An Inconsequential Slip of the Tongue? CDC Director is Quoted in Many Media Outlets as Stating that Youth Electronic Cigarette Experimentation Leads to Lifelong Addiction

Several weeks ago, I reported that CDC Director Dr. Thomas Frieden stated that many youth have become cigarette smokers because they experimented with electronic cigarettes, which then led to their smoking initiation.

Specifically, Dr. Frieden stated:

"What we are doing first is tracking, and we are seeing some very concerning trends. 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."

I argued that: "This statement, sadly, appears to be a fabrication. The CDC survey did not show that many youth smokers actually started with e-cigarettes. In fact, the survey did not even assess that question. It measured the prevalence of smoking and electronic cigarette use among youth, but it was a cross-sectional survey and it did not track youth over time to determine their vaping and smoking patterns. Moreover, it did not collect complete smoking and vaping histories from the youth so that it could answer this question. In other words, Dr. Frieden apparently just fabricated this evidence and presented it as being a result of the CDC's surveillance of youth e-cigarette use."

Last week, I presented these facts at the TMA conference on electronic cigarettes. A CDC official defended Dr. Frieden's statement on three grounds:

First, it was merely a "slip of the tongue."

Second, it was inconsequential because very few people saw it.

Third, it is only one minor sentence out of a much longer and more detailed presentation  of the survey results.

The Rest of the Story

It is difficult to see how this could merely be a slip of the tongue because it appears to be a pretty well thought-out statement that depicts a complex sequence of events. I have a hard time seeing how a statement that youth are starting with e-cigarettes and then going on to smoke tobacco cigarettes is merely a slip of the tongue. The CDC survey did not address this issue and it seems hard to believe that adding this as a conclusion of the CDC study simply "slipped out."

Moreover, this was a live interview, not a reporter editing together sound bites. So if it had been a slip of the tongue, Dr. Frieden could easily and immediately have corrected it. Once it "slipped out," he could easily have just corrected the statement and explained that the survey actually did not find that electronic cigarettes are serving as a gateway to smoking and that it didn't actually assess that question.

Furthermore, even if we assume that it was a slip of the tongue and that the mistake wasn't noticed at the time, it could have been corrected afterwards, once the video and transcript were published online. I have no doubt that Medscape would post a corrective statement.

The argument that this is inconsequential because very few people saw the statement is refuted by data on the popularity of the Medscape web site. According to Alexa, which monitors the popularity of web sites, Medscape is among the top 2,000 most viewed web sites in the United States. It appears that even in its early years, Medscape had over 1,000,000 members, "far exceeding the reach of any medical journal in history and most consumer publications."

Moreover, the idea that the CDC would downplay a factual misstatement because the media outlet is inconsequential doesn't hit me right (and seems to be somewhat of an insult to Medscape).

The third argument - that this is just one minor sentence somehow taken out of a larger context - ignores the way in which public health advocates and policy makers are influenced by the media. A single conclusion by a prominent health official in the media is enough to influence the knowledge, conclusions, and positions of health organizations and policy makers for years. For example, the FDA's misleading insinuation back in 2009 that electronic cigarettes contain "anti-freeze" is still widely quoted by public health groups and policy makers to this day, and it has undoubtedly influenced public policy on this issue.

Words matter, especially when they come from the head of such a distinguished and respected organization like the CDC.

Moreover, the CDC statement is not taken out of context or extracted as a minor sentence from a larger presentation of the study results. In fact, I included the entire quotation of Dr. Frieden's comments regarding the conclusion of the CDC survey. The entirety of his presentation of the study results in the interview was as follows: "What we are doing first is tracking, and we are seeing some very concerning trends. 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." I don't see how or why we should simply ignore that statement and pretend that it doesn't exist (especially when the statement is still on the web site, still being viewed by readers, and hasn't been corrected).

But that's not the whole rest of the story.

The rest of the story is that CDC has in at least two other media interviews presented the gateway hypothesis as a definitive conclusion of its survey.

First, in a widely circulated Associated Press story, which appeared in numerous newspapers and on television station sites, Dr. Frieden was quoted as stating that electronic cigarettes are "condemning many kids to struggling with a lifelong addiction to nicotine." These articles also state that Dr. Frieden suggested the CDC survey data indicate that many kids experiment with e-cigarettes and then go on to smoke cigarettes.

According to the AP story: "But health officials worry e-cigarettes could re-ignite teen cigarette use. They point to a finding in the study that 20 percent of middle school e-cigarette users had never tried conventional cigarettes. When the same question was asked of high school students, only 7 percent had never tried regular smokes. That suggests many kids experiment with the electronic devices and move on to cigarettes by high school, said CDC Director Dr. Tom Frieden. "In effect, this is condemning many kids to struggling with a lifelong addiction to nicotine," he said."

Fortunately, Mike Stobbe also included in his article an opposing quote from Dr. Kurt Ribisl from the University of North Carolina who pointed out that the survey results "don't prove that e-cigarettes are a gateway to smoking cigarettes."

A quick Google search shows at least 52 different media outlets that disseminated this information. Was this statement, that e-cigarettes are condemning kids to a lifetime of addiction, also just a slip of the tongue? And is it also inconsequential? Is this just another minor public statement that is being taken out of context?

Second, in a CNN interview, Dr. Frieden concluded that while the reported benefits of electronic cigarettes -- aiding smoking cessation -- are merely "possible," the speculated and undocumented potential harms -- such as hooking kids to smoking -- are "definite":

"I think what we can say basically is they might or might not be able to help you quit, but there are definite harms that they can cause. And those definite harms are in different environments. So, if they get kids hooked on nicotine, that's a really bad thing. If they get a smoker who would have quit smoking to continue smoking, that's a bad thing. If they get a smoker who stopped mo smoking and going back to nicotine addiction and then smoking, that's a bad thing. And if they re-glamorize the act of smoking, that's a bad thing. So, we have possible benefits and definite harms."

Here, it is hard to imagine that this is merely a slip of the tongue. Dr. Frieden appears to go out of his way to emphasize that the potential benefits of electronic cigarettes are just speculative, but that the potential harms are definite. In other words, we don't have scientific evidence to support the conclusion that e-cigarettes can help people quit smoking, but we do have evidence that they contribute to increased smoking.

Taken together, I simply don't see any support for the argument that these statements are all just slips of the tongue that are inconsequential because very few people are seeing them and that they are minor statements that have been inappropriately extracted out of context.

Instead, it appears to me that the CDC's intention was to infer to the public that there is now scientific evidence that electronic cigarettes are causing societal harm by helping to hook youth on nicotine and push them into a lifetime of smoking. In fact, I think CDC did a great job of making this point and I don't see how it would have been accomplished any better had there actually been a study documenting that a substantial proportion of nonsmoking youth are becoming addicted to nicotine and then progressing to cigarette smoking.

CDC Director and Prominent Anti-Smoking Researcher Appear to Be Fabricating Scientific Evidence to Oppose Electronic Cigarettes

The issue of electronic cigarettes is a complex one and there is plenty of room for - and in fact a need for - vigorous discussion and debate on both sides of the issue. However, what I don't believe there is room for is tobacco control scientists and government agency leaders making up scientific evidence to support pre-determined positions. Science, not ideology, should be guiding the complex decisions that need to be made regarding the handling of the electronic cigarette issue.

Unfortunately, it appears that last week two prominent public health and tobacco control figures fabricated scientific evidence to bolster their opposition to electronic cigarettes.

1. CDC Director Dr. Thomas Frieden Stated that Many Youths Have Started Smoking Because of Electronic Cigarettes

In an interview with Medscape, CDC Director Dr. Thomas Frieden stated that many youth have become cigarette smokers because they experimented with electronic cigarettes, which then led to their smoking initiation.

