His commentary, entitled "A Promising Candidate for Most Dangerously Dishonest Public Health News Release of the Year," provides the most detailed analysis I have seen regarding the CDC's communications surrounding its April 2015 MMWR article. This is an issue about which I have written extensively in the past months. Dr. Sandman supports my arguments with an analysis that is guided by attention to basic risk communication and public health principles.
Dr. Sandman argues that the CDC papered over the most significant finding of the article - that youth smoking dropped dramatically to historically low levels - by considering e-cigarettes to be tobacco products and thereby being able to emphasize, instead, that overall "tobacco" use among youth remained steady.
This would be equivalent to the CDC reporting that heroin use dropped from 10% to 1%, while methadone use increased from 1% to 10%, and putting out headlines noting that there has been no change in opiate use in the population. Or to make it more extreme, suppose that every heroin user switched to methadone and the CDC headline was that opiate use has remained unchanged over time.
Dr. Sandman gives many more relevant examples of the deception in CDC's communications. He also speculates on the reasons for this deception. One hypothesis: "What might lead 12 public health experts to coauthor a report that papers over the comparative risk of vaping versus smoking? I don’t know. Something deeply ideological, I think. Something puritan and fundamentalist. All tobacco use is (equally) evil because it all enriches the tobacco industry? All tobacco use is (equally) disgusting because it all enables users to get illicit pleasure?"
Another important point that Dr. Sandman makes relates to the CDC's absolute refusal to address the relative risks of vaping compared to smoking. He writes: "Frieden’s clarification also tells us why he wanted to talk about the uptick [in overall tobacco use] in the first place. He saw it as a rationale to argue that vaping wasn’t replacing smoking but rather supplementing it. To make this case he ignored not just the small size of the uptick in the number of kids using any tobacco product, but also the absence of any uptick at all in the number of kids using more than one tobacco product, the decline in the number of kids smoking cigarettes, and the decline in the number of kids smoking anything. The real issue here isn’t Frieden’s decision to lean on a statistically insignificant increase in kids’ overall tobacco use to argue against the replacement hypothesis. The real issue is adding apples and oranges. Combining e-cig use, real cig use, and the use of seven other tobacco products into one overall number (the percentage of kids using any tobacco product) means treating the distinction between vaping and smoking as if it were unrelated to health. This is especially deceptive in the absence of any discussion of the decline in total teen smoking between 2011 and 2014."
Dr. Sandman concludes that: "The MMWR report, the CDC news release accompanying the report, and the CDC press briefing about the report are all seriously misleading about the findings of the annual National Youth Tobacco Surveys. The press briefing is the most explicitly misleading of the three, but the news release almost certainly had the most influence on coverage and thus on what the public learned. All three go out of their way to distort the study results and the underlying facts on four key points:
- They highlight the bad news (potentially, maybe, somewhat bad news) that teenage e-cigarette use has soared.
- They obscure the good news (definitely, wondrously good news) that teenage real cigarette use and overall smoking are continuing to decline, despite an increase in the use of hookahs.
- They assert that e-cigarettes are dangerous, imply that e-cigarettes are as dangerous as real cigarettes, and hide that virtually all experts agree e-cigarettes are significantly safer than real cigarettes.
- They ignore or deny the suggestive evidence (suggestive but far from conclusive) that teenage vaping might be replacing smoking, not leading to it.
Finally, Dr. Sandman notes that the CDC's communication campaign is not just deceptive, but potentially damaging as well: "The other difference is that the CDC isn’t just exaggerating the risk of e-cigs. It is misrepresenting the comparative risk of e-cigs and real cigs. And it is denying the possibility that vaping might help woo some teenagers from smoking or keep them from starting to smoke in the first place. I frankly don’t care much if the public ends up believing that electronic cigarettes are more dangerous than they really are. But I care enormously if the public – and especially the teenage public – ends up believing that vaping is just as dangerous as smoking so they might as well smoke. Several surveys have shown that while most Americans and most American teenagers still believe that vaping is safer than smoking, the number who believe that vaping and smoking are equally dangerous has climbed substantially. Making that number continue to climb is a key goal of the public health “education” campaign against electronic cigarettes, one small recent piece of which I have discussed in this column."
The Rest of the Story
I urge all of my readers to read Dr. Sandman's excellent critique.
To me, as a former CDC employee (I worked in the Office on Smoking and Health, which is largely responsible for most of these reports and communications), the saddest part of this story is the seeming loss of perspective that has taken place at the agency. In the face of the most dramatic decline in youth smoking in history, the CDC is essentially arguing that there is no cause for celebration because lots of kids are now experimenting with e-cigarettes, which are just as bad as tobacco cigarettes. The CDC has redefined the problem from morbidity and mortality to nicotine use. It doesn't matter how many people die, as long as we minimize the use of nicotine in the population. By the CDC's logic, if every smoker in the nation switched completely to vaping, it would have no public health benefit because the overall use of "tobacco" would remain unchanged.