Findings from the 2025 National Youth Tobacco Survey that Anti-Nicotine Groups Don't Want You to Know

Earlier this week, the FDA released the data from its 2025 National Youth Tobacco Survey. This is a public use dataset so it is freely available to all. My own analysis of these data revealed some important findings that I want to share. To the best of my knowledge, the questions I investigated in my analysis are questions that no health agency or anti-nicotine organization has ever examined. When you see the results, you will understand why.

First, I want to put forth the conceptual thinking that led me to ask these particular questions. It is based on adolescent risk-taking theory, which posits that adolescent risk-taking is not necessarily a sign of brain dysfunction, but rather a normal, necessary, and adaptive part of development. According to the UCLA Center for the Developing Adolescent: "It’s not only normal for adolescents to take risks and try new things, it’s an essential part of learning during these years. Being able and willing to take risks is a part of our natural tendency to explore new things in adolescence—in ways that help us discover who we are, expand our skills, and ultimately leave the safe nest of home." 

Moreover, independence and rebellion are the core values of adolescence. Risk-taking is a way of expressing autonomy and rebelling against adult authority. It is also a way of coping with the stresses of adolescent life. Given what is going on in the world today, it is not surprising that youth are facing unprecedented challenges to their mental health. Most are going to engage in some form of risky behavior in order to cope. The problem with authoritarian thinking in the tobacco control movement is that we have committed ourselves to the goal of eliminating all nicotine-related risk among youth rather than attempting to employ a harm reduction approach and ensure that the risks youth do take are relatively safe, at least in comparison what they could otherwise be doing.

The general theory in the tobacco control movement is that youth vape because Big Tobacco is evil and has tricked them into thinking that vapes are safer than cigarettes, has enticed them with gummy bear and cotton candy flavors, and used targeting marketing in an attempt to addict a new generation to a behavior that is a gateway to smoking and most likely, a lifetime of tobacco use. This argument is flawed for many reasons -- not the least of which is that it is untruthful -- but beyond that there is strong evidence that vaping went viral largely because of social media influencers combined with the addictive nature of nicotine. Remember that even without an addictive component, "six-seven" took off in 2025 and fidget spinners became a viral toy craze in 2017. 

The bottom line is that adolescents engage in risk-taking behavior and that youth who take one type of risk are also more likely to take other risks. For example, we know that youth who use marijuana are also more likely to smoke. So the question I posed is: Could it be that youth who use e-cigarettes are also more likely to smoke or to vape other even more risky substances, like THC, CBD, or synthetic marijuana like K2 or spice? 

The Rest of the Story

Based on my analysis of the 2025 National Youth Tobacco Survey, the prevalence of current e-cigarette use (defined as use within the past 30 days) among middle and high school students was 5.2%, drastically down from a peak of 20.0% in 2019. Among these youth current e-cigarette users, about half (51.0%) also were current smokers and/or current users of THC, CBD, or synthetic marijuana vapes. Among heavy e-cigarette users (defined as use on at least 20 of the past 30 days), a large majority (63.5%) also were current smokers and/or current users of THC, CBD, or synthetic marijuana vapes.

What this means is that for nearly two-thirds of youth heavy e-cigarette users, the biggest risk they face is not the e-cigarettes but either smoking or using black market marijuana vapes. 

The reason tobacco control groups don't want you to know this is that it exposes their culpability in the EVALI outbreak, which resulted in nearly 3,000 hospitalizations and 68 deaths. These groups were insistent upon blaming the outbreak on e-cigarettes. They promoted bans on e-cigarettes and continually insisted that the problem was e-cigarettes but failed to tell youth the truth: black market THC products tainted with vitamin E acetate are the cause and you need to stop using these product today!

The failure to warn youth about the dangers of black market THC products was very much responsible for many hospitalizations and perhaps deaths. The health groups did such a poor job of communicating this essential fact that only 11% of youth knew that EVALI was caused by marijuana vaping.

These data paint a very different picture of the youth vaping "epidemic." The large majority of youth who use e-cigarettes regularly are engaging in multiple risk taking behaviors, including ones that are far more dangerous than nicotine vaping. The use of black market THC vapes or synthetic marijuana vapes could literally be life-threatening or at least pose a significant risk of immediate health harm severe enough to require hospitalization. Even though vitamin E acetate is no longer a common component of THC vapes, the use of any black market vaping product carries the risk of tainting with synthetic cannabinoids or other drugs, a risk that is not present with the use of nicotine-containing e-cigarettes that originated in a retail store. These drugs can cause heart attacks, strokes, and seizures. Black market THC vape pens may also contain synthetic opioids whose use could be fatal. 

Based on my analysis, an alarming 15.2% of youth daily e-cigarette users are also vaping synthetic marijuana. While anti-vaping groups are trying to ban e-cigarettes, most are not even informing youth about this risk and seem to be more concerned about a youth ripping a cherry vape than having hallucinations, seizures, or being hospitalized because of black market drug use.

Yes, youth e-cigarette use is a public health problem. However, our insistence on a prohibition-based approach rather than focusing on harm reduction is putting youth at great risk, not less.

Paper Concludes that São Paulo Smoking Ban Reduced Heart Attack Deaths Despite Striking Increase in Heart Attack Deaths Following Ban

One of the things I always teach my public health students about research is that when you conduct any type of longitudinal or time-series data analysis, you should always start by graphing the outcome variable over time and visually inspecting the data. A perfect demonstration of what might happen if you fail to do this was published last week in the journal Tobacco Control.