Specifically, Dr. Frieden stated:

"What we are doing first is tracking, and we are seeing some very concerning trends. 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."

The Rest of the Story - #1

Dr. Frieden shares two pieces of data from the CDC's tracking of electronic cigarette use among youth. First, he reports that the use of e-cigarettes in youth doubled in the past year. This statement is true, as the CDC survey did in fact show a doubling of experimentation with electronic cigarettes among youth.

The second piece of data from the survey that Dr. Frieden shares is that many of the youth smokers in the survey started as pure electronic cigarette users and that the electronic cigarette use ultimately led to their initiation of cigarette smoking.

This statement, sadly, appears to be a fabrication. The CDC survey did not show that many youth smokers actually started with e-cigarettes. In fact, the survey did not even assess that question. It measured the prevalence of smoking and electronic cigarette use among youth, but it was a cross-sectional survey and it did not track youth over time to determine their vaping and smoking patterns. Moreover, it did not collect complete smoking and vaping histories from the youth so that it could answer this question.

In other words, Dr. Frieden apparently just fabricated this evidence and presented it as being a result of the CDC's surveillance of youth e-cigarette use.

If you examine the methodology and questionnaire for the National Youth Tobacco Survey, you'll note that:

1) It is a cross-sectional survey, so it did not examine the trajectory of smoking initiation in relation to electronic cigarette use; and

2) The questionnaire only assessed ever use and past 30 day use of conventional and electronic cigarettes and it did not ascertain the longitudinal history of smoking initiation in relation to experimentation with electronic cigarettes.

Thus, in contrast to Dr. Frieden's statement, the survey provides no evidence that "many kids are starting out with e-cigarettes and then going on to smoke conventional cigarettes."

Moreover, I am aware of no other scientific evidence that many youth who started out with e-cigarettes then initiated smoking.

Unfortunately, the rest of the story is that this piece of scientific evidence appears to have been fabricated to support the CDC's opposition to electronic cigarettes.

Here, I am not criticizing the CDC for its position on electronic cigarettes (that is a separate issue), but instead, I am criticizing the apparent fabrication of scientific evidence to support that position. If the evidence does not support the CDC's assertions, then the agency should not make up evidence to support those assertions. Perhaps it should instead re-think those assertions.

I believe that one of the core ethical principles of public health is honesty and transparency. Here, it appears that the CDC is being neither honest nor transparent.

2. Anti-Smoking Researcher Dr. Stan Glantz Stated that Electronic Cigarettes Present 10% to 20% of the Risk of Tobacco Cigarettes

In an article on electronic cigarettes in TIME magazine, Dr. Glantz is quoted as asserting that electronic cigarettes pose 10% to 20% of the risk of tobacco cigarettes, and therefore, since the risks of cigarette smoking are enormous, electronic cigarette use is a major health risk.

Specifically, Dr. Glantz is quoted as stating:

"The studies that the e-cigarette people point out, claiming that these things are harmless, are really, really, really crappy. It is probably about 10% to 20% of what a cigarette puts out, so looked at that way, they are really nice. On the other hand, if you look at absolute levels of risk, they are pretty bad, because a cigarette is just ridiculously toxic and ridiculously polluting. ... If you say an electronic cigarette is only 10% to 20% less polluting than a massive forest fire, that's not so good."

The Rest of the Story - #2

Here, Dr. Glantz has essentially fabricated scientific evidence that doesn't exist. He asserts that electronic cigarettes pose 10% to 20% of the risk of conventional cigarettes. However, no such evidence exists. Basically, he is just making this up.

If you examine the constituents in electronic cigarette vapor compared to tobacco smoke, Dr. Glantz' assertion holds no water. Cigarette smoke contains between 10,000 and 100,000 chemicals, including more than 60 known human carcinogens. Electronic cigarette vapor contains about 15 chemicals, of which only about five are of any significant health concern, and the levels of those five chemicals in electronic cigarettes are comparable to those in nicotine replacement products like the nicotine inhaler, nicotine gum, or nicotine patch.

I have argued that there are a few potential health risks associated with vaping, including long-term respiratory health effects of propylene glycol, carcinogenic effects of formaldehyde, and cardiovascular and reproductive health effects of nicotine. However, so far there is no actual scientific evidence that electronic cigarettes are causing any significant health harm to users. To assert that the risk is 10% to 20% of that of cigarettes is not only absurd, but it is just a fabrication.

If what Dr. Glantz is asserting is true, then if used over many years at the same prevalence as cigarettes, electronic cigarettes would eventually cause between 40,000 and 80,000 deaths per year. Obviously, that's a fabrication as there is no current evidence that vaping poses any significant mortality risk. What specific diseases does Dr. Glantz assert that e-cigarettes cause and what specific chemicals cause those diseases?

I would readily acknowledge that we don't have enough scientific evidence to precisely quantify the absolute risk levels associated with vaping. But that's quite the point. By asserting that the risk is 10% to 20% of that of cigarette smoking, Dr. Glantz is essentially just making up a risk estimate, without any scientific justification, support, or evidence.

Once again, the rest of the story is that another prominent tobacco control scientist appears to be fabricating scientific evidence to support a pre-determined position against electronic cigarettes. There is no room for tobacco control scientists and government agency leaders to make up scientific evidence to support pre-determined positions. Again, science, not ideology, should be guiding the complex decisions that need to be made regarding the handling of the electronic cigarette issue.

CDC Director Apparently Fabricating More "Scientific Evidence" to Demonize Electronic Cigarettes

In an NPR interview, CDC director Dr. Thomas Frieden claimed that scientific evidence demonstrates that large numbers of ex-smokers are returning to the use of nicotine products by taking up vaping. He also claimed that electronic cigarettes are deterring smokers from quitting.

According to the interview transcript, Dr. Frieden told the public: "I certainly see the theory that they could be helpful and I've heard some anecdotes about individuals who say they have helped them quit. But much more importantly is the actuality that right now we're getting millions of kids experimenting with or using regularly e-cigarettes. We're getting smokers who are perhaps using them not to quit but to keep smoking regular cigarettes. We're seeing large numbers of ex-smokers going back to nicotine products for the first time in years using e-cigarettes. We're seeing the re-glamorization of smoking as an act. And we're also seeing potential exposure of nonsmokers, including pregnant women, to the nicotine in e-cigarette products. So I see theoretical potential benefits but definite harms occurring."

The Rest of the Story

The rest of the story is that Dr. Frieden continues to fabricate scientific evidence in an apparent effort to demonize electronic cigarettes. I have already reported how he made up scientific evidence that he purported to demonstrate that electronic cigarettes are a gateway to a lifetime addiction to smoking cigarettes. Here, he apparently makes up scientific evidence that large numbers of ex-smokers are returning to nicotine use by taking up vaping. While I follow the electronic cigarette literature extremely closely, I am aware of no studies which have shown that large numbers of ex-smokers are taking up vaping. In contrast, there is much evidence that large numbers of vapers are quitting smoking, and thus becoming ex-smokers.

A recent study from the UK involved a survey of 12,171 adults in February and March of this year. The survey found that 4.7% of ex-smokers were regularly using electronic cigarettes. Among these ex-smokers, 71% reported that they were using e-cigarettes to try to quit smoking and 48% reported that they were using e-cigarettes to try to keep off tobacco products. These data suggest that the overwhelming majority of ex-smokers using e-cigarettes are people who smoked and then quit smoking because of these products, rather than ex-smokers who returned to nicotine use via e-cigarettes.

At any rate, I'm aware of no data demonstrating that a large proportion of vapers who are ex-smokers were drawn back into nicotine product use after having completely quit smoking.

Moreover, there is no evidence that - as Dr. Frieden claims - we're seeing many smokers who are inhibited from quitting because they try electronic cigarettes.

