of cigarette sales could not be raised to 21 nationally.

The Campaign for Tobacco-Free Kids could not be more disingenuous if it tried.

Friday, March 13, 2015

The Complete Blindness of Some E-Cigarette Opponents: Re-Normalization Hypothesis Defies Science and Logic, Ideology Prevents Them from Thinking Straight

In a position statement on electronic cigarettes published by the Canadian Pediatric Society, Dr. Richard Stanwick, its past president, opines that electronic cigarettes are a "gateway" to smoking that will renormalize smoking by "representing smoking as a socially acceptable public practice."

Later in the same statement, Dr. Stanwick complains that "Both the size and value of the e-cigarette industry are expanding rapidly. Currently estimated to be worth more than $2 billion in the United States alone, e-cigarette sales are expected to surpass conventional cigarette sales over the next decade."

Dr. Stanwick goes on to state: "Health advocates have achieved truly historic successes in curbing tobacco use ... through a variety of effective public policy interventions. E-cigarettes have the potential to undermine this framework."

The Rest of the Story

This same argument has been repeated by many groups and advocates that oppose electronic cigarettes. And the rest of the story is that the argument is ridiculous. It makes no sense, is illogical, and is internally inconsistent.

If electronic cigarette sales surpass conventional cigarette sales over the next decade, as Dr. Stanwick seems to predict, then electronic cigarettes will go down in history as the single most effect intervention ever to reduce cigarette smoking. Imagine: a 50% drop in cigarette consumption. That would be an unprecedented public health victory. Never before has any public health or anti-smoking intervention resulted in a smoking reduction of that magnitude.

Moreover, if cigarette sales are cut in half, then smoking will be completely denormalized. Nothing denormalizes smoking more than having very few people smoking.

You can't have it both ways. You can't argue that electronic cigarettes are a huge gateway to smoking that is going to renormalize smoking and at the same time acknowledge that electronic cigarette sales are going to reduce cigarette sales in half over the next decade. The argument makes no sense and is internally inconsistent. If electronic cigarettes are so successful as a public health intervention that they take over half of the overall cigarette market, it will be a tremendous public health victory of historic proportions that will have greatly reduced cigarette use, denormalized smoking, and saved lives.

This story demonstrates that many electronic cigarette opponents have lost the ability to think straight. They are so blinded by ideology that they seem incapable of making a coherent argument. They are talking complete nonsense.

And in fact, I believe that the reason so many e-cigarette opponents are talking such nonsense is that they don't have a leg to stand on. They can't rely on the actual scientific evidence and on coherent arguments because the facts do not support the contention that electronic cigarettes are renormalizing smoking. So they are left with crafting nonsense arguments that fly in the face of their own lack of logic.

The truth is that electronic cigarettes do appear to be a gateway: a gateway away from smoking and towards vaping. This means that electronic cigarettes are denormalizing smoking. The only thing electronic cigarettes may be normalizing is vaping.

The argument that electronic cigarettes are renormalizing smoking makes no sense, is unsupported by evidence, and should be completely abandoned before any more damage is done to the public's health.

Wednesday, March 11, 2015

New Study Provides Evidence that Switching to E-Cigarettes Can Enhance Smoking Cessation, Even for Dual Users

Electronic cigarette opponents have long argued that dual use offers no health benefits to smokers. Dual use refers to the use of both e-cigarettes and tobacco cigarettes. While clinical trials show that a small proportion of electronic cigarette users are able to quit completely, a quite large proportion of these smokers are able to substantially reduce their cigarette consumption. Anti-smoking advocates have widely argued that this reduction in consumption offers no health benefits. I have already debunked that myth by showing that substantial reductions in cigarette consumption can produce dramatic improvements in respiratory health, especially among smokers with asthma or other forms of obstructive lung disease.

Today, I present new evidence that beyond the direct respiratory health improvement, switching to e-cigarettes, even partially (i.e., dual use), can significantly enhance the prospects of a smoker quitting completely.

