Monday, June 10, 2019

Wednesday, April 17, 2019

Lawsuit Against Juul/Altria Alleging Fraudulent Misinformation Provides Fraudulent Misinformation

Parents of a Florida teenager who became addicted to Juul have sued Juul, Altria, and Philip Morris USA based on a number of claims, including fraud, negligence, and violation of the RICO statute (the compliant is here). Dr. Stan Glantz and Lauren Lempert provide a nice summary of the reasoning behind the lawsuit and the specific claims being made. The case was filed on Monday in the federal district court for the middle district of Florida.

The Rest of the Story

Although the main complaint is that the company fraudulently provided misinformation about the product, its health risks, and its addictiveness, the complaint itself provides a huge amount of misinformation and distortion of the scientific facts related to vaping and Juul. Here is a sampling of the false or completely unsupported information that is claimed in the complaint:

1. Vaping causes chronic obstructive pulmonary disease (COPD): The lawsuit claims that "just like traditional cigarette smoke," vaping causes COPD because it "introduces foreign substances into the lung." There is absolutely no evidence to support this claim. Despite at least 12 years of use and prolonged vaping by millions of Americans, I'm not aware of a single case of COPD that has been documented to be caused by vaping. While vaping does cause acute respiratory irritation, there is no evidence at this point that prolonged exposure to e-cigarette aerosol is extensive enough to cause permanent lung obstruction.

2. Nicotine is a carcinogen: The lawsuit claims that "nicotine itself is a carcinogen." The leading, objective, international body that studies carcinogens (the International Agency for Research on Cancer [IARC]) has not declared nicotine to be a carcinogen.

3. Juul delivers carcinogens to users: The lawsuit claims that Juul "delivers toxins and carcinogens to users." However, the complaint does not specify exactly what toxins or carcinogens Juul delivers to users. Studies of the aerosol produced by Juuling, to the best of my knowledge, have not demonstrated the presence of detectable levels of carcinogens.

4. Juul is designed to transition users to cigarette smoking: The lawsuit claims that Juul is designed to make it "easier for e-cigarette users to transition to conventional cigarettes." The truth is the exact opposite. Juul was designed specifically to transition conventional cigarette smokers to vaping. Juul Labs would be stupid if they designed the product such that its users would transition back to smoking. The company makes no money if its users go back to smoking. In fact, the economic incentive for Juul is to eliminate smoking altogether. The more smokers who switch from conventional cigarettes to Juul, the more money the company makes. There is abundant evidence that Juul has succeeded in transitioning hundreds of thousands of smokers away from conventional cigarette use, but no evidence that Juul has transitioned anyone to cigarette smoking.

5. Juul is defectively designed: The lawsuit claims that the Juul e-cigarette is "defectively designed" because it delivers nicotine so effectively. The truth is that this is actually an incredibly effective design because it provides the greatest chance that a smoker will successfully quit smoking by switching to vaping. The problem with most other e-cigarettes is precisely that they do not deliver nicotine effectively. Juul corrected this problem and as a result, it has become the most effective smoking cessation product currently on the market. This is demonstrated by the tremendous market share that Juul holds among adult smokers trying to quit.

6. Juul aggravates nicotine addiction in cigarette smokers: The lawsuit claims that the company knew that Juul "posed a risk of aggravating nicotine addiction in those already addicted to cigarettes." There is no evidence to support this claim and the truth is likely the opposite. While smokers who switch to Juul are obviously still addicted to nicotine, they are no longer addicted to smoking. The behavior of smoking is a huge component of the addiction to nicotine that is observed in cigarette smokers. By eliminating that aspect of the addiction, the overall addiction is almost certainly lessened.

7. Juul fails to inform users that its product has not been found to be safe: The lawsuit claims that the company "fails to inform users that its products have not been found to be safe." The truth is that Juul says right on its web site that: "No tobacco-based or nicotine e-liquid product should be considered safe." In addition, Juul informs customers that: "Inhalation of e-vapor from JUUL may aggravate pre-existing respiratory or heart conditions. Additionally, ingestion of nicotine, at any level, may cause other conditions (such as an increase in your heart rate and blood pressure, may cause dizziness, nausea, and stomach pain)." The company also warns users about ingesting the e-liquid, informing them that the product: "Contains nicotine, which is an addictive chemical and can be poisonous. Avoid contact with skin and eyes. Do not drink."

8. Juul falsely claimed that it is not affiliated with Big Tobacco: It is true that Juul claimed that it had no affiliation with Big Tobacco. But that was prior to its partial acquisition by Altria. You can hardly blame the company for making a true statement, as long as they no longer make that claim. A Google search revealed that, ironically, the only current internet source of the claim that "Juul Labs is not Big Tobacco" is the lawsuit itself.

9. Juul and Altria plan to use Juul as an entry point for youth to start smoking Marlboro cigarettes: Not only is there no evidence to back up this claim, but it is patently ridiculous. You don't get kids addicted to Marlboro by marketing Juul. You get kids addicted to Juul by marketing Juul. Data from the PATH study demonstrate that becoming a regular vaper is a path away from smoking, not towards smoking. In fact, the only kids who currently progress to smoking are those who do not become regular vapers. Why would a company think that by addicting kids to a mango-flavored product, they would suddenly develop a desire for the harsh taste of Marlboro? Altria may have a history of being sinister, but they are not stupid.

None of this is to deny the fact that Juul use among youth has become a serious public health problem that needs to be addressed urgently. None of this is to deny that Juul carries some responsibility for having created the problem. However, it doesn't seem fair to file a lawsuit against the company for making false claims by putting false claims into the complaint.

Ultimately, I go far beyond nearly all of my colleagues in public health because I believe that the use of nicotine salts is simply not a viable long-term option for a harm reduction strategy that is based on trying to get smokers to switch to vaping. Nevertheless, I don't think it is appropriate to sue the company based on alleged facts that are either completely undocumented or simply untrue.

Tuesday, April 09, 2019

New Study Finds Vaping is Not Associated with Cardiovascular Disease among Never Smokers; But Tobacco Control Researcher Dismisses Findings

A new study published online ahead of print in the American Journal of Medicine reports that there is no association between vaping and cardiovascular disease among never smokers.