And furthermore, there is no evidence that electronic cigarettes are causing nonsmoking youth to become regular users. In fact, there is no evidence that any substantial proportion of nonsmoking youth who tried these products are continuing to use them regularly (more than once per month).

Finally, there is also no evidence that we are seeing the reglamorization of smoking. In fact, current evidence suggests that electronic cigarettes have led to the deglamorization of smoking and have enticed tens of thousands of smokers to try to get off of cigarettes.

I don't begrudge the CDC for enumerating the potential population-level risks of the introduction of electronic cigarettes to the market. However, I do criticize the agency for fabricating scientific evidence in order to support what is clearly a pre-determined agenda: the demonization of e-cigarettes.

In his column on the Hit & Run blog, Jacob Sullum nicely points out the way in which Dr. Frieden is completely ignoring the multitude of data showing that literally thousands of ex-smokers were able to quit smoking using electronic cigarettes. He continues to call these people nothing but "anecdotes." Sullum also points out that Dr. Frieden is "inventing facts from whole cloth in an effort to portray the product as a grave threat to public health and a menace to 'our children.'"

I agree, except that I would characterize the material from which Dr. Frieden is inventing these "facts" not as whole cloth but as cloth full of holes, more like a piece of Swiss cheese.

Cambridge Public Health Department Follows the CDC's Lead, Claims that Electronic Cigarettes are a Gateway to a Lifetime of Tobacco Use

Following the lead set by CDC in telling the public that electronic cigarettes are a gateway to tobacco cigarette smoking, the Cambridge (Massachusetts) Public Health Department has proclaimed that e-cigarettes "are powerfully addictive and often serve as a 'gateway' to a lifelong tobacco habit."

In a memorandum to the City Manager, the Cambridge Public Health Department writes as follows:

"The manner in which tobacco companies have targeted younger groups also poses a long-term concern, as many younger individuals may not understand that e-cigarettes are powerfully addictive and often serve as a 'gateway' to a lifelong tobacco habit."

The memorandum recommends that the city tobacco ordinance be amended to ban the sale of electronic cigarettes to minors.

The Rest of the Story

I completely agree with this policy recommendation. However, I don't believe it was necessary to rely upon a false or unsupported statement to support this recommendation.

There is, in fact, no evidence that electronic cigarettes serve as a gateway to a lifelong tobacco habit. In fact, there is not even any evidence that electronic cigarettes serve as a gateway to a short-lived tobacco habit. The only study to examine this hypothesis found that electronic cigarettes are not currently serving as a gateway to cigarette smoking among young people.

Although more research needs to be done, it is safe to say that at the present time, the evidence suggests that electronic cigarettes are not a major gateway to smoking initiation among youth. At the very least, however, it is undeniable that there is no evidence to support the assertion that electronic cigarettes are leading to smoking among youth, much less a lifelong addiction to tobacco.

The larger part of this story is the question of how the public health department came to believe that electronic cigarettes are a gateway to a lifetime of smoking.

It is possible, and in fact, likely, that this local health department was simply reiterating material that was spewed out by the CDC in a widely circulated Associated Press story, which appeared in numerous newspapers and on television station sites, Dr. Frieden was quoted as stating that electronic cigarettes are "condemning many kids to struggling with a lifelong addiction to nicotine." These articles also state that Dr. Frieden suggested the CDC survey data indicate that many kids experiment with e-cigarettes and then go on to smoke cigarettes.

It is certainly curious that the Cambridge Public Health Department's language mirrors that of Dr. Frieden.

According to the AP story: "health officials worry e-cigarettes could re-ignite teen cigarette use. They point to a finding in the study that 20 percent of middle school e-cigarette users had never tried conventional cigarettes. When the same question was asked of high school students, only 7 percent had never tried regular smokes. That suggests many kids experiment with the electronic devices and move on to cigarettes by high school, said CDC Director Dr. Tom Frieden. "In effect, this is condemning many kids to struggling with a lifelong addiction to nicotine," he said."

Fortunately, in the same article, there is an opposing quote from Dr. Kurt Ribisl from the University of North Carolina who pointed out that the survey results "don't prove that e-cigarettes are a gateway to smoking cigarettes." However, the CDC's point had already been made.

A quick Google search shows at least 52 different media outlets that disseminated this information, including the quote indicating that electronic cigarettes are "condemning many kids to struggling with a lifelong addiction to nicotine."

At a recent TMA conference on electronic cigarettes, a CDC official defended Dr. Frieden's statement on the grounds that: (1) It was merely a "slip of the tongue"; and (2) it was inconsequential because very few people saw it.

Apparently, this slip of the tongue, which was disseminated nationwide through more than 50 media outlets, will have no impact on local public health organizations. However, based on today's rest of the story, it appears that this unsupported statement may in fact be leading local public health practitioners to further disseminate this misleading information.

Fortunately, in this case, the misleading information is not supporting a damaging public health policy. However, in other cases, it might well result in a policy that could harm the public's health.

In at least one other case, public health practitioners were explicit in noting that their hypotheses regarding electronic cigarettes and a lifelong addiction to smoking came directly from the CDC. In their op-ed piece published in the Spring Grove (MN) Herald, Shelton (CT) Herald, Los Angeles Daily News, and perhaps other local newspapers, writers from the American Lung Association tell us that: "We share the CDC's concern that children who begin by using e-cigarettes may be condemned to a lifelong addiction to nicotine and cigarettes."

Words matter, and the words spoken by the CDC matter even more than those of most health organizations. Many state and local health groups, like the Cambridge Public Health Department, look to the CDC for guidance on health science and policy issues. This is why it is particularly important for the CDC to get it right and not to disseminate false statements that mislead the public.

An associate professor of Pediatrics at the Ohio State University goes so far as to claim that: "a lifelong addiction to nicotine can start with one e-cigarette." We know that this professor relies heavily upon the CDC for his information because earlier in his article he cites the CDC's report on electronic cigarette use among youth. (By the way, he goes on to state: "Even if you assume that e-cigarettes are “cleaner” than tobacco, they still deliver a potent drug that can lead to lifelong dependence in many teenagers").

Meanwhile, the CDC's deceptive statements live on.

Just last week, a full eight weeks after the CDC's original statements, they are still being disseminated nationally through the media. An article on electronic cigarettes in Spry, dated November 21, reads: "According to a recent CDC report, the number of high school students who tried e-cigarettes rose from 4.7% in 2011 to 10% in 2012. In the report, CDC officials expressed concern about the potential for abuse and addiction inherent in e-cigarettes. “The increased use of e-cigarettes by teens is deeply troubling,” said CDC Director Tom Frieden, M.D., M.P.H. “Nicotine is a highly addictive drug. Many teens who start with e-cigarettes may be condemned to struggling with a lifelong addiction to nicotine and conventional cigarettes.”"

I believe that it is now the CDC's responsibility to correct its previous statements and to make it clear to state and local public health practitioners that there is no evidence that electronic cigarettes are serving as a gateway to cigarette smoking among young people.

CDC Again Lies to Public in Attempt to Demonize Electronic Cigarettes

Last November, I reported that CDC was lying to the public by telling us that an agency survey had found that electronic cigarettes are a gateway to smoking. Specifically, I noted that CDC director Dr. Thomas Frieden stated at that time: "What we are doing first is tracking, and we are seeing some very concerning trends. 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." However, the CDC was a cross-sectional one and it didn't track e-cigarette users over time to see whether they went on to smoke conventional cigarettes. Thus, Dr. Frieden was lying to the public.

The Rest of the Story issued a call for a corrective statement by CDC to clarify this error, but none was forthcoming.

Instead, in response, a CDC official defended Dr. Frieden by suggesting that the statement was just an inconsequential slip of the tongue.

Today, I reveal that CDC has again lied to the public, which suggests that its dishonesty is not just an inconsequential slip, but a pattern of dishonest behavior intended to demonize electronic cigarettes.