Briefly, as I reported last week: A new study published online ahead of print in the journal Tobacco Control purported to demonstrate that a smoke-free bar and restaurant law implemented in São Paulo, Brazil in August 2009 resulted in a 11.9% decline in the heart attack death rate for the first 17 months after the law was in effect (through December 2010). The paper used a time-series analysis to compare the monthly rate of heart attack deaths prior to the smoking ban to the rate after the ban was implemented. The baseline period was January 2005 through July 2009. The implementation period was August 2009 through December 2010. Thus, the researchers had data for approximately 5 1/2 years before the ban and for 17 months after the ban. The paper concluded: "In this study, a monthly decrease of almost 12% was observed in mortality rate for myocardial infarction in the first 17 months after the enactment of the comprehensive smoking ban law in São Paulo city."

The problem is that if you take the time to look at the actual data, you find that there was actually a striking increase in heart attack deaths in the year following the smoking ban:


Christopher Snowdon over at Velvet Glove, Iron Fist has graphed out the monthly data, and the picture looks the same:

From: Christopher Snowdon. Velvet Glove, Iron Fist. "Brazilian Smoking Ban Miracle," December 1, 2016.

You can see that there was a seasonal decline in heart attack deaths late in 2009, but a striking increase in heart attack deaths in 2010 that was sustained throughout the year. In fact, the number of heart attack deaths for each month in 2010 was higher than the number of heart attack deaths during the same month in any of the previous years in the study period!

As Snowdon explains the actual data: "Before the ban, the number of deaths hardly ever exceeded 600 per month and was often below 500. Within a few months of the ban, there were never fewer than 700 deaths per month."

In my post last week, I struggled to understand how an error like this could have escaped the attention of the investigators, the reviewers, and the journal and speculated that: "It appears that either nobody looked at the actual data or that they looked but ignored it. Either way, this demonstrates a severe bias on the part of the investigators, reviewers, and editorial team. Had the study found no effect of a smoking ban, you can rest assured that everyone would have scoured over the paper for hours, trying to find some explanation for why the results came out "wrong." But here, since the results were "right" (that is, favorable), it appears that there was no desire to sincerely "review" the paper."

However, in the back of my mind, I wondered whether this was all just a mistake. Perhaps there was just a typographical error and the data presented in Table 2 were mistaken. Perhaps the 2010 data presented were an anomaly and were not transcribed correctly from the original manuscript to the typeset paper. I was actually "hoping" that this would be the case and that I would have to write a retraction and correction.

The Rest of the Story

It was not to be so. The lead author of the paper confirmed that the data in Table 2 are correct. In other words, the statistical analysis miraculously turned a clear and rather striking increase in heart attack deaths into an 11.7% decline: a true miracle. Instead of blindly reporting these results, this inconsistency should have instead led the investigators to figure out what went wrong, and it should have led the reviewers and journal editors to question the analysis and interpretation of the data.

This might seem like a rather obvious epidemiological point to make but you cannot have a decline in the heart attack death rate if the heart attack death rate goes up.

Before anyone suggests as a possible explanation that perhaps the population rose drastically in 2010, thus making the high number of deaths in 2010 translate into lower death rates, let me emphasize that explanation is impossible. The paper did not use the actual annual populations but simply used a geometric progression to interpolate the populations based on censuses conducted in 2000 and 2010. Thus, the rate of population growth throughout the study period was constant, by definition.

It also needs to be remembered that even if the paper had found an actual decline in heart attack deaths in 2010, this would not justify the conclusion that the smoking ban caused a decrease in heart attacks. Another critical and fatal methodological flaw of this paper is that there is no comparison group. It is very possible that heart attack death rates were declining during the study period anyway, even in the absence of smoking bans. We actually know this to be the case from abundant international data. To conclude that the smoking ban had an effect on heart attacks, one would need to first control for secular trends in heart attack mortality that were occurring anyway, independent of the smoking ban. The paper could easily have done this by including some comparison group -- such as a nearby city, the county, the state, or the country. But there needs to be some control for secular trends.

The rest of the story is that we have here another example of the severe bias in modern-day tobacco control research. The zealotry has reached such a level that you can report frivolous findings that are not even consistent with visual observation of the data and still publish your paper without questioning from peer reviewers or journal editors, as long as the findings you are reporting are "favorable" to the cause. You can rest assured that had the paper found "unfavorable" findings, they would have received critical scrutiny.

For a similar take on this study, see Christopher Snowdon's commentary.

New Study Shows the Blatant Bias in Modern-Day Tobacco Control Research and Demonstrates Why You Need to Look at the Actual Data

A new study published online ahead of print in the journal Tobacco Control purports to demonstrate that a smoke-free bar and restaurant law implemented in São Paulo, Brazil in August 2009 resulted in a 11.9% decline in the heart attack death rate for the first 17 months after the law was in effect (through December 2010).

The paper used a time-series analysis to compare the monthly rate of heart attack deaths prior to the smoking ban to the rate after the ban was implemented. The baseline period was January 2005 through July 2009. The implementation period was August 2009 through December 2010. Thus, the researchers had data for approximately 5 1/2 years before the ban and for 17 months after the ban.

The paper concluded: "In this study, a monthly decrease of almost 12% was observed in mortality rate for myocardial infarction in the first 17 months after the enactment of the comprehensive smoking ban law in São Paulo city."

The methods used in the study are quite complex and are summarized as follows: "We performed a time-series study of monthly rates of mortality and hospital admissions for acute myocardial infarction from January 2005 to December 2010. The data were derived from DATASUS, the primary public health information system available in Brazil and from Mortality Information System (SIM). Adjustments and analyses were performed using the Autoregressive Integrated Moving Average with exogenous variables (ARIMAX) method modelled by environmental variables and atmospheric pollutants to evaluate the effect of smoking ban law in mortality and hospital admission rate. We also used Interrupted Time Series Analysis (ITSA) to make a comparison between the period pre and post smoking ban law."