Like previous studies of its kind, this was a cross-sectional study that examined the association between current vaping/smoking status and ever having been told that one has cardiovascular disease (including heart attack, coronary artery disease, or stroke). Previous studies used data from the National Health Interview Survey (NHIS) or the Population Assessment of Tobacco and Health (PATH) study; this paper used data from the Behavioral Risk Factor Surveillance Survey (BRFSS).

The authors reported no association between current vaping and self-reported cardiovascular disease among never smokers. However, they found that among current dual users there was an increased odds of having ever been told that one has cardiovascular disease.

In response to the study, one prominent tobacco control researcher concluded that dual use is causally associated with cardiovascular disease, while dismissing the negative finding that e-cigarette use was not associated with vaping among never smokers. He wrote: "The fact that the authors did not find an effect of e-cigarettes alone may be because they stratified the sample on e-cig and cigarette use, which reduces the sample size for each comparison, and so the power to detect an effect."

The Rest of the Story

This reminds me of what the tobacco industry used to do. If they saw a finding that they liked, they would emphasize that finding, but if they saw a finding that they didn't like, they would just dismiss it. This is sometimes called "cherrypicking." I've never picked cherries, but I assume that when doing so, one only picks the cherries that you like and disregards the ones that you don't.

As objective scientists, we can't cherrypick. It allows one to have a pre-conceived conclusion and then to simply publicize findings that support the conclusion while dismissing those that do not. It appears that this is what is going on here.

Cherrypicking is becoming more and more common among tobacco control researchers and advocacy groups. Recently I spoke at a conference on vaping, and one of the other speakers on the panel told the audience that there was no evidence vaping can help people quit smoking. The basis of that conclusion was that "there is no clinical trial that shows vaping to be effective ... we need a clinical trial." When I then pointed out that a randomized, clinical trial published last month in the prestigious New England Journal of Medicine found that vaping was twice as effective as nicotine replacement therapy for smoking cessation, they simply dismissed it, saying: "Well I still don't think it's effective." (The same person also did not think there is enough evidence to conclude that vaping is any safer than smoking.)

The reality is that many tobacco control researchers and advocates will not be convinced by any amount of data. You could have two clinical trials, both finding that vaping is effective for some smokers, and they would still dismiss the findings. (In fact, we do have two clinical trials -- it's amazing to see how many tobacco control advocates continue to insist that there have not been any clinical trials on the use of vaping for smoking cessation.)

Here, a positive finding is accepted and touted, while a negative finding is just dismissed. The reasoning given -- that the study didn't have the power to detect an effect -- doesn't hold water because the sample size of never smoking vapers in the study (15,863) exceeded the number of dual users (12,908).

But even the conclusion that dual use is causally associated with cardiovascular disease is unsupported by the evidence presented in the paper. This is a cross-sectional study, so it is entirely possible that the onset of cardiovascular disease preceded the vaping. In fact, this is almost certainly the case for most of the study subjects because e-cigarettes have been popular for only about eight years, and it takes decades for cardiovascular disease to develop.

It may actually be that the cardiovascular disease "caused" the vaping because having a heart attack or stroke is a strong stimulus for a smoker to try to quit, and many smokers try to quit by using e-cigarettes.

Moreover, dual users are almost certainly a different population from exclusive vapers and one systematic difference between the groups is likely that dual users have a heavier or more intense smoking history, making it more difficult for them to get off of e-cigarettes. If this were the case, it would explain the observed finding that dual use was associated with a higher risk of reporting cardiovascular disease. 

The bottom line is that we can't draw causal conclusions from a cross-sectional study like this one, especially one in which it is impossible to determine which came first: the heart attack or the vaping. So to tout the association between dual use and heart disease as a causal finding is bad enough. But cherrypicking findings that support a pre-determined conclusion, while dismissing those which do not support that conclusion, is sinking to the level of the tobacco industry which we once criticized for doing the very same thing.

Friday, March 29, 2019

Public Misunderstanding of Health Risks is "a Good Thing" According to Some in the Tobacco Control Movement

Somewhere along the line, I must have gone astray. During my master's in public health program, I was taught that one major goal of public health is to educate the public about the risks of various exposures. I was also taught that accurately communicating these risks, as well as helping the public to accurately understand the relative risks between different hazardous behaviors or products was critical.

Well, based on an editorial published this morning in the Journal of the American Medical Association (JAMA) Network Open, I was misguided. For in this editorial, it states that the increasing public misunderstanding of the relative risks of smoking compared to vaping is "a good thing."

The editorial responds to new research also published this morning in the same journal which documents that the majority of adults in the U.S. completely misunderstand the dangers that smoking poses compared to those posed by vaping and furthermore, that the proportion of people with this misunderstanding has been growing substantially over time. (See: Huang J, Feng B, Weaver SR, Pechacek TF, Slovic P, Eriksen MP. Changing perceptions of harm of e-cigarette vs cigarette use among adults in 2 US national surveys from 2012 to 2017. JAMA Network Open. 2019;2(3):e191047).

According to the study, in 2012, only 39.4% of adults perceived e-cigarettes as less harmful than real cigarettes. This is pitiful, given the overwhelming scientific evidence that vaping is much less hazardous than smoking. But even worse, the proportion of adults who correctly perceived vaping to be safer than smoking dropped to only 33.9% in 2017. Thus, two out of every three adults in the U.S. incorrectly believes that smoking is no more hazardous than vaping.

Perhaps even scarier, nearly 10% of adults in 2017 perceived vaping to be more harmful than smoking!

The Rest of the Story

Instead of lamenting the fact that the public's perception of the severe hazards associated with cigarette smoking has been seriously undermined over the past decade or so, the editorial almost joyfully celebrates this massive public deception that has occurred. (See: Glantz SA. The evidence of electronic cigarette risks is catching up with public perception. JAMA Network Open. 2019;2(3):e191032).

It is quite a feat of magical writing to take the dismal news that the public is increasingly downplaying the severe risks of smoking and completely misunderstands the relative risks of smoking compared to vaping and to turn that into a tremendous public health victory.