The Rest of the Story

In an article published last week in the Los Angeles Times, CDC director Dr. Thomas Frieden was quoted as stating:

"The challenge that the FDA has is that they will be challenged by the tobacco industry, as they have been at every step of the way. [The FDA] tried to regulate e-cigarettes earlier, and they lost to the tobacco industry. … So the FDA has to balance moving quickly with moving in a way that’s going to be able to survive the tobacco industry’s highly paid legal challenge."

Assuming that this is an accurate quote from Dr. Frieden, the CDC is lying. It is not true that the FDA lost a lawsuit to the tobacco industry when it tried to regulate e-cigarettes earlier. The lawsuit it lost was filed by two electronic cigarette companies, neither of which were owned by Big Tobacco. In fact, at the time of that lawsuit, the tobacco companies were not even in the business of selling e-cigarettes. All e-cigarette companies at that time were independent of Big Tobacco.

Clearly, this statement by the CDC is intended to imply that Big Tobacco has been fighting the FDA's attempts to first ban and now regulate the product. This is false. In fact, the tobacco companies were not involved in the earlier lawsuit and since entering the market, they have strongly supported the FDA's regulation of electronic cigarettes.

In fact, it is unlikely that the tobacco companies will challenge the deeming regulations. These companies stand to gain the most by the regulations, which make it much more difficult, if not impossible, for the non-tobacco-related electronic cigarette companies (especially the smaller ones) to survive. If the deeming regulations are challenged, that challenge is more likely to come from the smaller manufacturers, not the tobacco companies. And any such challenge would not be from "highly paid" sources, but from companies that cannot independently afford such a challenge. They would have to pool resources to have any chance of affording such a challenge, which makes me believe that any serious challenge to the regulations is unlikely.

If this statement was misquoted by the Times, then the CDC should have immediately corrected it. Since I do not see any correction (as of the time of the writing of this post), I have to assume that the statement is correct.

As I remarked last week, I do not begrudge the CDC for holding a different position than I do on the e-cigarette issue. However, the agency crosses the line when it lies to the public in order to support its position. Dishonesty has no place on the agenda of a federal public health agency, especially one that is as highly reputed as the CDC.

First Study to Examine E-Cigarette Gateway Hypothesis Can Find Only One Nonsmoker Who Initiated with E-Cigs and Went on to Smoke

In the first study to examine the hypothesis that electronic cigarettes are a gateway for youth to become addicted to cigarettes, Dr. Ted Wagener from the University of Oklahoma Health Sciences Center reports being able to find only one young person who initiated nicotine use with e-cigarettes and then went on to smoke cigarettes, out of a sample of 1,300 college students.

The study has not yet been published, but it was presented Tuesday at the annual meeting of the American Association for Cancer Research in Washington, D.C.

According to Brenda Goodman's HealthDay article summarizing the study: "E-cigarettes don't appear to entice teens to try smoking tobacco, a new study says. ... Last month, the U.S. Centers for Disease Control and Prevention warned that "vaping," or inhaling the nicotine vapors from e-cigarettes, might be a dangerous new fad that could set teens up for smoking. In just one year, the number of kids in grades six through 12 who said they'd ever tried an e-cigarette more than doubled, rising from 3.3 percent to 6.8 percent. Among the 2.1 percent who said they were current e-cigarette users, more than three-quarters said they also smoked regular cigarettes. Given that overlap, many health experts worried that e-cigarettes might be acting like a gateway drug, sucking kids more deeply into nicotine addiction, and law officials urged the U.S. Food and Drug Administration to regulate e-cigarettes as tobacco products."

"The new study suggests that may not be the case. Researchers surveyed 1,300 college students about their tobacco and nicotine use. The average age of study participants was 19. "We asked what the first tobacco product they ever tried was and what their current tobacco use looked like," said researcher Theodore Wagener, an assistant professor of general and community pediatrics at the University of Oklahoma Health Sciences Center, in Oklahoma City. Overall, 43 students said their first nicotine product was an e-cigarette. Of that group, only one person said they went on to smoke regular cigarettes. And the vast majority who started with e-cigarettes said they weren't currently using any nicotine or tobacco."

"It didn't seem as though it really proved to be a gateway to anything," said Wagener, who presented his findings at a meeting of the American Association for Cancer Research, in National Harbor, Md."

The Rest of the Story

This study provides preliminary evidence that electronic cigarettes are not currently serving as a major gateway to cigarette smoking. Of course, more studies of this nature, as well as longitudinal studies, are necessary to firmly answer this question. And importantly, this only reflects the current situation and things can change at any time. It is important that we remain vigilant and closely monitor youth electronic cigarette use over time.

I should also make it clear that in no way am I arguing that sales and marketing restrictions are not needed. In fact, I am hoping that the FDA will promulgate regulations that do strictly regulate the sale and marketing of electronic cigarettes to youth.

What this evidence does highlight is how unfortunate it was that CDC Director Dr. Thomas Frieden disseminated to the public a conclusion about this research question, telling the public that we already know the answer and that electronic cigarettes are a gateway to tobacco addiction. Dr. Frieden stated that: "many kids are starting out with e-cigarettes and then going on to smoke conventional cigarettes."

Unfortunately, this premature speculation (or conclusion, as the above statement does not seem to be speculative) led to widespread media dissemination to the public of the news that electronic cigarettes are a gateway to tobacco addiction. These articles are already having an effect on policy makers throughout the country.

In a Forbes magazine online column today, Jacob Sullum explains how many tobacco control advocates, including Dr. Frieden, "jumped all over CDC survey data indicating that the percentage of teenagers who have tried e-cigarettes doubled (from 3.3 percent to 6.8 percent) between 2011 and 2012." Sullum writes: "'Many teens who start with e-cigarettes may be condemned to struggling with a lifelong addiction to nicotine and conventional cigarettes,' CDC Director Tom Frieden worried. But the survey data [the CDC data] provided no evidence that e-cigarettes are a gateway to the conventional kind, and a new study [the Wagener study] casts further doubt on that hypothesis."

The issue of whether electronic cigarettes serve as a gateway to youth tobacco addiction is a very serious one. It should not be taken lightly. If these products lead to increased cigarette smoking among youth then this harm would offset the benefits of enhanced smoking cessation and electronic cigarettes would no longer have net public health benefits. So this is a crucial research question.

But I emphasize that it is a "question." It does a disservice to the public to draw pre-determined conclusions, as Dr. Frieden did in telling the public that we already have the answer: kids are starting out with e-cigarettes and going on to smoke conventional cigarettes.

Our public policies must be science-based. But when one draws pre-determined conclusions, rather than rely on the scientific evidence, this does not lead to evidence-based policies. My fear is that because of a strong pre-existing ideology against electronic cigarettes because they simulate the physical actions of smoking, tobacco control groups are drawing conclusions based on ideology rather than on science.

Congratulations to the Tens of Thousands of "Anecdotes" Who Have Successfully Quit Smoking via Electronic Cigarettes

On this Friday afternoon, I want to give a huge shout out to the literally tens of thousands of "anecdotes" out there who have successfully quit smoking via the use of electronic cigarettes.

You may wonder why I am calling these people - smokers who have quit smoking via electronic cigarettes - anecdotes.

The reason is this:

According to CDC Director Dr. Thomas Frieden, the thousands of smokers who have quit smoking via electronic cigarettes are nothing but anecdotes. As Dr. Frieden told the Los Angeles Times in this article, referring to smokers who have quit using e-cigarettes: "the plural of anecdote is not data."

The complete quote from this article:

"Frieden acknowledged that “stick to stick, they’re almost certainly less toxic than cigarettes" and that many people have quit smoking tobacco cigarettes with the help of e-cigarettes. However, he said, “the plural of anecdote is not data.”"