The Rest of the Story

A study published online ahead of print this month in the journal Nicotine & Tobacco Research demonstrates that smokers who are able to reduce the number of cigarettes smoked per day are more likely to eventually quit smoking.

The authors report the major findings as follows: "The intervention trials that reported effect sizes found that every one percent decrease in CPD or carbon monoxide (CO) was associated with a 3% to 4% increase in the odds of cessation. The naturalistic studies found that ordinal (e.g., quartile) increases in participants’ magnitude of reduction in CPD were associated with 50% to 290% increases in the odds of cessation."

By these numbers, if an electronic cigarette user (a dual user) cut down her cigarette intake by 80% - which is not uncommon among smokers who use e-cigarettes - her odds of quitting could increase by as much as 320%.

Of course, in these studies nicotine replacement therapy was used to achieve the initial reduction in cigarette consumption. However, there is no reason to believe that a dramatic reduction in cigarette consumption achieved through the use of electronic cigarettes would not also increase the odds of eventual cessation.

All in all, these results suggest that rather than being a bad result of e-cigarette trial, dual use may instead be a bridge to eventual smoking cessation.

This is important because it means that anti-smoking groups which are encouraging dual users to return to smoking by telling them it is no better than smoking exclusively are harming the health of the public, both directly and in terms of impeding smoking cessation.

Thursday, March 05, 2015

Public Policy Maker Becomes the First to Embrace Vaping as a Public Health Strategy to Combat Cigarette Smoking

I have waited a long time for this, but it has finally happened. A public policy maker has become the first to publicly embrace vaping as a public health strategy to combat cigarette smoking. Alameda County Board of Supervisors member Nate Miley was present at the ribbon-cutting ceremony for the opening of a new vaping store called Ready, Set, Vape in Castro Valley.

Supervisor Miley noted the controversy over e-cigarettes, but emphasized that he could not help but support an intervention that is helping smokers get off deadly cigarettes.

My relationship with Supervisor Miley goes back to 1992, when - as an Oakland City Council member - Nate played the lead role in spearheading the campaign to enact a smoke-free restaurant ordinance for the city of Oakland.

I already had an incredible amount of respect for Nate Miley, but this action increases that respect and appreciation even further. It was a courageous action and a true sign of leadership.

Finally, a public policy maker is willing to stand up against the destruction and deaths being caused by cigarette smoking. The FDA might not be willing. The CDC might not be willing. State health departments might not be willing. But Nate Miley is. Congratulations to him!

Wednesday, March 04, 2015

My Interview with the Texas E-Cigarette and Vaping Association

The Texas E-Cigarette and Vaping Association was kind enough to conduct an interview with me on electronic cigarettes. You can listen to the interview here.

Tuesday, March 03, 2015

Study Finds Almost No Hazardous Chemicals in Aerosol of Blu or Sky-Cig E-Cigarettes

A study published in journal Regulatory Toxicology and Pharmacology reports that the two brands of electronic cigarettes tested - Blu and Sky Cigs - contain levels of hazardous chemicals that are almost all indistinguishable from levels in ambient air. The few chemicals that were detected were present at levels between 50 and 900 times lower than that in cigarette smoke.

The study highlights were as follows:
  • "The e-cigarettes contained and delivered mostly glycerin and/or PG and water.
  • Aerosol nicotine content was 85% lower than the cigarette smoke nicotine.
  • The levels of HPHCs in aerosol were consistent with the air blanks.
  • Mainstream cigarette smoke HPHCs (∼3000 μg/puff) were 1500 times higher than e-cigarette HPHCs.
  • No significant contribution of tested HPHC classes was found for the e-cigarettes."
The authors conclude that: "The deliveries of HPHCs tested for these e-cigarette products were similar to the study air blanks rather than to deliveries from conventional cigarettes; no significant contribution of cigarette smoke HPHCs from any of the compound classes tested was found for the e-cigarettes. Thus, the results of this study support previous researchers’ discussion of e-cigarette products’ potential for reduced exposure compared to cigarette smoke."