The truth is, however, that this public misunderstanding is having devastating public health consequences. Convinced that vaping is no safer than smoking, many former smokers who quit using e-cigarettes are returning to smoking. After all, what's the point of staying smoke-free using e-cigarettes if vaping is just as bad as smoking? You might as well go back to your Marlboros.

In addition, this misinformation is deterring many smokers who would otherwise have tried to quit using e-cigarettes to just continue smoking. After all, why quit smoking and switch to e-cigarettes if vaping is every bit as harmful. You might as well just stick with your Marlboros.

Huang et al., the authors of the featured article, correctly point out that: "The need for accurate communication of the risk of e-cigarettes to the public is urgent and should clearly differentiate the absolute from the relative harm of e-cigarettes." But somehow, Professor Glantz does not believe that accurate communication is the way to go. Apparently, inaccurate communication is better.

This would almost be funny, were it not for the fact that many adults are going to die because of it. As Huang et al. point out: "Perception of e-cigarette harm [compared to smoking] may deter current smokers from initiating or continuing use of e-cigarettes. This perception may also deter a complete switch from cigarettes to e-cigarettes among smokers. In light of this possibility, the observed upward trend of perceiving e-cigarettes to be more as harmful as or more harmful than cigarette smoking among US adults warrants heightened attention."

In public health, the means do not justify the ends. We do not lie to people in order to persuade them to change their behavior. Telling the truth is a core ethical value of public health practice. But maybe not so much in tobacco control. For us, it is apparently acceptable to spread hysteria using false comparisons and lies simply because we can't handle the idea that there are millions of vapers who have saved their lives using a device that delivers nicotine.

Wednesday, March 20, 2019

Response to Press Release Announcing Proposed Ban on Electronic Cigarettes in San Francisco

Here is my point-by-point response to several of the statements made in the press release issued by City Attorney Herrera announcing the introduction of legislation to ban the sale of all electronic cigarettes in the city of San Francisco:

"City Attorney Dennis Herrera and Supervisor Shamann Walton today announced joint steps to curb the epidemic of youth e-cigarette use, which has erased more than a decade’s worth of progress in reducing youth tobacco consumption."

The “epidemic” of youth e-cigarette use has not “erased” progress in reducing youth tobacco consumption. The gains in reducing youth smoking prevalence are very real and will translate into millions of lives saved down the road. The problem of vaping has nothing to do with tobacco use because e-liquids do not contain any tobacco. Youth who vape are not tobacco users. They are vapers. So youth e-cigarette use has not undermined gains in reducing smoking. It is a separate problem that, while serious, is far less of a hazard to the public’s health than the epidemic of youth smoking.

"San Francisco has never been afraid to lead,” Herrera said, “and we’re certainly not afraid to do so when the health and lives of our children are at stake."

San Francisco is apparently afraid to lead because they are willing to take the politically expedient step of requiring safety testing for e-cigarettes, but they are not willing to place the same requirement on real cigarettes. In fact, tobacco cigarettes have already had their safety testing and they failed miserably. If San Francisco wants to lead, then why isn’t it taking cigarettes off the shelves?

"Banning vaping products that target young people and push them towards addiction to nicotine and tobacco is the only way to ensure the safety of our youth."  

Let’s stipulate that. But if that’s true, then certainly banning tobacco products (i.e., cigarettes and smokeless tobacco) that target young people and push them towards addiction to nicotine and tobacco is also the “only” way to ensure the safety of our youth.

"San Francisco, along with the City of Chicago and the City of New York, sent a letter to the FDA this morning demanding that the FDA do its job and immediately conduct the required public health review of e-cigarettes that, by law, was supposed to happen before these products were on the market." 

The law does not require the FDA to conduct a public health review of e-cigarettes. What it requires is that manufacturers who want their products to remain on the market must submit a pre-market tobacco application to the agency for approval. This review was not supposed to happen before the products were on the market. They were already on the market in 2014 when the FDA issued its regulations. The FDA delayed the deadline for these applications because not doing so would have resulted in the elimination of vaping products, forcing millions of ex-smokers back to smoking and removing a huge competitor to cigarettes. It would have been a huge gift for cigarette companies. So it’s a good thing that the FDA did not enforce its original August 2016 deadline.

"In coordination with the City Attorney’s Office, Supervisor Walton is introducing groundbreaking legislation at the Board of Supervisors today that would prohibit the sale in San Francisco of any e-cigarette that has not undergone FDA review." 

This is not ground-breaking. What would have been ground-breaking is if the city introduced legislation to ban all tobacco products that have not been reviewed by the FDA and found to be reasonably safe. Surely, cigarettes would have been on this list.

"This is not an outright ban on e-cigarettes. It’s a prohibition against any e-cigarettes that haven’t been reviewed by the FDA to confirm that they are appropriate for the protection of public health."

It is essentially an outright ban on e-cigarettes because the city knows full well that there isn’t a single e-cigarette that has gone through the pre-market approval process (since that deadline was extended until 2021). But the more important question is why the Board of Supervisors believe that e-cigarettes should only be sold if they are shown to be appropriate for the public health, while they are allowing cigarettes to be sold even though we know for certain that they are not “appropriate for the public’s health.”

"The FDA has simply failed to do its job in unprecedented fashion,” Herrera said. “These are prudent steps to ensure that we know the health and safety implications of products being sold here. If the FDA hasn’t reviewed it, it shouldn’t be on store shelves in San Francisco." 

If they really mean what they say, then certainly, cigarettes should be on store shelves in San Francisco. You can’t take as a serious public health effort a proposal that e-cigarettes should be taken off of store shelves in San Francisco because we’re not certain of their health implications, yet it’s perfectly fine to let cigarettes remain on store shelves in San Francisco despite the fact that they have dismally failed their “safety review.” There is simply no public health justification for banning e-cigarettes but not real cigarettes.

"Tobacco use is the leading cause of preventable disease and death in the United States. Tobacco kills more than 480,000 people a year in this country. That’s more than AIDS, alcohol, car accidents, illegal drugs, murders and suicides combined." 

Exactly! Yet vaping products are not responsible for a single one of those 480,000 deaths. And so the city of San Francisco’s response to 480,000 deaths from cigarettes is: Let’s ban the fake cigarettes and let the real ones, which are causing 480,000 deaths a year, to stay on the shelves.