The Rest of the Story

There is one thing you almost never hear most anti-smoking advocates and groups say to smokers who have quit via electronic cigarettes ...

... "Congratulations."

I have long found it curious that anti-smoking advocates and groups fail to praise and congratulate vapers who have completely quit smoking for having completely quit smoking. Apparently, in tobacco control, it is not just important to quit smoking, but you have to quit smoking the right way (a.k.a., with Big Pharma drugs).

Today, I'd like to clearly and unequivocally say, as a staunch anti-smoking advocate:

"Congratulations to all the tens of thousands of vapers out there who have quit smoking using electronic cigarettes. You have helped to improve your health and perhaps save your life. You have taken the most important step in improving your health. And you have done a tremendous favor for your family, friends, and loved ones."

"Do not listen to what the CDC and the FDA are telling you. There is no question that by quitting smoking, you have greatly improved your health. There is no question that vaping is much safer than smoking. Do not allow yourself to be deceived by the propaganda. Do not return to cigarette smoking in fear that somehow there are hidden risks in vaping that could render them just as dangerous as cigarettes."

"And most importantly, you are not just anecdotes. Each one of you is a real, courageous person who has accomplished one of the most difficult personal struggles that a person can face in terms of health behavior: quitting smoking, one of the strongest and most powerful addictions. Congratulations!"

Incidentally, it is just not true that the plural of anecdote is not data. In fact, a single anecdote is "data." One of the most basic study designs in epidemiology is something called a "case study." That is the "anecdote" about a single individual. The next basic design is a "case series," which is simply a number of "anecdotes."

Some of the most important conclusions in epidemiologic research have come not from large case-control or cohort studies or clinical trials, but from case studies or case series, or as Dr. Frieden would say, "anecdotes."

For example, I am proud of having been part of a team that was the first ever to report that the dietary supplement L-tryptophan can cause pulmonary hypertension via the eosinophilia-myalgia syndrome. This important conclusion - which had major public health policy implications - was based on a single reported case of pulmonary hypertension. In other words, it was based on a single "anecdote." Had we dismissed this finding because a single anecdote is not data, then we would have failed to report this relationship and many more patients would have suffered that fate, possibly leading to fatalities.

Anecdotes are in fact data. Of course, what you do with that data and how you interpret it is affected by the nature of how the data were obtained. But anecdotes are data. Remember, the connection between smoking and lung cancer itself was first uncovered by a case series. Physicians started to note multiple cases of lung cancer - which was very rare at the time - all occurring in smokers. While these patients could be called "anecdotes," they were also people who provided very real and important data that led to the discovery that smoking causes lung cancer. That connection would not have been found had these "anecdotes" been dismissed.

CDC Continues to Spread Unsupported Propaganda and Misinformation About Electronic Cigarettes

In an article published early this week in the Los Angeles Times, CDC director Dr. Thomas Frieden issues a blistering attack on electronic cigarettes. In the article, he compares the damage and destruction caused by tobacco cigarettes with e-cigarettes, suggesting that another generation of our kids is going to become addicted to smoking because of e-cigarettes. He argues that the electronic cigarette industry is harming "hundreds of thousands of children."

Dr. Frieden is quoted as stating that: "E-cigarettes are a tobacco product."

In addition, Dr. Frieden insinuates that electronic cigarettes are a gateway to smoking, are impeding smokers from quitting, are causing ex-smokers to return to smoking, and deterring smokers who want to quit from quitting.

He states: “If they get another generation of kids more hooked on nicotine and more likely to smoke cigarettes, that’s more harm than good. If they get smokers who would have quit to keep smoking instead of quitting, more harm than good. If they get ex-smokers who have been off nicotine to go back on nicotine and then back to cigarettes, more harm than good. If they get people who want to quit smoking and would have taken medicines to think e-cigarettes are going to help, but they don’t, more harm than good."

Furthermore, the reporter interpreted Dr. Frieden as asserting that "e-cigarettes are as dangerous as tobacco cigarettes."

The Rest of the Story

The rest of the story is simple: the CDC is spreading unsupported propaganda and misinformation to the public as part of an unscientific and unwarranted attack on electronic cigarettes. Sadly, this attack on electronic cigarettes is doing a huge favor to Big Tobacco because it is going to deter smokers who would otherwise have quit or cut down using e-cigarettes from doing so and it may well cause many ex-smokers who quit via electronic cigarettes to return to cigarette smoking.

I do not begrudge the CDC for holding a different position than I do regarding electronic cigarettes. However, I find it abhorrent that the CDC is supporting this position by disseminating false and misleading information that is completely unsupported by scientific evidence. Our nation's leading public health agency should not be acting in this way.

There is absolutely no evidence that electronic cigarettes are a gateway to smoking. There is no evidence that vaping is impeding smoking cessation or that it is causing former smokers to return to smoking. In fact, the existing evidence suggests that the opposite is true: it appears that electronic cigarettes are increasing quitting attempts and enhancing smoking cessation without serving as a gateway to youth smoking.

There is no evidence that the e-cigarette industry is harming hundreds of thousands of children. Most of the youth who have used e-cigarettes are those who were already users of tobacco products, so it is entirely possible that the use of e-cigarettes among these children actually decreased their tobacco use. Moreover, the assertion that e-cigarettes are a gateway to smoking is inconsistent with actual data on trends in youth smoking rates. Furthermore, the assertion that e-cigarettes are impeding smoking cessation is inconsistent with data on cigarette consumption trends.

That the CDC has apparently drawn pre-determined conclusions about these questions is both inappropriate and unfortunate. And it is not only unscientific but it precludes the agency from making evidence-based decisions or recommendations.

Even claiming that electronic cigarettes are tobacco products is disingenuous because these products do not contain tobacco. It is true that electronic cigarettes are being regulated as "tobacco products," but they are not tobacco products in the ordinary usage of this term. Calling them tobacco products will mislead the public into thinking that electronic cigarettes contain tobacco. This is of course not true.

While as I said, I do not begrudge the CDC for holding this position on e-cigarettes, the fact that it is resorting to fabricating evidence in support of its position suggests that its position is untenable. If your position is strong, you should be able to support it with actual facts and scientific evidence. When all you can do to support your position is to produce false and misleading propaganda, then it's pretty clear you don't have a leg to stand on.

Dishonesty of Vaping Opponents (Health Agencies) is Out of Control; Urgent Action is Needed

The misleading information being spread to the public by vaping opponents, including prominent health agencies like federal, state, and local health departments, has become out of control. It threatens to do immense public health damage by protecting cigarette sales at the expense of a much safer alternative - electronic cigarettes - and at the same time it also threatens the reputation of public health agencies.

Today, I highlight four examples of misinformation about electronic cigarettes from vaping opponents, representing four levels of health groups: international, national, state, and local.

International

World Health Organization: 

Vaping does not help people stop smoking

The World Health Organization (WHO) is waging an all-out war on electronic cigarettes, which is ironically helping to protect real cigarettes from what otherwise could have been immense competition from a much safer product. The WHO could hardly be doing the cigarette companies around the world any greater favor. Recently, a WHO report prepared for the Conference of the Parties (COP-7) meeting concluded that vaping does not help people stop smoking. Furthermore, the head of the convention secretariat made clear her opinion that electronic cigarettes "should not be promoted widely."

According to an article in The Guardian, Anna Gilmore, professor of public health at the University of Bath and the UK Centre for Tobacco Control Studies, stated: "The tobacco industry uses e-cigarettes to claim it is committed to harm reduction, but meanwhile it continues to engage in harm maximisation by spending millions to promote tobacco and oppose any policy that would reduce its use."

How ironic that Professor Gilmore is attacking the tobacco industry for opposing "any policy that would reduce" tobacco use, while at the very same time (and in the same sentence) she is vigorously opposing one of the most promising strategies ever for reducing tobacco use (vaping). In the same sentence, she condemns the tobacco industry for not being "committed to harm reduction," yet expresses her own opposition to harm reduction.