In simple terms, the investigators compared the trend in heart attack deaths in São Paulo before the smoking ban to the trend in heart attack deaths in São Paulo after the smoking ban. They concluded that there was an 11.7% drop in the heart attack death rate in the 17 months following the implementation of the smoking ban.

The investigators attributed the observed decline in heart attack deaths to a reduction in secondhand smoke exposure, citing evidence that just 30 minutes of exposure to secondhand smoke can cause a heart attack.

The Rest of the Story

To demonstrate the blatant bias in the reporting of the study results, simply take a look yourself at the actual data from the study. Below, I have plotted the data from Table 2 (Monthly number of deaths for myocardial infarction, city of São Paulo, Brazil, January 2005 to December 2010), but I have added the monthly numbers to yield annual figures, which smooths the data making it much easier to inspect visually.



The smoking ban went into effect in August 2009. You can easily see from the figure that in 2010, there was a striking increase in the number of heart attack deaths, which reached an all-time high for the study period.

Somehow, it appears that all this fancy modeling yielded a completely spurious result. This is why I teach my students to always start out by looking at the actual data. When you put the data into a fancy statistical model, strange things can happen. You always need to make sure that the results of a statistical model are consistent with what you are observing visually when you look at the data. If there is a major inconsistency, as in this case, then you must suspect that something is wrong: namely, that the statistical technique is for some reason not modeling the data correctly. It is also possible that the data are wrong. But clearly, something is wrong here.

Here, an examination of the actual data reveals that there is absolutely no basis to conclude that the smoking ban resulted in an 11.7% decline in heart attack deaths.

But why did nobody see this? It's difficult to believe that the authors didn't see it, the reviewers didn't see it, and the journal editorial team didn't see it. This should in fact be the first thing that everybody looks at. Even if you just look at the data in Table 2 without plotting it out, it is immediately apparent that there was a striking increase in heart attack deaths in 2010, wiping out the possibility that the smoking ban led to a large and sustained decline in heart attack deaths through 2010.

It appears that either nobody looked at the actual data or that they looked but ignored it. Either way, this demonstrates a severe bias on the part of the investigators, reviewers, and editorial team. Had the study found no effect of a smoking ban, you can rest assured that everyone would have scoured over the paper for hours, trying to find some explanation for why the results came out "wrong." But here, since the results were "right" (that is, favorable), it appears that there was no desire to sincerely "review" the paper.

Finally, it is critical to mention that even if the paper had found a decline in heart attack deaths in 2010, this would not justify the conclusion that the smoking ban caused a decrease in heart attacks. The critical and fatal methodological flaw of this paper is that there is no comparison group. It is very possible that heart attack death rates were declining during the study period anyway, even in the absence of smoking bans. We actually know this to be the case from abundant international data. To conclude that the smoking ban had an effect on heart attacks, one would need to first control for secular trends in heart attack mortality that were occurring anyway, independent of the smoking ban. The paper could easily have done this by including some comparison group -- such as a nearby city, the county, the state, or the country. But there needs to be some control for secular trends.

Thus, even if this paper had convincingly demonstrated that there was a decline in heart attacks in São Paulo after the smoking ban, it would not have been valid to conclude that this was a causal effect. Without a comparison group, this study is as good as worthless.

When the tobacco industry used to put out studies like this to show that smoking bans cause massive losses of revenue for restaurants, we attacked them for conducting time series analyses without using an appropriate control group. Now it appears that we are doing the same thing ourselves. This certainly has the appearance of a severe bias: results that are "favorable" are correct and the methodology is automatically valid and those which are "unfavorable" are incorrect and the methodology must be attacked.

Perhaps one of my great frustrations of 2016 is the way in which science has largely disappeared from the public policy agenda. Decisions are being made almost completely on political grounds. It is a bad enough state of affairs that we in public health don't need to contribute to it. Even though we are working for worthwhile causes, we cannot let loose our insistence on rigorous science. Once we do that, then we're really sinking to the level of our opponents.

Finally, I should make it clear that any failure of this study to detect an immediate decline in heart attack deaths does not affect my support for smoke-free bar and restaurant laws. It's just that in promoting such laws, I believe we need to rely upon solid scientific data, not hocus pocus that comes out of some complex statistical model that no one really understands and which ends up completely misrepresenting the actual data -- data that one can see with one's own eyes.

Helena Miracle? Not So Much; New Study Casts Doubt on Conclusions of Anti-Smoking Groups

For many years, anti-smoking groups have been claiming that smoking bans result in an immediate and dramatic decline in hospitalizations for heart attacks. This claim is based on studies like that conducted in Helena, in which the authors concluded that there was a 40% reduction in heart attack admissions within 6-18 months after a bar and restaurant smoking ban was implemented.

When these studies were first published, I warned anti-smoking groups not to use these conclusions to promote smoking bans because I believed that the conclusions were not adequately supported by the data. In particular, I criticized these studies and questioned their conclusions because they did not adequately account for secular trends in heart attack rates that were occurring even in the absence of smoking bans.

I also argued that it was not plausible to see such large effects in so short a time span because it takes many years for heart disease to develop. In contrast, I noted that respiratory effects might be observed immediately.

Finally, I argued that these findings were largely a result of publication bias. Cities for study were not chosen randomly. Instead, in places where there appeared to be a dramatic decline in heart attacks, that community was chosen for study. The few studies that did systematically examine this research question failed to find an immediate effect of smoking bans on heart attack hospitalization rates.

This week, a new study was published in the journal Medical Care Research and Review which re-examines the relationship between smoking bans and heart attack hospitalization rates.