The Rest of the Story

This study adds to the abundant and growing body of evidence that electronic cigarettes are orders of magnitude safer than tobacco cigarettes and suggests that brands of e-cigarettes that do not overheat the e-liquid may be associated with very minor absolute health risks.

This should put an end to the assertions of many e-cigarette opponents that electronic cigarettes are not any safer than tobacco cigarettes. It exposes those public statements as being lies.

This research also demonstrates how misguided the FDA is in its scientific judgment. Despite all of the evidence, with numerous studies demonstrating results similar to those above, with studies showing rapid clinical improvement in smokers who switch to e-cigarettes, and with studies showing that the acute cardiovascular and pulmonary effects of smoking due not occur with vaping, the FDA is not sure that smoking is not any more hazardous than vaping.

In the deeming regulation proposal, the FDA stated: "Many consumers believe that e-cigarettes are "safe" tobacco products or are "safer" than cigarettes. FDA has not made such a determination and conclusive research is not available." Clearly, the FDA does not believe that there is sufficient evidence at the present time to conclude that cigarette smoking is any more hazardous than vaping. 

Furthermore, one of the problems noted in the deeming regulations was the fact that: "The vast majority of the respondents who were aware of these products indicated that they believed e-cigarettes were less harmful than traditional cigarettes...". Once again, the FDA is stating that smoking may not be any more hazardous than vaping.

Combined with the existing body of scientific evidence, this study blows out of the water the argument of e-cigarette opponents that we have no idea how hazardous vaping is and that we can't be sure that vaping is significantly safer than smoking.

Nevertheless, I'm sure electronic cigarette opponents will continue to make these assertions because they are being primarily motivated by ideology and not by science.

Monday, March 02, 2015

Anti-Smoking Advocate Claims that Vaping One Cartridge is The Same Thing as Smoking 1 1/2 Packs of Cigarettes

In an article published in the Ft. Wayne (IN) Health Sentinel, the executive director of the Indiana Youth Institute was quoted as stating: "If you used the entire (e-liquid) canister at one time, it would be the same as smoking 1 1/2 packs of cigarettes at one time."

The Rest of the Story

While it may be true that vaping one full cartridge of e-liquid is approximately equivalent to smoking 1 1/2 packs of cigarettes in terms of nicotine intake, it is certainly not true that vaping one cartridge of e-liquid is the same as smoking 1 1/2 packs of cigarettes. While vaping one cartridge will expose you to nicotine, propylene glycol and/or glycerin, flavorings, and potentially to some by-products such as formaldehyde and acrolein, smoking 1 1/2 packs of cigarettes will expose you to more than 10,000 chemicals, including more than 60 known carcinogens, as well as to radioactivity. So the statement that vaping one cartridge is the same as smoking 1 1/2 packs of cigarettes is blatantly false.

Once again, The Rest of the Story has caught an e-cigarette opponent lying about the relative health risks of smoking and vaping. This lie is a particularly damaging one because it insinuates that smoking is no more hazardous than inhaling vapor from a device which contains no tobacco and involves no combustion. The statement seriously undermines the public's appreciation of the severe hazards of cigarette smoking.

Why is it that e-cigarette opponents are apparently forced to lie in order to support their opposition to these products? The answer, I think, is that the truth simply does not support their position. The truth - based on current scientific evidence - is that e-cigarettes are helping millions of smokers in the U.S. to either quit or significantly cut down on the amount they smoke. And they are doing this without undermining smoking cessation, without causing ex-smokers to return to smoking, and without serving as a gateway to youth smoking.

Therefore, in order to craft a tenable position against e-cigarettes, its opponents have no choice but to fabricate evidence, to mislead the public, and to lie in their public statements. Telling the truth just doesn't provide support for their position; thus, the need to distort the science and/or lie to the public.