The rest of the story is that it is not the tobacco industry that is holding up the use of harm reduction as a widespread tobacco control strategy. In fact, the tobacco companies are largely supporting a harm reduction approach, and they are vigorously promoting vaping products. On the other hand, it is the tobacco control community and health agencies like the WHO that truly are holding up harm reduction through their opposition to promoting vaping as a much safer alternative to smoking.

National

Centers for Disease Control and Prevention: 

Reductions in the amount of cigarettes smoked daily by smokers represent great progress, but not among vapers
 
The director of CDC - Dr. Tom Frieden - was quoted recently as stating: "The pack-a-day smoker has become more and more rare. What we've seen is a shift from heavier smokers to lighter smokers. We're seeing really good progress."

What Dr. Frieden failed to reveal was that one major reason for recent declines in cigarette consumption is that millions of smokers are switching - in whole or in part - to vaping. And even those who switch only in part (so-called "dual users") are greatly improving their health if they cut down substantially on the amount they smoke. They are also reducing their level of smoking addiction which makes it easier for them to quit in the future. There is no question that the widespread use of electronic cigarettes, while strongly opposed by Dr. Frieden and the CDC - is contributing to declines in the amount smoked daily by smokers. Thus, the CDC is hindering the very "progress" that it claims to support.

State

The Ohio State University Comprehensive Cancer Center

We have no idea whether vaping is any safer than smoking

According to a statement from the deputy director of the Ohio State University Comprehensive Cancer Center, we have no idea whether vaping is any safer than smoking: "There is minimal data available regarding the direct health effects of e-cig use or vaping, but these products have gained rapid popularity among existing smokers and non-smokers alike, including young adults. We are concerned that people assume these products have fewer negative health effects as compared with cigarettes and other tobacco products. The reality is that they are still a tobacco product and people are still inhaling potentially harmful chemicals. They should not be considered a 'safer' option until science has the opportunity to catch up with the consumer market."

To further emphasize his statement that we have no idea whether smoking is any more hazardous than vaping, the deputy director said: "We have no idea where in the spectrum these are, in terms of safety. Are they like cigarettes, or nothing like cigarettes?"

It is disturbing to me that a comprehensive cancer center that every day sees the devastation to people's health and lives caused by smoking is unable to conclude that smoking is any more hazardous than vaping, despite scores of studies demonstrating the relative safety of vaping compared to smoking. Are you serious? Anyone who takes an even cursory look at the scientific evidence will tell you that there is no question that vaping is much safer than smoking. Even Stan Glantz - a vaping opponent - acknowledges that there is no question vaping is safer than smoking.

Local

Knox County Health Department (Knoxville, Tennessee)

Vaping is not healthier than smoking

According to a "fact sheet" from the Knox County Health Department: "Vaping devices are often marketed as the “smarter” or “healthier” alternative to smoking. The literature has yet to prove this claim. ... There is no proof that they are “safer” or “healthier” than smoking, or if they pose different or additional risk."

A public health department should not be telling the public in 2016 that there is no proof that smoking is any more hazardous than vaping. Even the tobacco companies themselves aren't saying this. In fact, the tobacco companies are telling the truth and acknowledging that vaping is a safer alternative to smoking. It seems only to be health agencies that are still denying the science on vaping and smoking.

The Rest of the Story

For years we attacked the tobacco companies for misleading the public about the health effects of smoking. Now we are doing exactly the same thing. But I don't believe that it is unacceptable for the tobacco industry to mislead people while it's acceptable for us to do it. We need to be beyond reproach in our dissemination of information, and especially recommendations, to the public. A fear that vaping might spread does not justify deception of the public. Honesty is the best policy. In a political climate that is full of dishonesty, I think the last place we need more of it is in public health.

Politicians are Repeating CDC Propaganda, Word for Word, in Pushing Vaping Bans

What I have been predicting for the past few weeks is now coming true, as the CDC propaganda campaign about how electronic cigarettes are leading to a lifetime addiction to smoking is now being repeated - verbatim - by politicians who want to ban vaping in public places.

According to an article in the Orange County Register:

"On Tuesday night, the council voted 8-0 to have City Attorney Charles Parkin find ways to amend the City Code to regulate the trendy electronic cigarettes just like traditional tobacco products. ... “We’re not banning them, we’re not asking them to be sold in our city, what we’re asking for is a standard that we already enjoy with tobacco users,” said John Edmund, chief of staff for District 6 Councilman Dee Andrews, in a presentation to the council. ... “Many teens who start with e-cigarettes may be condemned to struggling with a lifelong addiction to nicotine,” Edmond said."

The Rest of the Story

When I presented on electronic cigarettes at the TMA conference in October, I criticized the CDC director for a series of statements indicating that electronic cigarettes are a gateway to youth smoking. I argued that there is no evidence to support such a conclusion and so the CDC director should not be telling the public that e-cigarettes are a gateway to a lifetime of addiction to cigarette smoking, as he was doing. The director of CDC's Office on Smoking and Health responded by arguing that the CDC director's comments were inconsequential, that few people saw these comments, that I was drilling down to dissect the comments inappropriately, and that no one was going to pay attention to them.

Today, we learn that politicians are now taking Dr. Frieden's statement - word for word - and using it as reputable evidence to support vaping bans.

Here is what the chief of staff to Councilman Andrews was quoted as saying:

"Many teens who start with e-cigarettes may be condemned to struggling with a lifelong addiction to nicotine."

And here is what CDC director Dr. Thomas Frieden stated:

"Many teens who start with e-cigarettes may be condemned to struggling with a lifelong addiction to nicotine and conventional cigarettes."

Last week, I wrote: "At a recent TMA conference on electronic cigarettes, a CDC official defended Dr. Frieden's statement on the grounds that: (1) It was merely a "slip of the tongue"; and (2) it was inconsequential because very few people saw it. Apparently, this slip of the tongue, which was disseminated nationwide through more than 50 media outlets, will have no impact on local public health organizations. However, based on today's rest of the story, it appears that this unsupported statement may in fact be leading local public health practitioners to further disseminate this misleading information."

After today's story, I rest my case.

CDC's False Statements About E-Cigs are Still Doing Damage; Agency Needs to Retract Statements Immediately

Although it has been a year and a half since the CDC disseminated to the public inaccurate information about electronic cigarettes being a gateway to smoking among youth, this false propaganda is still doing damage.

It was in fall 2013 that CDC made the following statements regarding electronic cigarettes being a gateway to smoking:

1. 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." 

2. In addition, Dr. Frieden was quoted as stating that electronic cigarettes are "condemning many kids to struggling with a lifelong addiction to nicotine and conventional cigarettes."

This past Sunday, in an article in the Newburyport Daily News, the CDC was again quoted as concluding that electronic cigarettes are a gateway to youth smoking.

According to the article: "While supporters say e-cigarettes are a less dangerous alternative to cigarettes, health officials said they worry the devices could spur teen cigarette use, possibly undermining decades of work to reduce smoking rates. At least 10 percent of high school students say they tried e-cigarettes in 2012, up from 4.7 percent in 2011, according to a National Youth Tobacco Survey by the US Centers for Disease Control and Prevention. “The increased use of e-cigarettes by teens is deeply troubling,” CDC director Thomas Frieden said in a recent statement. “Many teens who start with e-cigarettes may be condemned to struggling with a lifelong addiction to nicotine and conventional cigarettes.”"

Even a brief search of the internet reveals that this statement continues to be relied upon by anti-smoking groups throughout the country in pressing the case that e-cigarettes are a gateway to youth smoking. The quote is even featured in an argumentative writing assignment for 9th graders at the Moore public schools in
Oklahoma.