(See: Ho V, et al. A nationwide assessment of the association of smoking bans and cigarette taxes with hospitalizations for acute myocardial infarction, heart failure, and pneumonia. Medical Care Research and Review 2016. Published online ahead of print on September 12, 2016. DOI: 10.1177/10775587/16668646.)

The authors summarize the study as follows:

"We examine the association between county-level smoking-related hospitalization rates and comprehensive smoking bans in 28 states from 2001 to 2008. Differences-in-differences analysis measures changes in hospitalization rates before versus after introducing bans in bars, restaurants, and workplaces, controlling for cigarette taxes, adjusting for local health and provider characteristics. Smoking bans were not associated with acute myocardial infarction or heart failure hospitalizations, but lowered pneumonia hospitalization rates for persons ages 60 to 74 years."

The Rest of the Story

The results of this study support the arguments that I made back in 2006, and which I have continued to emphasize on this blog over the past 10 years. The key finding of the study is that once you account for time-specific local trends in heart attack hospitalization rates, there is no longer a significant observed decline in heart attack rates associated with the implementation of these smoking bans.

The key data are in Table 2. Helpfully, this table provides regression estimates both with and without the inclusion of region-specific (in this case, county-specific) time trends in the rate of hospitalization for heart attacks. Note that without the county-specific time trends, the authors do find a significant decrease in hospitalizations for heart attacks associated with the implementation of smoking bans. But once they control for these local time trends, there is no longer a significant effect.

What this suggests is that communities that implemented smoking bans happened to be those which had a higher pre-existing rate of decline in heart attacks and that once you adjust for that, there is no difference associated with the implementation of the smoking bans.

The authors further demonstrate that the previous conclusions were spurious by showing that when you examine the impact of smoking bans on hospitalizations for hip fractures (which are not plausibly related to smoking bans), you find a significant effect of smoking bans when you don't include regional time trends. That spurious effect disappears once you control for the regional time trends.

The regional time trends are important to consider in these models because without them, you are making the assumption that the secular rates of decline in heart attacks at baseline were the same in communities with and without smoking bans. Apparently, this is not a fair assumption because the nature of cities that enacted smoking bans differed from that of cities which did not enact such laws. And those differences were reflected in higher rates of decline in heart attacks in the intervention communities.

It is interesting to note that it was my expression of the above opinions about these studies back in the mid-2000's that led to my "expulsion" from the tobacco control movement, including being thrown off several list-serves, ostracized by many of my colleagues, accused of being a "tobacco mole," being characterized by my hero and mentor - Stan Glantz - as being "a tragic figure," having copyright to one of my articles violated by an anti-smoking organization, no longer being invited to speak at tobacco conferences, not being able to present at tobacco control conferences anymore, not being able to obtain further research grants, and having colleagues refuse to appear with me at conferences to discuss these or any other scientific issues. In fact, it was this censorship that led to the creation of the Rest of the Story in the first place.

Nearly three million page views later, perhaps these groups knew what they were doing because it appears that I may have been right all along. By silencing me, these groups were able to disseminate their pre-determined conclusions widely to the public through the media long enough for the conclusions to be generally accepted. Now, it is too late to undo the damage. The media and the public have already made up their minds, and one article noting the results of this new study is not going to correct or undo 10 years of dissemination of unsupported and errant scientific conclusions.

To be clear, this issue has nothing to do with my support for smoking bans. My readers understand that I have and continue to support 100% smoke-free policies for all workplaces (including bars, restaurants, and casinos). However, I do believe that we can advocate for such policies without misrepresenting scientific evidence or exaggerating findings beyond what is scientifically defensible.

Another Study Concludes that Smoking Ban Reduced Heart Attacks While Data Show No Effect

A study published online in the journal PLoS ONE concludes that a partial smoking ban in Prince Edward Island resulted in a 14%-24% decline in heart attack admissions, while the study data show that the rate of heart attacks actually increased in the five-year period following the smoking ban compared to the five-year period before the ban.

(See: Gaudreau K, Sanford CJ, Cheverie C, McClure C. The Effect of a Smoking Ban on Hospitalization Rates for Cardiovascular and Respiratory Conditions in Prince Edward Island, Canada. PLoS ONE 8(3): e56102. doi:10.1371/journal.pone.0056102.)

A partial smoking ban went into effect in Prince Edward Island on June 1, 2003. Smoking was banned in all public places and workplaces, but was still allowed in designated smoking rooms. The study compares the rate of heart attack admissions before and after the smoking ban.

It finds that: "The mean rate of acute myocardial infarctions was reduced by 5.92 cases per 100,000 person-months (P = 0.04) immediately after the smoking ban."

It concludes that: "A comprehensive smoking ban in PEI reduced the overall mean number of acute myocardial infarction admissions...".

The Rest of the Story

The study conclusion is based entirely on the abnormally low heart attack rates observed during the period 1995-1997. If one compares the trend in heart attacks from 1998-2003 (five years prior to the smoking ban) with the trend from 2003-2008 (five years after the smoking ban), one finds that the smoking ban was actually associated with an increase in the rate of heart attacks.

Here are the approximate trends in the heart attack rates in the five-year periods before and after the smoking ban:

1998-2003 (PRIOR TO BAN): -0.4% per year
2003-2008 (AFTER BAN): +1.1% per year

Thus, prior to the smoking ban, the heart attack rate was quite steady, declining slightly by about 0.4% per year. Following the ban, the heart attack rate increased by 1.1% per year.

These findings are hardly indicative of a significant and substantial (14%-24%) reducing in the heart attack rate that is attributable to the smoking ban. In fact, an examination of the data indicates that the finding reported in the paper is not at all robust and neither the data nor the analysis supports the study's conclusion.