"These companies may hide behind the veneer of harm reduction, but let’s be clear: their product is addiction." 

Veneer of harm reduction? There is overwhelming evidence that vaping is much safer than smoking. It is convenient to ignore this scientific evidence because it doesn’t make for as good of a story. But public health needs to be guided by science and evidence, not by political expediency.

San Francisco Considering Banning Electronic Cigarettes, But Letting Deadly Real Cigarettes Stay on the Shelves

Yesterday, San Francisco City Attorney Dennis Herrera and Supervisor Shamann Walton announced that they are introducing an ordinance to the Board of Supervisors that would ban all electronic cigarettes until they are officially reviewed and approved by the Food and Drug Administration (FDA). Since there is not a single e-cigarette on the market that has undergone such an approval process, the ordinance does indeed ban the sale of all electronic cigarettes in the city of San Francisco.

The reasoning behind the proposal is as follows: "Today we are taking action to protect our kids. By law, before a new tobacco product goes to market, the Food and Drug Administration is supposed to conduct a review to evaluate its impact on public health. Inexplicably, the FDA has failed to do its job when it comes to e-cigarettes. Until the FDA does so, San Francisco has to step up. These products should not be on our shelves until the FDA has reviewed the threat they pose to public health."

The Rest of the Story

This has to be one of the most insane public health proposals I have ever seen. This legislation basically says: "We care so much about the health of our kids that we can't allow e-cigarettes to remain on the market until they have a complete safety review. However, we are perfectly happy allowing cigarettes--which have had extensive safety reviews and been found to be killing hundreds of thousands of Americans each year--to remain on the market. Let us be honest. We care enough about our kids to take the politically expedient step of making it look like we are truly protecting their health by banning e-cigarettes, but we don't care about our kids so much that we want to actually protect them by removing from the market a product that we know is going to kill half of those kids who become addicted to it."

This is truly a political maneuver under the guise of a desire to protect children's health. Let's be clear. If the Board of Supervisors were sincerely committed to protecting kids, they would immediately remove cigarettes--the most deadly consumer product--from the market. Cigarettes are addicting and eventually killing more than 400,000 Americans each year. Yet you mean to tell me that in light of that, the Board of Supervisors wants to conduct a safety review for the fake cigarettes?

And what's the point of such a safety review? We already have a safety review of cigarettes and know that they are deadly. And in light of that, the San Francisco Board of Supervisors nevertheless feels perfectly comfortable allowing those products to be sold. Do they think that electronic cigarettes are actually more hazardous than cigarettes? Of course not. They know full well that e-cigarettes are far safer than the real ones.

Clearly, the reason why they want to ban the fake cigarettes but not the real ones is because they don't have the political courage to take the step that would most substantially protect the public's health. This is an easy opportunity to make it look like they are totally committed to protecting kids when in fact, they are apparently perfectly content to allow the most dangerous consumer product in history to be sold on retail shelves in gas stations, convenience stores, and other places that are easily accessible to kids throughout the city.

This is an easy political victory because they know the vaping industry is not organized or centralized enough to fight it successfully. But if they are justified in banning e-cigarettes, then it is certainly imperative upon them - and actually much more justified - to ban real cigarettes. However, the tobacco industry is organized, centralized, and powerful.

The rest of the story is that what is really going on here is that the proponents of this ordinance simply do not have the political courage to take the real action that would protect the public's health: banning cigarettes. Removing e-cigarettes from the shelves is an easy political victory that may make it seem like they desire to protect kids, but the truth is that they are apparently perfectly content with allowing deadly cigarettes to be sold to the kids who they purport to be protecting.

Ultimately, this is politics, not public health.

Sunday, March 17, 2019

Purported Links Between Vaping and Heart Attacks are Based on Crappy Science

Another crappy study has come along, this one again using cross-sectional data from the National Health Interview Survey to claim that e-cigarette use is associated with a higher risk of having a heart attack, developing coronary artery disease, and having depression.

This study, being presented tomorrow (Monday) morning at the annual meeting of the American College of Cardiology in New Orleans, reports that "adults who report puffing e-cigarettes, or vaping, are significantly more likely to have a heart attack, coronary artery disease and depression compared with those who don’t use them or any tobacco products."

These conclusions were based on a cross-sectional analysis of data from the 2014, 2016, and 2017 National Health Interview Surveys. Respondents were asked to report whether they had ever been diagnosed with having had a heart attack, coronary artery disease, or depression. The analysis found that people who reported vaping were more likely to have ever had a heart attack, to have ever been told they have coronary artery disease, or to have ever been diagnosed with depression. The analysis did control for smoking by including smoking status as a variable in the regression model.

The Rest of the Story

This is yet another example of the junk science that is rapidly being spewed out by anti-tobacco researchers who are apparently more interested in demonizing vaping than in using rigorous scientific reasoning.

The problem with the study's conclusion is that this is a cross-sectional analysis and the researchers have no idea which came first: the vaping or the heart attack, heart disease, or depression.

Let's consider heart attacks. It is entirely possible (and actually quite likely) that most - if not all - of the respondents who reported that they are vapers had started vaping after, not before their heart attacks. In fact, a likely explanation for the findings is that smokers who experience a heart attack are much more likely to try to quit smoking, and since switching to vaping is a common method of attempting to quit smoking, they are more likely to respond that they are vapers.

The investigators claim that they have controlled for smoking. But here's the problem: smoking is not only a confounder in the analysis; it is also an effect modifier. This means that the association between vaping and having had a heart attack is different for nonsmokers and smokers. For nonsmokers, there is no association. The association only holds for former smokers and current smokers. In the presence of effect modification, treating smoking purely as a confounder will yield inaccurate results. In order to model the relationship correctly, you need to stratify the analysis on smoking status: that is, you need to report the relationship separately for nonsmokers, former smokers, and current smokers.

None of the papers that have claimed vaping causes heart attacks, heart disease, stroke, or COPD have done that. They treat smoking as a confounder, but do not test for effect modification.

It is unfortunate that this crappy science is being reported at scientific conferences and in scientific journals. But what makes this a real tragedy is that this junk science is being used to justify policies to regulate vaping more harshly than smoking, by: (1) heavily taxing these products; (2) banning e-cigarette flavors; and/or (3) completely banning the sale of e-cigarettes in convenience stores.