The Rest of the Story

I can certainly understand if the CDC made a mistake. I do it all the time. Anyone can misspeak or say something in an interview that is not correct. The important thing is that you correct the error, especially if it will have a major effect on public policy.

But here we are a year and a half after the original statements and the CDC has failed to make any attempt to retract or correct these statements. They even have the original press release up with no note of any correction.

Given this failure to correct what is obviously a completely unsupported statement and one which appears to be false, one has to at this point infer that the deception of the public is intentional.

I call on the CDC to immediately retract these statements before any further damage is done. Failing to do so will only solidify my conclusion that the agency is intentionally misleading the public to promote its anti-e-cigarette agenda.

New CDC Report on E-Cigarettes Shatters Gateway Myth, Suggests Shift from Hazardous Smoking to Much Safer Vaping among Youth

A new CDC report released moments ago and published in tomorrow's MMWR (Morbidity and Mortality Weekly Report) presents new data from the 2014 National Youth Tobacco Survey which show a tripling of past 30-day ("current") e-cigarette use from 2013 to 2014 among both high school and middle school students.

(See: Arrazola RA et al. Tobacco use among middle and high school students -- United States, 2011-2014. MMWR, Vol. 64, No. 14, April 17, 2015.)

The report shows a dramatic and statistically significant increase in current use of e-cigarettes among both high school and middle school students over the period 2011-2014. The actual data are as follows:

Current (past 30-day) E-Cigarette Use 

High school students
2011: 1.5%
2012: 2.8%
2013: 4.5%
2014: 13.4%

Middle school students
2011: 0.6%
2012: 1.1%
2013: 1.1%
2014: 3.9%

In a press release issued by CDC, the director of the FDA's Center for Tobacco Products stated: "In today’s rapidly evolving tobacco marketplace, the surge in youth use of novel products like e-cigarettes forces us to confront the reality that the progress we have made in reducing youth cigarette smoking rates is being threatened."

The Rest of the Story

The CDC, FDA, and anti-smoking groups are only telling one aspect of the story. There is indeed a "rest" of the story, and here it is:
What the CDC fails to mention in its report is that these new data pretty much shatter the gateway myth that the CDC has been disseminating over the past two years.

The CDC has been telling the public that its data from the National Youth Tobacco Survey provides evidence that e-cigarettes are a gateway to cigarette smoking among youth. Remember that 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, in response to the 2011-2012 increase in youth e-cigarette use: "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."

However, today's CDC report reveals that something very different appears to be occurring. It appears that rather than serving as a gateway toward cigarette smoking, e-cigarettes may actually be acting as a diversion away from cigarettes. Perhaps the most important finding of the new report is that despite the dramatic increase in e-cigarette use among youth, the prevalence of smoking among youth has fallen dramatically during the same time period.

Among high school students, while current use of e-cigarettes increased from 1.5% in 2011 to 13.4% in 2014, current use of real cigarettes declined from 15.8% to 9.2%. Moreover, the prevalence of overall tobacco use among youth has remained steady during this time period, both among high school and middle school students.

These data do not support, and in fact, help to refute the CDC's assertions that e-cigarettes are a gateway to cigarette smoking among youth. These new data are simply not consistent with such a conclusion. Moreover, the data suggest the opposite. The data suggest that overall tobacco use among youth is not changing, but the form of that use is shifting dramatically: away from combustible cigarettes and towards non-tobacco-containing and much safer electronic cigarettes.

This is actually a good thing. While we of course do not want the reduction in smoking among youth to be "offset" by increases in the use of safer products, such as e-cigarettes, because we would prefer that youth not use any form of nicotine, the reality is that the observed shift away from real tobacco cigarettes and towards the fake cigarettes is actually a positive phenomenon in terms of improving the public's health. This shift is going to result in a great reduction in disease and death down the road, because vaping is far safer than smoking.

The truth is that the increase in e-cigarette use is not "offsetting" the decline in cigarette smoking because a large component of the increase in non-cigarette tobacco products is a dramatic rise in hookah use, which among high school students increased from 4.1% in 2011 to 9.4% in 2014.

The rest of the story, then, is that what the CDC data show, but the CDC fails to acknowledge, is that overall use of tobacco among youth is stable, but the form of that use is shifting from the most hazardous type of nicotine-delivering product (real tobacco cigarettes) to less hazardous products (especially electronic cigarettes). There is no question that we need to redouble our efforts to discourage youth from all forms of tobacco and that our goal should be to reduce all tobacco use, not just cigarette use. However, that goal does not justify misrepresenting the scientific data as indicating that the rise in e-cigarette use is troubling because it is going to lead to eventual smoking addiction.

The rest of the story is that the opposite phenomenon appears to be occurring. The advent of this novel product (e-cigarettes) actually appears to be diverting youth who are at high risk of smoking away from tobacco cigarettes and towards e-cigarettes. In essence, e-cigarettes are a gateway product, but they are a gateway away from, rather than towards cigarette smoking.

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.


WEST REGIONAL

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."

SOUTH REGIONAL

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.


MIDWEST REGIONAL 

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.

EAST REGIONAL

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.

THE WINNERS

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.

SEMIFINAL MATCHUPS

1. California Department of Health Services vs. Mayo Clinic

2. CDC vs. FDA

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

Today, I reveal the semifinalists for the 2015 Rest of the Story Worst E-Cigarette Lie Championship. The champion will be revealed next week. 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. See my previous post for a full description of the Elite Eight organizations that made it to the quarterfinals.

The semifinal matchups were as follows:

SEMIFINAL MATCHUPS

1. California Department of Health Services vs. Mayo Clinic

2. CDC vs. FDA

Here are the relevant statements (lies) of each semifinalist organization:

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."

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.
 
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."

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.

THE WINNERS
 
 1. California Department of Health Services vs. Mayo Clinic

The California Department of Health Services wins in a blowout. Buoyed up by further lies coming out of the state health department, the team was in rare form. The Department's web site is full of lies, including the whopper that e-cigarettes are no healthier than regular cigarettes. Other web site lies include the insinuation  that e-cigarettes are actually more harmful than regular cigarettes because they contain more particles, that vaping causes asthma attacks, that e-cigarettes cause heart attacks, that vaping causes as much lung inflammation as smoking, and that nicotine is as addictive as heroin. In addition, the Department is running a campaign to keep smokers from quitting by switching to electronic cigarettes.

2. The Centers for Disease Control and Prevention vs. the Food and Drug Administration

In a close contest, CDC defeats the FDA. This was a tightly contested battle, and the CDC only pulled ahead in the final minutes. The CDC's lies about e-cigarettes being a gateway to smoking have had such a huge impact on public policy throughout the nation that CDC pulled away with the victory.

FINAL MATCHUP

California Department of Health Services vs. CDC

Rest of the Story Reaches Consensus on Corrective Statements for CDC and Anti-Smoking Groups

According to an article at CSPnet.com: "The nation's tobacco companies and the U.S. Department of Justice (DOJ) have reached an agreement on publishing corrective statements that say the companies lied about the dangers of smoking and requires them to disclose smoking's health effects, said an Associated Press report."

The article reports that: "Under the agreement with the DOJ, each of the companies must publish full-page ads in the Sunday editions of 35 newspapers and on the newspapers' websites, as well as air prime-time TV spots on CBS, ABC or NBC five times per week for a year. The companies also must publish the statements on their websites and affix them to a certain number of cigarette packs three times per year for two years."

"Each corrective ad is to be prefaced by a statement that a federal court has concluded that the defendant tobacco companies 'deliberately deceived the American public.' Among the required statements are that smoking kills more people than murder, AIDS, suicide, drugs, car crashes and alcohol combined, and that 'secondhand smoke kills over 38,000 Americans a year.'"