In fact, the authors could just have easily compared the five-year periods before and after the smoking ban and concluded that the ban led to an increase in hospitalizations for acute myocardial infarction.

Incidentally, I would not have expected this policy to reduce heart attacks because it did not eliminate smoking, it restricted it to designated smoking rooms. But whether expected or not, the data simply do not support the study's conclusion that this partial smoking ban resulted in a significant and substantial decline in heart attack admissions.

At this point, it has become clear to me that there exists a strong investigator bias in favor of finding a significant effect of smoking bans on the reduction of heart attacks. So many studies have drawn conclusions that are simply not supported by the data that it is apparent that investigators want to find an effect.

I "want" there to be an effect as well, since I've devoted much of my career to promoting workplace smoking bans. But we have to remain objective and use rigorous scientific methods. In the long run, I don't think it serves us to lower the level of scientific analysis in order to be able to put out "favorable" findings. After all, our scientific integrity and the public's trust of the quality of our science are the foundation upon which pu.blic health is built.

New Study Reports Decline in Heart Attacks After Smoking Ban, But There Was No Decline in Heart Attacks After Smoking Ban

A new study published last week in PLoS ONE reports that a partial smoking ban enacted in Spain in 2006 resulted in an 11% decline in heart attack incidence and an 18% decline in heart attack mortality rates in six counties in northern Spain.

(See: Aguero F, et al. Impact of a partial smoke-free legislation on myocardial infarction incidence, mortality and case fatality in a population-based registry: the REGICOR study. PLoS ONE 2013; 8(1): e53722. doi:10.1371/journal.pone.0053722.)

The study compared the incidence and mortality rates for acute myocardial infarction for the four years prior to the partial smoking ban (2002-2005) with those during the first three years after implementation of the law (2006-2008). The law banned smoking in workplaces, but exempted hospitality establishments including bars and restaurants. The data were collected from a population-based heart attack registry, covering six counties in northeast Spain served by a single tertiary care hospital with a coronary care unit.

The paper used a negative binomial regression to model the annual rates of heart attack incidence or mortality, with an indicator variable corresponding to whether the data were from before or after the partial smoking ban.

The results were reported as follows: "In the post-ban period, AMI incidence and mortality rates significantly decreased (relative risk [RR] = 0.89; 95% confidence interval [CI] = 0.81–0.97 and RR = 0.82; 95% CI = 0.71–0.94, respectively)."

The conclusion was: "The 2006 Spanish partial smoke-free legislation was associated with a decrease in population AMI incidence and mortality, particularly in women, in people aged 65–74 years, and in passive smokers. These results clarify the association between AMI mortality and the enactment of a partial smoke-free legislation and reinforce the effectiveness of smoking regulations in preventing CHD."

The results were disseminated widely through the media. The press release boasted that: "Implementation of smoke-free legislation reduces the number of acute myocardial infarctions by 11 percent."

The Rest of the Story

There's just one problem with this study concluding that the partial smoking ban implemented in 2006 reduced the number of heart attacks by 11% (and the number of heart attack deaths by 18%):

The data show that there was no decrease in heart attacks or heart attack deaths following the smoking ban.

One can easily see this in Figure 1 of the paper. There was indeed a decline in heart attack incidence and mortality in northeast Spain during the study period, but the decline occurred prior to the smoking ban, not after it. There was in fact little or no change in heart attack incidence or mortality after implementation of the smoking ban.

The data speak for themselves:

Here are the heart attack incidence rates for 2005 (immediately before the ban) and 2008 (after the ban):

Before: 173.35
After: 175.15

Here are the heart attack hospitalization rates for 2005 (immediately before the ban) and 2008 (after the ban):

Before: 144.90
After: 142.71

Here are the heart attack mortality rates for 2005 (immediately before the ban) and 2008 (after the ban):

Before: 37.58
After: 39.57

As you can easily see from the data reported in the paper, heart attack incidence and mortality rates were almost the same after the partial smoking ban as they were immediately prior to the ban.

What's quite clear is that the heart attack rates were dropping significantly during the baseline period, from 2002-2005. From 2005-2008, they remained relatively steady. Therefore, a negative binomial regression is going to "pick up" an "effect" of the smoking ban, that is not at all due to the smoking ban. Instead, this detection of an 11% "decline" in heart attacks is simply a reflection of the secular decline that occurred during the baseline period. If you just use data from 2005 for the pre-ban period, this effect will completely disappear!

This is hardly surprising, since the ban was hardly a "ban." It simply eliminated smoking in office-type workplaces, but it didn't get rid of smoking in bars or restaurants. Since most people were already working in smoke-free offices in 2005 anyway, and because the law didn't apply to bars and restaurants, one would not have expected to observe any decline in heart attacks to begin with. I find it surprising that the study authors actually expected to see such an effect.

But the most significant aspect of this story is that the paper is reporting a conclusion based on data which demonstrate the opposite. The paper reports that heart attacks declined after the smoking ban, but the data show that heart attacks did not decline after the smoking ban.

This is yet another study on the acute cardiovascular effects of smoking bans that reports exactly the opposite of what the study data demonstrate. It appears that anti-smoking researchers are so determined to find an effect of smoking bans on heart attacks that they will manufacture conclusions that simply are not consistent with the reported data.

In most of the public's eyes, a change from 173 to 175 is not an 11% decline, but the minds of anti-smoking researchers, it is. After all, we're working for a good purpose, and so it's perfectly acceptable to manipulate the data with statistical models so as to find an effect that doesn't really exist.