The rest of the story is that rather than demonstrating that vaping causes heart attacks, heart disease, COPD, and depression, what these studies show is that when smokers get very sick, they are highly motivated to quit in order to save their lives, and many of them do so by switching to vaping.

This is about 11 million lives, not 11 million lies.

11 Million Lies: The Tobacco Control Movement is Committing Public Health Malpractice by Misrepresenting the Health Effects of Vaping

My colleagues and I in the tobacco control movement have based our entire careers on the principle that it is wrong to lie to the public. The bulk of our campaign against Big Tobacco was based on the contention that the cigarette companies lied to the public about the health risks of smoking. Numerous lawsuits were filed against Big Tobacco, seeking damages based on the claim that the companies are responsible because they misrepresented the health effects of their products, thus preventing smokers from making an informed choice. The name of the major youth anti-tobacco campaign is called "Truth." Clearly, honesty is the central value that has been at the core of the tobacco control movement for decades.

In the last few years, however, I believe that our movement has largely abandoned truth as a central value in our campaigns against vaping. Driven by an almost puritanical inability to accept the fact that a person could obtain pleasure from nicotine without it killing them, we have made the demonization of vaping the solitary goal of the movement, at the direct expense of what I always believed was our primary goal: to make smoking history.

Why is vaping so threatening to the tobacco control movement? Is it threatening because it is extremely dangerous -- basically as harmful as smoking -- and therefore is is harming the health of the nation's 11 million adult vapers?

No - it's precisely the opposite. It is threatening to us because it is not as harmful as smoking. We simply cannot tolerate the fact that there are millions of adults who are deriving pleasure from, and improving their health because of, the use of a much safer form of nicotine delivery. The problem with vaping is that it is not killing anyone, so there is no punishment for the vice of being addicted to nicotine. And that's something that the tobacco control movement can simply not tolerate.

I believe that it is precisely because the truth is so threatening that many anti-tobacco groups, public health agencies, physicians, and researchers have resorted to lying to the public about the health effects of vaping.

The Rest of the Story

While the tobacco control movement is spewing numerous lies about vaping, perhaps the most damaging to the public's health is the false claim that vaping is not any safer than smoking. This is a direct affront to each one of the 11 million adult vapers in the United States who are trying to improve their health by switching from combustible tobacco use (i.e., smoking) to the use of non-tobacco-containing, non-combusted vaping products. And it is particularly offensive to the more than 2.5 million adult vapers who quit smoking completely because of these products and who are now relying on vaping to keep them from returning to smoking. For these 2.5 million ex-smokers, vaping has literally saved their lives.

So it is shameful that we are now trying to take that away from them based on a complete lie: that switching to vaping is doing nothing to protect their health.

Today, I highlight just a few of the individuals and organizations that are spreading the lie that vaping is no safer than smoking. Keep in mind that by definition, what these groups are saying is that smoking is no more dangerous than vaping. That's quite a claim, given the fact that smoking kills more than 400,000 people a year, contains more than 10,000 chemicals, and contains more than 60 known human carcinogens, while vaping aerosol, at worst, contains a few chemicals of concern and has not, after 12 years of use by millions of people, resulted in a single death (excepting one person who was killed due to an exploding battery, but not to the health effects of vaping itself).

So here is today's top 10 examples of the individuals, groups, and researchers who are helping to spread the false assertion that cigarette smoking is no more hazardous than vaping.

#1) National Center for Health Research

"The body’s reaction to many of the chemicals in traditional cigarette smoke causes long-lasting inflammation, which in turn leads to chronic diseases like bronchitis, emphysema, and heart disease. Since e-cigarettes also contain many of the same toxic chemicals, there is no reason to believe that they will significantly reduce the risks for these diseases. ... Because they are smokeless, many incorrectly assume that e-cigarettes are safer for non-smokers and the environment than traditional cigarettes. ... There are no long-term studies to back up claims that the vapor from e-cigarettes is less harmful than conventional smoke."

#2) Loyola University Medical Center

"E-cigarettes are not safer than cigarettes. .. They have not been scientifically proven as healthier or safer, and the U.S. surgeon general has not approved them for use in smoking cessation." 

#3) South Dakota Department of Health

"Vape is not safer than cigarettes."

#4) Tennessee Medical Association

"Despite being marketed as a safe alternative to smoking, e-cigarettes are not safer and they never have been. They have simply been marketed that way. As a result, many people believe trading a traditional combustible cigarette for vaping is going to make them healthier, and that the vaping or e-cigarette use is far less damaging health-wise."

#5) Harford County Health Department

"E-cigarettes are not safer than smoking tobacco."

#6) Jane Goodall Institute

"E-cigarettes are the biggest problem, and for the third year in a row they are the first choice among youth smokers. But contrary to popular belief, they are not safer than other tobacco products, they are actually more addictive due to the menthol component that makes them so easy to consume."

#7) Des Moines Children's Hospital

"It is absolutely not safer than smoking, that is a fallacy that adolescents believe because it tastes good."

#8) Texas Tech University School of Pharmacy

"These data suggest, from a cerebrovascular perspective, that e-Cig vaping is not safer than tobacco smoking, and may pose a similar, if not higher risk for stroke severity."

#9) University of Rochester Medical Center

"Studies by his group and others, Rahman says, suggest that vaping is not safer than smoking: 'It’s equally bad.'"

#10) East Rockaway Prevention Task Force

"Too many teens, officials said, believe vaping is safer than smoking, when it’s not."

Wednesday, February 27, 2019

Switching from Smoking to Juul Reduces Toxic Chemical Biomarkers to the Same Degree as Quitting Cold Turkey

According to a study conducted by Juul and presented Saturday at the Big-Pharma funded SRNT annual meeting, there is no difference between switching from smoking to Juul and quitting smoking cold turkey in terms of the reduction in biomarkers of toxic chemicals.

In the study, a group of 90 adult smokers were randomized to either: (1) continue to smoke as usual; (2) stop smoking cold turkey; or (3) switch completely from smoking to Juul. After five days, the researchers measured the change in the level of nine different biomarkers for toxic chemicals, which indicates the level of exposure to these chemicals.