The Rest of the Story

At the same time that the tobacco companies and the U.S. Department of Justice reached a consensus on the location of the tobacco industry corrective statements, the Rest of the Story has reached a consensus on the text and location of a set of corrective statements it is ordering that CDC and several anti-smoking groups and advocates make, in the wake of last year's revelation that they lied about the dangers of electronic cigarettes.

The consensus, which was reached over the weekend, requires public corrective statements from the CDC, the Mayo Clinic, Dr. Stan Glantz, and the University of Kentucky Cancer Center.

The required text for the corrective statements and their required placement is as follows:

For CDC:

The Rest of the Story has ruled that the Centers for Disease Control and Prevention has lied to the American public by telling them that studies have demonstrated electronic cigarettes are a gateway to a lifetime addiction to smoking, and has ordered the CDC to make this statement. Here is the truth:

• We lied to you when we told you that "many kids are starting out with e-cigarettes and then going on to smoke conventional cigarettes."
 
• The truth is that the study we relied upon did not measure the time course of electronic cigarette and cigarette use. Thus, it could not determine whether the kids who were using both cigarettes and electronic cigarettes had initiated with smoking or with electronic cigarettes.

• The only study to examine this question found that e-cigarettes are not a gateway to smoking.

• There is no evidence at the current time that kids are starting out with e-cigarettes and then going on to smoke conventional cigarettes.

Placement:

1. Medscape - where the original interview with Dr. Frieden appears
2. The 52 media outlets that carried the story and quoted Dr. Frieden as stating that electronic cigarettes are "condemning many kids to struggling with a lifelong addiction to nicotine."
3. CDC web site

For the Mayo Clinic:

The Rest of the Story has ruled that the Mayo Clinic has lied to the American public by telling them that absolutely no studies have examined the health effects of electronic cigarettes and that doctors have no way of assessing the impact of this product, and has ordered the Mayo Clinic to make this statement. Here is the truth:

• We lied to you when we told you that "No studies have been done to examine the safety of e-cigarettes."
 
• The truth is that there are at least 10 published studies that examined the health effects of electronic cigarettes. And this doesn't even include the more than 20 studies in which the chemical constituents of electronic cigarette liquids or vapor have been analyzed using gas chromatography/mass spectrometry.

• We also lied to you when we told you that "with nicotine inhalers you receive only nicotine."

• The truth is that nicotine inhalers deliver to users the following chemicals:

Formaldehyde

Acetaldehyde

o-methylbenzene

Cadmium

Nickel

Lead

Placement:

1. Mayo Clinic web site
2. Mayo Clinic Proceedings

For Stan Glantz:

The Rest of the Story has ruled that I lied to the American public by telling them that studies have demonstrated electronic cigarette experimentation leads to nicotine addiction among nonsmokers who try these products, and has ordered me to make this statement. Here is the truth:

• I lied to you when I told you that in the Choi and Forster study, "e-cigarettes were a pathway to renewed or new nicotine addiction."
 
• The truth is that the study only measured ever use of electronic cigarettes, not current use, regular use, or addiction to nicotine. Thus, it could not determine whether the kids who had tried electronic cigarettes ever used them again. So it could not tell if these kids were addicted to nicotine. They may have simply tried an electronic cigarette and not vaped again.

• I also lied to you when I told you that my own study demonstrated that electronic cigarettes are "a new route to smoking addiction for adolescents." The study was a cross-sectional one, so I could not draw that conclusion. And I admitted it in the article itself. But that's not what I told you.

Placement:

1. Stan Glantz blog
2. Stan Glantz announcement list
3. UCSF web site

For the University of Kentucky Cancer Center:

The Rest of the Story has ruled that we lied to the American public by telling them that electronic cigarettes are every bit as harmful as smoking, and has ordered us to make this statement. Here is the truth:

• We lied to you when we told you that electronic cigarettes may be "every bit as dangerous" as tobacco cigarettes.
 
• The truth is that there is abundant evidence that electronic cigarettes are much safer than regular cigarettes. Even the tobacco industry itself acknowledges that smoking is more hazardous than vaping. 

Placement:

1. University of Kentucky Cancer Center web site
2. Letter to all Kentucky state legislators

2014 Anti-Smoking Myth of the Year Award Goes to CDC, Dr. Stan Glantz, and Dr. Michael Fiore

The Rest of the Story is pleased to announce the recipients of the 2014 Anti-Smoking Myth of the Year Award. This year's award goes to:

• The Centers for Disease Control and Prevention (CDC);
• Dr. Stan Glantz; and
• Dr. Michael Fiore

for publicly spreading the myths that electronic cigarettes have been found to be a gateway to smoking among youth and that electronic cigarette experimentation leads to a lifelong addition to nicotine.

The CDC was first to the punch, with its director misrepresenting cross-sectional CDC survey data as conclusive evidence that electronic cigarettes are a gateway to smoking. Specifically, CDC Director Dr. Thomas Frieden stated:

"What we are doing first is tracking, and we are seeing some very concerning trends. 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."

The Office on Smoking and Health (where I used to work) vigorously supported these statements and failed to offer any public corrections. Nor am I aware of any other CDC corrections or retractions of these claims.

More recently, Dr. Stan Glantz began disseminating the conclusion that e-cigarettes are a gateway to smoking. In an article published in USA Today, he 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."

And even more recently, Dr. Michael Fiore rang in the new year with a public statement that electronic cigarettes can lead youth to a lifetime addiction to nicotine. He was quoted as stating: "One of the biggest concerns about e-cigarettes is that they will serve as a gateway drug to lifelong nicotine dependence and all of the harms we know result from cigarette smoking. We know that the adolescent brain is very sensitive to nicotine. Use of e-cigarettes, with its exposure to nicotine, puts these adolescents at risk of lifelong nicotine addiction."

The Rest of the Story

As I have repeatedly pointed out, there is absolutely no existing evidence that electronic cigarettes are a gateway to smoking among youth or that electronic cigarette experimentation is leading youth to a lifetime of addiction to nicotine. In fact, the only evidence to date suggests that among U.S. youth, electronic cigarettes are not a gateway to smoking and e-cigarette experimentation does not appear to lead to regular (greater than weekly) use, much less to a lifetime of addiction.

President John F. Kennedy once said: "The great enemy of truth is not the lie--deliberate, contrived, and dishonest--but the myth--persistent, persuasive, and unrealistic." Here indeed, the repeated statements of the CDC and a number of prominent anti-smoking researchers have effectively created a myth, one that has become persistent and persuasive, even though it lacks evidence. And as a result, the media and in turn, policymakers, are accepting this myth as truth and making poor policy decisions because of it.

Interestingly, what President Kennedy went on to say in that 1962 speech relates perfectly to the manner in which the anti-smoking movement is dealing with the scientific question of whether e-cigarettes are a gateway to smoking.

Kennedy went on to say: "Too often we hold fast to the cliches of our forebears. We subject all facts to a prefabricated set of interpretations. We enjoy the comfort of opinion without the discomfort of thought."

This is precisely what is occurring in the tobacco control movement. We are holding fast to the cliches of the fast (i.e., the knowledge that smokeless tobacco can act as a gateway to cigarette use). We are subjecting all evidence to a prefabricated set of interpretations. Even cross-sectional evidence is being interpreted as showing that youth are starting with e-cigarettes and then progressing to active smoking. The CDC and some anti-smoking researchers are enjoying the comfort of expressing their conclusions about the gateway hypothesis without having to actually "think" (i.e., to actually analyze and interpret the scientific evidence that bears directly on this question).

I will close as President Kennedy did: "The stereotypes I have been discussing distract our attention and divide our effort. These stereotypes do our Nation a disservice, not just because they are exhausted and irrelevant, but above all because they are misleading--because they stand in the way of the solution of hard and complicated facts. It is not new that past debates should obscure present realities. But the damage of such a false dialogue is greater today than ever before... ."