Once Again, Anti-Smoking Advocate Responds with Personal Attack Rather than Substantive Argument

In a commentary published yesterday on my blog, I criticized a post on Dr. Stan Glantz' blog which embraced the Congressional Budget Office's analysis of the costs to society of an anti-smoking intervention (a 50 cent federal tax increase) due to its saving of lives, thus resulting in more people on the Social Security rolls. Dr. Glantz had taken solace in the fact that the CBO's analysis ultimately found long-term savings to society, while I dismissed the entire approach, arguing that even if the CBO analysis had found that the long-term costs did outweigh the benefits, we should not reject a public health intervention because it will increase Social Security costs by saving lives. I noted that this is a perverse concept and has no place in policy analysis, even if it is ultimately outweighed by benefits of a proposed program. I also pointed out that when Philip Morris set forth the exact same argument in 2001, anti-smoking groups roundly attacked the company, which was forced to apologize and disavow itself from the argument. But rather than disavow himself from this line of reasoning, Dr. Glantz has embraced the approach and went so far as arguing that it sets an example for the analysis of other public health policy issues.

In response to my commentary, Dr. Glantz has attacked me, calling me non-credible as a scientist who is driven purely by ideology and pays no attention to science.

Dr. Glantz writes:

"I normally do not comment on Mike Siegel's blog because he has long since lost all credibility with me as a scientist. He praises any study -- no matter how poorly done -- if it supports his ideological position that he is the one ethical voice in tobacco and trashes any study -- no matter how well done -- if it does not.
His latest commentary, on my praise for the Congressional Budget Office analysis of the effect of a 50 cent tobacco tax increase (indexed to inflation) on federal spending so seriously misrepresents my position that it warrants response. ... Having a reasonable projection of effects over a long time does not require that one use that time for policy making. Just to be clear, here is what I think about the ... issue:

• The appropriate time horizon for health policy decision making is 10 years, 20 if you really stretch it.  (That does not mean that one ought not try an develop longer-term projections, but decisions should be based on time horizons over which the projections are most reliable.)  As the CBO notes, the uncertainty in projections grows with time.
• Policies to improve health are worth doing even if they cost money.  If society did not accept this position, we would eliminate almost all medical care, certainly for the elderly or people with serious disabilities.

The reality is that actual policy decisions are usually made with very short time horizons, often just months. ... That is why I have put a lot of energy into estimating the short-term effects of tobacco control policies. ... Urging that 10 to 20 years is the appropriate horizon for health decisions does not make it invalid to do your best to develop longer term models."

The Rest of the Story

What troubles me is not that Dr. Glantz accuses me of being completely non-credible and of being a quack scientist. After all, I recently lost all credibility when I appeared on the same page as Khloe Kardashian and Lindsay Lohan in Star Magazine (see the latest issue of Star if you want to see the humbling picture - well, humbling for me and Lindsay, but perhaps not for Khloe).

By the way, my picture appearing within millimeters of Linsday Lohan puts me only 4 degrees of separation from Kevin Bacon, as Lindsay Lohan was in Georgia Rule with Felicity Huffman, Felicity Huffman was in Magnolia with Tom Cruise, and Tom Cruise was in A Few Good Men with Kevin Bacon.

If you're wondering, no - I didn't appear because like Lindsay Lohan I had been arrested - but because I was featured in an "Ask the Expert" column regarding electronic cigarettes.

What does trouble me is that Dr. Glantz fails to respond substantively to my argument, attacks me personally and then diverts the issue.

The issue is: whether it is appropriate to consider as a negative factor in a policy decision the Social Security savings because lives will be saved.

But Dr. Glantz switches the issue to: what is the appropriate time frame for a policy analysis?

But that's not the issue at all. Arguing that a policy analysis should only look 10-20 years down the road is not the same as arguing that a policy analysis should not consider whether saved lives will lead to Social Security savings.

For example, suppose we are analyzing a policy to require insurance coverage for mammograms for women in their 50's. These mammograms will save a considerable number of lives among the screened women and the costs of those saved lives in terms of increased Social Security spending will being to accrue in less than 10 years. This is within the time frame that Dr. Glantz argues is appropriate to consider. Thus, Dr. Glantz is implying that it is perfectly appropriate to consider these costs because they are short-term, not long-term costs.

I disagree. I believe that it is inappropriate to consider these costs at all in making a policy decision, regardless of when they accrue.

It would be valuable to have this discussion. And it is an important issue because the CBO has now legitimized the argument and set an example that may be followed in analysis of a wide range of public health issues. I'm afraid that Dr. Glantz has helped to legitimize the consideration of these costs and I am merely trying to point out the danger of doing so.

My argument hardly seems like such a radical argument that it requires an attack on my credibility (there are plenty of other things on which one could attack my credibility - but this is not one of them!). In fact, my argument is exactly the same one that many anti-smoking organizations made in 2001 in response to Philip Morris' report that counted these costs as a benefit of smoking.

While there are many reasons one could attack my credibility, that I evaluate science based on whether the results support my pre-determined position is not one of them. This attack makes no sense because if it were true, then I would not be criticizing studies that report finding an immediate effect of smoking bans on heart attacks or which find that thirdhand smoke causes massive skin and nerve damage in babies. I have devoted my career to preventing the public from the hazards of secondhand smoke and if I simply judged studies by my ideology, I would be praising all of these studies.

Dr. Glantz is correct about one thing. I am guided by ideology. My ideology is that science is about the pursuit of the truth, and that we have to seek the truth wherever it takes us, even if it sometimes turns out that the truth is not favorable to our advocacy positions. I believe, also, in honesty and transparency and believe that public health practitioners should not deceive the public or distort the science, even if doing so might garner more support for our policies.

And finally, I believe that science is about disagreement and dissent, but that disagreement should garner substantive discussion, not personal attacks on character. The most important advances in science have come from some of the sharpest disagreements. The focus, however, must always be on the science itself - on the arguments and the evidence - not on the personal qualities of those advancing the arguments.