The key finding of the study was that the degree of reduction in exposure to these toxic chemicals was identical for the group that quit smoking cold turkey and the group that switched from smoking to Juul.

The Rest of the Story

This study adds to the already overwhelming evidence that vaping is much safer than smoking. And it further emphasizes the degree to which the Pennsylvania Department of Health is lying about the relative health effects of smoking vs. vaping. As I reported last week, the Pennsylvania Department of Health informs the public on its web site that: "E-cigarettes, also known as e-cigs, e-hookahs, mods, vape pens, vapes or ENDS, are not safer than other tobacco products for youth."

This study is significant because it did not show that toxic chemical biomarker reduction with the Juul was at some level between continuing to smoke and quitting cold turkey. Instead, the level of reduction was indistinguishable from that resulting from cold turkey cessation.

In other words, if someone presented to a physician and the physician had to determine whether that person had quit smoking cold turkey five days earlier or switched to Juul five days earlier, the physician could not tell the difference, at least not based on the level of these toxic chemical biomarkers.

This new study adds to a large body of existing research that casts severe doubt on the assertions of many tobacco control researchers and organizations, and many health departments, that vaping is really not all that much different from smoking in terms of health.

Saturday, February 23, 2019

Pennsylvania Department of Health Urges Parents to Lie to their Kids About the Dangers of E-Cigarettes

A basic principle of public health ethics is that we don't lie to people. Telling the truth is a critical component of the public health code of ethics. It is important not only because it is unethical to lie, but also because we greatly risk losing credibility and the public's trust if we are found to be lying. And once that public trust is lost, it is extremely difficult, if not impossible, to gain back.

Therefore, it pains me today to have to report that the Pennsylvania Department of Health is urging parents to lie to their kids about e-cigarettes in order to dissuade them from vaping. In addition, the Pennsylvania Department of Health is lying to the public about the dangers of e-cigarettes and tobacco cigarettes as well.

The Pennsylvania Department of Health put out a tweet that read: "E-cigarettes, e-cigs, e-hookahs, mods, vape pens or vapes—whatever you call them, they are NOT safer than other tobacco products. Learn how you can help protect you child's health by talking about the dangers of vaping → ."

On its web site, the Pennsylvania Department of Health informs the public that: "E-cigarettes, also known as e-cigs, e-hookahs, mods, vape pens, vapes or ENDS, are not safer than other tobacco products for youth."

The Rest of the Story

It is simply not true that e-cigarettes are as dangerous as tobacco cigarettes, or that vaping is as dangerous as smoking. At this point, there is abundant scientific evidence that vaping is much safer than smoking. In fact, smokers who switch to e-cigarettes experience dramatic improvement in their respiratory symptoms and lung function.

The Royal College of Physicians concluded that vaping is at least 95% safer than smoking, but even if you don't agree that the risk difference can be quantified, the evidence demonstrates that e-cigarettes are a much safer product than real tobacco cigarettes. The reason for this is that e-cigarettes contain no tobacco and involve no combustion. While tobacco smoke contains more than 10,000 chemicals including more than 60 known human carcinogens, e-cigarette aerosol, at worst, contains more like 20 chemicals and perhaps 1 or 2 carcinogens. And this is only the case for e-cigarette brands that do not properly regulate the temperature of the heating coil. Studies of the aerosol of brands that have proper temperature regulation have not detected significant levels of any hazardous chemicals.

There is no question that e-cigarettes are much safer than cigarettes in terms of lung damage and in terms of cancer risk. E-cigarettes have been on the market now for 12 years and have been used by millions without any identified health effects (other than some mild respiratory irritation).

So what the Pennsylvania Department of Health is doing is lying to the public by telling us that vaping is no safer than smoking. Or, put another way, these health officials are asserting that cigarette smoking is no more hazardous than vaping.

Were a tobacco company to make the same statement, it would be rightly accused of fraud and deception. So why can a state health department make that statement with immunity?

The reason, I believe, is that most tobacco control groups no longer care about the truth and about scientific accuracy. They are more concerned with creating hysteria about vaping and scaring the public. While the ultimate goal - reducing youth vaping - may be considered to be laudable, the ends do not justify the means. Lying to kids to discourage them from engaging in a particular behavior is not the way to go. And it is not something that we condone in public health.

The Department of Health's message is also deceptive because it instructs parents that by preventing their kids from vaping, they can keep their kids tobacco-free. This is highly deceptive because it implies that a youth who vapes is using tobacco. That simply isn't true as there is no tobacco in an e-cigarette. In fact, the very thing that distinguishes an e-cigarette from a real cigarette or from a heat-not-burn tobacco product is the absence of tobacco. If an e-cigarette actually contained tobacco, then it would not be an e-cigarette. It would be a heat-not-burn tobacco product.

A youth who vapes is tobacco-free. They are not nicotine-free (unless they use an e-liquid that does not contain nicotine), but they are smoke-free and they are tobacco-free.

I believe that one of the reasons why public health groups have been so ineffective in reaching youth with anti-vaping messages is that the kids are seeing right through these lies. Kids are not stupid. They can see with their own eyes that when someone lights up a cigarette, the health effects are immediately apparent. Smokers cough, they are typically short of breath upon exertion, they are more prone to pneumonia and upper respiratory infections, etc. But kids see plenty of other kids vaping and Juuling without any visible health effects. Today's kids are just not going to buy the lies that the Pennsylvania Department of Health and other anti-nicotine groups are selling them.

Ultimately, I believe that the credibility and reputation of public health groups and agencies is going to be seriously undermined by the widespread lying and deception that is taking place regarding the relative risks of vaping compared to smoking. Disseminating false facts like this is unethical, it specifically violates the public health code of ethics, it puts the reputation of public health itself at risk, and at the end of the day, it doesn't even accomplish its intended objective of discouraging kids from vaping.

If you're going to tarnish the image of public health and violate our ethical code, at least do it in a way that accomplishes some great public health objective. Lying about vaping is doing plenty of tarnishing, but nothing to protect the public's health.

The rest of the story is that lying to kids isn't justified even if it did prevent them from vaping. But it is doing just the opposite, as kids see through the lies and in some ways, it makes vaping more attractive.