Thus, despite his attacks on me, Dr. Glantz remains a hero of mine. He was my original mentor and teacher and role model in tobacco control and it was his passion, zeal, and ability to develop research that will have the greatest impact on policy that has guided me throughout my career. In many ways, I view Dr. Glantz and another mentor of mine - Dr. Alan Blum - as two of the "fathers" of the anti-smoking movement. One of the things that I admire most about Dr. Glantz is his ability to always be ahead of the rest of the tobacco control movement. Of course, I also admire his willingness to tell it like it is and not be afraid of organizations or politicians and what they might say about him. That quality of Stan's continues to guide me.

Americans for Nonsmokers' Rights Accuses the Rest of the Story Author of Being Unprofessional for Sharing his Opinion About Smoking Ban/Heart Attack Studies; Attempt to Quell Dissenting Opinion is Unsuccessful

In an apparent attempt to quell dissent on the issue of whether smoking bans lead to immediate, dramatic reductions in heart attacks, Americans for Nonsmokers' Rights (ANR) has accused me of acting unprofessionally by sharing my opinion about the lack of scientific evidence to support the group's conclusion that smoking bans have such effects.

On Friday, I criticized an ANR document which purports to share with the public a list of the U.S. studies examining the short-term effects of smoking bans on heart attack rates. Under the category of "United States," ANR lists just one study - a study by Lippert and Gustat which concluded that smoking bans do lead to immediate reductions in heart attacks. I note in my commentary that ANR omitted from its list the two largest studies conducted in the U.S., both of which failed to find a short-term effect of smoking bans on heart attacks.

In response to my commentary, ANR wrote me and accused me of acting unprofessionally by sharing these opinions on my blog. ANR wrote: "Your approach to 'discussing' these sorts of issues continues to be exceedingly unconstructive and unprofessional."

The Rest of the Story

To translate ANR's message to me: "It is unprofessional of you to share your dissenting opinion publicly on your blog. You are free to disagree, but not to express your disagreement with others. That is unprofessional behavior."

This is a strange interpretation of academic freedom, free speech, and scientific integrity.

By the way, I don't begrudge ANR's disagreement, as it may exist, with my opinions regarding the scientific evidence related to the short-term effects of smoking bans on heart attacks. I would have been happy to discuss with ANR the scientific evidence and its strength, as well as the analytic and statistical issues involved with the scientific interpretation of these studies.

However, ANR's note was not simply a statement of scientific disagreement. It was an accusation of unprofessional behavior on my part. In other words, it was an attack on my personal character and integrity.

As I have noted before, this is a common tactic in the anti-smoking movement for dealing with dissent. Rather than deal substantively with the scientific issues, you attack the dissenter, trying to discredit him personally. This is also a tactic that I observed tobacco companies using in years past.

This is mildly ironic, as it was my disagreement with and discomfort with this very tactic that led to my resigning from the ANR Board of Directors in the first place. I now see that they haven't come very far since that time.

This story simply reinforces (and demonstrates) the argument I made in my commentary: "This is not science, it is politics. ANR has ceased being a science- or policy-based organization and has entered the political realm. ... It's sad for me to see the deterioration of the scientific integrity of the tobacco control movement, and it is particularly disheartening to see our organizations adopting many of the same tactics that we attacked the tobacco companies for using in years past."

While it would not be surprising to see ANR using this tactic against its "opponents" (and I have documented how ANR indeed uses this tactic against opposing groups), it is unfortunate that the organization has to resort to using this tactic against its own colleagues in the tobacco control movement.

ANR's response also demonstrates how it is cherry-picking the studies which have favorable results and intentionally excluding studies that don't have favorable results. The response argued that the Shetty et al. study should not included because of several methodological weaknesses, including the fact that it defined all smoking restrictions as "smoking bans" even if they were only partial bans. That's fine, but if one is going to restrict studies that have methodological weaknesses, then one has to do that with all studies, not just with the ones that have unfavorable findings.

In fact, the Lippert and Gustat study - which ANR cites as its only U.S.-based multi-state study, is the weakest of all studies on smoking bans and heart attacks. As I have pointed out previously, there are two major flaws of this study which render its conclusion invalid.

1. There is no control group.

The study simply compares changes in self-reported prevalence of heart attacks in states with smoking bans from approximately 2006 to 2009. The study finds that in some states, there was a significant decline during this three-year period. However, without knowing what happened in states without a smoking ban, it is impossible to attribute this change in heart attack prevalence to the smoking ban. One needs to know what was the change in heart attack prevalence from 2006 to 2009 in states that did not enact smoking bans.

The study does not report this information. However, from the Health Care Utilization Project (HCUP) data, we can obtain the changes in hospital discharges with a primary diagnosis of heart attack (i.e., incident heart attacks) in states without smoking bans between the years 2006 and 2009. Here are the data for all states without smoking bans in the HCUP database for which there are data for these years (the last column shows the percentage change from 2006 to 2009):

State	2006	2009
SC	9825	8890	-9.5
OK	8687	8030	-7.6
AR	7192	6837	-4.9
KY	12839	12444	-3.1
MO	15198	14310	-5.8
TN	17229	16493	-4.3
WV	6645	5891	-11.3
TOTAL	77615	72895	-6.1

From this table, one can see that in every state without a smoking ban for which HCUP data are available during the study period, there was a substantial decline in heart attacks, ranging from a decline of 3.1% in Kentucky to a decline of 11.3% in West Virginia. Overall, the decline in heart attacks in these 7 states without smoking bans was 6.1% from 2006 to 2009.

Therefore, how can this study conclude that the decline in self-reported heart attacks in the 17 smoking ban states from 2006 to 2009 was different than what would have been observed in the absence of these bans? Clearly, there is a secular trend of declining incident heart attacks in the United States that is independent of statewide smoking bans.

Given this baseline secular trend, the study cannot conclude that the observed declines in self-reported heart attacks observed in the 17 study states were attributable to the smoking bans in those states, as opposed to simply reflecting underlying secular trends, which are readily observable in states without such smoking bans.

2. The study conducts the wrong statistical analysis.

The study's conclusion that the smoking bans led to a significant reduction in heart attacks is based on the observation that in 10 of the 17 states, the prevalence of heart attacks declined. Of course, another way to look at this is to say that in 7 of the 17 states, the prevalence of heart attacks increased. The real question is this: if there were no true change in heart attacks, what percentage of the time would 10 out of 17 states show a decrease in heart attacks by chance alone?

Think of it this way. Suppose you flip a coin 17 times and come up with 10 heads. Can you conclude that this is not a fair coin, and that it must be weighted more heavily towards heads?

Well one can calculate the probability of obtaining 10 or more heads out of 17 coin tosses with a fair coin. Using the binomial distribution, one can determine that if one flips a fair coin 17 times, the chances of getting at least 10 heads is 31.5%.

Thus, by chance alone, if one were to examine changes in heart attack prevalence in 17 states, one would find that heart attacks decreased in 10 of those 17 states 31.5% of the time (if there were actually no true change in heart attacks). This is far beyond any reasonable level of statistical significance (which is usually set at about 5%).

If one is going to exclude any study because of methodological weaknesses, it would have to be the Lippert and Gustat study.

My impression remains that ANR is not objectively analyzing the methodology of these studies and excluding those whose methods are not scientifically solid. Instead, ANR is finding reasons to exclude the unfavorable studies while not applying the same standards to studies with favorable results.

The rest of the story is that this adds to the evidence that ANR's omission of all studies with unfavorable findings is an intentional action on the part of ANR to deceive the public about the scientific evidence by hiding negative studies and only sharing studies that support the organization's pre-determined conclusions.

Anti-Smoking Group Cherry-Picking Studies to Mislead Pubic About the Science: Americans for Nonsmokers' Rights is Hiding Information from the Public

As a former Board member of Americans for Nonsmokers' Rights (ANR), I can attest to the fact that as an organization, we used to attack the tobacco companies for cherry-picking studies that supported their claims, hiding key information from the public to make it appear that there was no evidence to show that secondhand smoke is harmful.

For example, the tobacco companies would point to one study which failed to find a connection between secondhand smoke and heart disease, while ignoring all the rest of the studies. Of course, we criticized the industry, arguing that all studies need to be considered and that failure to do so is misleading the public by hiding key scientific information.

Today, I report that Americans for Nonsmokers' Rights is itself engaging in cherry-picking by only sharing one side of the scientific evidence on the relationship between smoking bans and immediate reductions in heart disease.

In this document, ANR purports to share with the public a list of the U.S. studies examining the short-term effects of smoking bans on heart attack rates. Under the category of "United States," ANR lists just one study - a study which concluded that smoking bans do lead to immediate reductions in heart attacks.

The Rest of the Story

Curiously, ANR omitted from its list, the two largest studies conducted in the U.S., both of which failed to find a short-term effect of smoking bans on heart attacks.

What ANR could have, and should have added to the list are these studies:

1. Shetty KD, DeLeire T, White C, Bhattacharya J. Changes in U.S. hospitalization and mortality rates following smoking bans. Journal of Policy Analysis and Management 2011; 30(1):6-28.

This study by researchers from the RAND Corporation, Center for Studying Health System Change, University of Wisconsin, and Stanford University is the first to examine the relationship between smoking bans and heart attack admissions and mortality trends in the entire nation, using national data. All previous U.S. studies only examined one particular city. In contrast, this study examined data from the Nationwide Inpatient Survey (NIS), which is nationally representative and includes 20% of all non-federal hospital discharges in the United States.

The study found no significant effect of any smoking restrictions (including bar and restaurant smoking bans) on either heart attack admissions or mortality. The paper concludes: "We find no evidence that legislated U.S. smoking bans were associated with shortterm reductions in hospital admissions for acute myocardial infarction or other diseases in the elderly, children, or working-age adults."

2. Rodu B, Peiper N, Cole P. Acute myocardial infarction mortality before and after state-wide smoking bans. J Community Health 2011.

This study systematically examined changes in heart attack mortality trends within the first year of implementation of smoking bans in the six states which adopted such bans during the period 1995-2003. The results were that in four of the six states (California, Utah, Delaware, and South Dakota), the smoking bans were not associated with any significant short-term decline in heart attack mortality. In one of these states - South Dakota - there was an 8.9% increase in heart attack mortality during the first year of the smoking ban which was significantly different from the expected decline of 7.2%. The paper concludes: "The major finding of this study is that state-wide smoke-free laws resulted in little or no measurable immediate effect on AMI [acute myocardial infarction] death rates."

What's Going On Here?

Unfortunately, I no longer believe that the omission of these studies is just a curious, inadvertent omission of these key studies. Instead, I now believe that this is an intentional action on the part of ANR to deceive the public about the scientific evidence by hiding negative studies and only sharing studies that support the organization's pre-determined conclusions.

This is not science, it is politics. ANR has ceased being a science- or policy-based organization and has entered the political realm. This, of course, is the reason why I stepped down from the ANR Board when I first saw the organization start eschewing scientific integrity in favor of using these political tactics (a fact that incidentally - ANR acknowledged).

It's sad for me to see the deterioration of the scientific integrity of the tobacco control movement, and it is particularly disheartening to see our organizations adopting many of the same tactics that we attacked the tobacco companies for using in years past.