Thursday, February 21, 2019

SRNT Under Fire for Accepting Sponsorship Money from E-Cigarette Company for Annual Meeting

Controversy is brewing in San Francisco this week as it was revealed that the Society for Research on Nicotine and Tobacco (SRNT) accepted money from an e-cigarette company to sponsor its annual meeting which is being held this week.

It was reported this morning that SRNT accepted funding from GreenSmokeKloud, an e-liquid distributor whose products are competing with nicotine replacement therapy and Chantix for a share of the smoking cessation market.

Critics pointed out that sponsorship of the conference by GreenSmokeKloud presents a severe conflict of interest because its products are being used for smoking cessation and the SRNT conference involves numerous presentations dealing with the effectiveness or lack of effectiveness of e-cigarettes and vaping products similar to or including those manufactured by GreenSmokeKloud.

Stanley Glanton, a professor at CFSU, told The Rest of the Story that: "This is a clear-cut conflict of interest. You can't have a conference sponsored by a company that makes products which are being discussed at scientific sessions. How can we have an objective conversation about electronic cigarettes and the epidemic of youth vaping when GreenSmokeKloud signs are all over the place and conference attendees know that this company is a major sponsor of the conference?"

Several tobacco control researchers pointed out that the Food and Drug Administration is actually presenting at the conference and the FDA has regulatory jurisdiction over vaping products, creating a further conflict of interest. They also pointed out that a major theme of the research being presented is what should be the appropriate role of vaping products in smoking cessation efforts and that GreenSmokeKloud has a vested interest in the outcome of those discussions.

"You might as well just give them a seat at the table," complained one smoking cessation researcher. "They may not be physically or consciously affecting the presentations, but subconsciously everyone knows that GreenSmokeKloud is sponsoring the conference and if we diss them in our presentations, it's unlikely that they will sponsor SRNT next year. It's inappropriate that whether SRNT can get the same sponsorship money next year may actually depend on what is said or not said in the scientific presentations."

Another tobacco researcher agreed: "If the consensus at this conference is that vaping products are really not an effective smoking cessation tool and there is too much risk of youth addiction, you can bet that GreenSmokeKloud will back out of next year's conference. Let's not forget that this is a corporation whose primary goal is to make money. If their products are not cast in a positive light, they will have no incentive to return next year."

Although each speaker discloses their conflicts of interest, some conference attendees have suggested that every speaker should be required to disclose that GreenSmokeKloud is a sponsor of the conference itself. According to Dr. Glanton: "It needs to be remembered that GreenSmokeKloud is casting a cloud on this entire conference. If a vaping company is sponsoring the conference, attendees should be reminded of that at the beginning of each and every presentation, especially if the talk is evaluating e-cigarettes in terms of their use in smoking cessation."

The Rest of the Story

Wait a minute. I apologize. I just received word that I got the story slightly wrong. GSK is indeed sponsoring the conference, but GSK doesn't stand for GreenSmokeKloud, it stands for GlaxoSmithKline, and it's not producing vaping products for smoking cessation, it's producing nicotine replacement products for smoking cessation. Also, Pfizer is another conference sponsor and they produce Chantix, a drug that is marketed for smoking cessation.

Indeed, according to the official SRNT program, GlaxoSmithKline and Pfizer are both major sponsors of the conference.

After the tobacco researchers quoted above were informed of my mistake, they all retracted their statements and told me that they saw nothing wrong with these pharmaceutical companies sponsoring the conference, even though they make products whose effectiveness is being discussed at the conference and their financial well-being depends on the consensus that may develop at the conference based on the content of the presentations that directly address their effectiveness.

"We don't see any conflict of interest here and the financial support of these corporations is necessary to continue to hold these important conferences," one of the researchers told me.

Since being informed of my mistake, everything has calmed down and it is back to business as usual at the SRNT conference.

Monday, February 18, 2019

Landmark Study Fails to Find Any Evidence that Vaping is a Gateway to Smoking among Youth

A landmark study, published on January 25 in the Journal of the National Cancer Institute, found no evidence that vaping is a gateway to smoking among youth. The data come from the largest, longitudinal study of youth smoking initiation -- the PATH (Population Assessment of Tobacco and Health) study -- and include two waves of observations on nearly 12,000 U.S. youth.

The surveys asked numerous questions about both vaping and smoking behavior, including the frequency of these behaviors. It also assessed numerous risk factors for smoking that can be controlled for in multivariate analyses of smoking initiation rate differences between various groups. The baseline survey was conducted in 2013/2014 and the one-year follow-up survey occurred in 2014/2015. 

The main reported finding of the study was that ever use of e-cigarettes at baseline is a risk factor for ever use of cigarettes at follow-up. This is consistent with the findings of several other studies.

The Rest of the Story

Buried deep within the article is the rather startling, but most critically relevant finding of the entire study: The investigators were unable to report a single youth out of the 12,000 in the sample who was a cigarette naive, regular vaper at baseline who progressed to become a smoker at follow-up. Why? Because the number of these youth was so small that it was impossible to accurately quantify this number.

Based on my own calculations from the data presented, out of the 12,000 youth, there were only 21 who were even past 30-day e-cigarette users at baseline (cigarette naive) who progressed even to ever smoking at follow-up. These youth reported using e-cigarettes only 1-5 days in the past 30 days at baseline, so it is not even clear that they were regular vapers. They literally could have tried an e-cigarette once 30 days earlier.

It is possible that vaping was not a gateway to smoking for any of these 21 youth, but even if it was, they represent just 0.2% of the youth population.

In addition, the study found that although ever use of e-cigarettes increased the risk of smoking initiation, recent use of e-cigarettes (within the past 30 days) did not increase the risk of smoking initiation. This finding is consistent with the hypothesis that youth who try e-cigarettes and do not particularly enjoy them such that they become regular users are the ones who are more likely to try smoking, but that youth who actually become vapers are not any more likely to subsequently try a real cigarette.

The bottom line is that despite the widespread claims that vaping is a gateway to smoking initiation among youth, the most definitive study to date of this issue fails to provide any evidence to support that contention. If anything, it provides evidence suggesting that vaping acts as a kind of diversion that can keep some youth away from cigarette smoking.

We will certainly need to await the results from future waves of the PATH study to have a clearer idea of the trajectory of youth vaping and smoking, but at the present time, I do not believe there is any evidence that vaping serves as a gateway to smoking among youth. In contrast, the evidence to date suggests that a culture of vaping is replacing, not enhancing, a culture of smoking.

Saturday, February 09, 2019

Researchers Tell Public that Vaping Causes COPD as Scientific Rigor in Tobacco Control Drops to an All-Time Low

Based on the results of a cross-sectional study showing an association between using e-cigarettes and reporting that one has ever been told they have COPD (chronic obstructive lung disease), a number of researchers have essentially concluded that vaping causes COPD, and one researcher is telling the public that use of e-cigarettes increases one's risk of COPD just like cigarettes.

The paper, published in Drug and Alcohol Dependence, reports the results of a cross-sectional study based on the 2016 Behavioral Risk Factor Surveillance System (BRFSS) survey in Hawaii. The outcome variable was reporting ever having been told that one has COPD. The main predictor variable was ever having used an e-cigarette. The key finding of the study was that: "there was a significant association of e-cigarette use with COPD among nonsmokers (AOR = 2.98, CI 1.51–5.88, p <  .01), but the association was not significant among smokers (AOR = 1.29, CI 0.94–1.77, ns.)."

The paper concludes that: "The fact that findings for respiratory symptoms occurred primarily for nonsmokers argues against several alternative interpretations of the results." In other words, the paper is essentially arguing that this is most likely a causal effect (i.e., vaping causes COPD).

The Rest of the Story

There is absolutely no way one can conclude, or even speculate, based on the results of this cross-sectional study, that vaping is a cause of chronic obstructive lung disease. Remember, we are talking here about emphysema and chronic bronchitis (that's what is meant by COPD).

To see how ridiculous such a conclusion, or even such speculation is, one needs only to look at the sample size of never smokers in the 2016 Hawaii BRFSS who were current e-cigarette users and reported having COPD. It's 13 (based on the CDC's BRFSS online analysis tool). According to the article itself, the total sample of never smokers who were current vapers was only 45. A simple bivariate online analysis of the relationship between ever use of e-cigarettes and ever diagnosis of COPD among the never smokers in the 2016 Hawaii BRFSS reveals no significant association.

If you do the same analysis using the entire 2016 BRFSS (including all states), the proportion of never smokers who report having been diagnosed with COPD is actually higher among non-vapers (2.9%) than ever vapers (2.4%).

It's not just that there are dangers with drawing causal conclusions like this from a cross-sectional study. In this case, the sample size upon which the conclusion is being drawn is so low that the analysis is not at all reliable to begin with.

The paper ignores (and does not cite a single article from) a body of literature showing that smokers with COPD who switch to electronic cigarettes experience an improvement in their symptoms.

However, the worst problem with these conclusions (and even with the speculation) is that it is biologically implausible that vaping for a few years can cause emphysema or chronic bronchitis. Since vaping did not become widely popular until about 2011, the average number of years that the vapers in the 2016 Hawaii BRFSS used e-cigarettes could not be more than about five years.

There is simply no way that you can develop COPD from vaping for five years. Even among heavy chain smokers, it takes several decades before they develop COPD. I'm not aware of more than a handful of smokers who were diagnosed with COPD (caused by smoking) before they reached the age of 40. Population-level data show that the observed increase in COPD incidence among smokers does not begin until about age 45.

Even assuming that someone did not start smoking until they reached 20, it still takes a minimum of two decades of smoking to do enough damage to the lungs that a person develops and is diagnosed with COPD. So how can you get COPD from vaping (which is even less frequent than smoking) for just a few years?

People are just not thinking. The idea that there are a substantial number of never smokers in Hawaii who have developed COPD after just a few years of vaping is absurd on its face.

This leads me to believe that there is a strong, subconscious bias among many researchers who are so determined to find an association between vaping and chronic disease that they are forgetting basic pathology.

Moreover, there have not even been anecdotal reports of nonsmokers developing COPD after a few years of vaping. And clinical studies have failed to detect any decline in lung function, as measured by spirometry, among vapers.

Furthermore, if vaping was causing COPD, we would expect to see an increase in the prevalence of COPD over the past few years, especially since vaping rates started to increase exponentially starting in about 2011. Instead, we see little if any change in COPD prevalence since 2011.

The reason this is all so disturbing to me is not simply that it shows how scientific rigor in tobacco control literature has deteriorated. It is disturbing because disseminating these scientifically unsupported claims is going to discourage many smokers from trying to quit using e-cigarettes and may even cause many former smokers to return to smoking. After all, if you can get COPD from vaping, then why not go back to the real thing?

The unsupported, sweeping, hysterical conclusions being drawn from these studies are not just scientifically poor, they are causing harm to the public's health as well.

Sunday, February 03, 2019

Having Health Insurance Increases Your Risk of a Heart Attack, and Other Cross-Sectional Study Foibles

Later this week, a research study will be presented at the International Stroke Conference in Hawaii that purports to show that vaping increases the risk of heart attacks. In a recent post, I showed that this research is fatally flawed because it violates the basic principle in epidemiology that correlation does not equal causation. The study found a correlation between using e-cigarettes and ever having had a heart attack. The authors conclude that vaping must therefore increase heart attack risk. However, the more likely explanation is the opposite: smokers who experience a heart attack are more likely to try to quit smoking and therefore more likely to use e-cigarettes.

As an exercise, I used the same data (the 2016 Behavioral Risk Factor Surveillance Survey) to show that by the same reasoning, making a quit attempt increases your risk of a heart attack.

Here are some other factors that increase your risk for a heart attack, based on the 2016 BRFSS:
  • Having health care insurance (67% increase in heart attack risk)
  • Having a health care provider (174% increase)
  • Going to the doctor annually for a routine physical exam (150% increase in risk)
  • Having ever received the pneumonia vaccine (253% increase in risk)
  • Ever having had a mammogram (52% increase in risk)
So according to anti-vaping researcher logic, obtaining health care insurance, obtaining a health care provider, going to the doctor for routine exams, getting vaccinated for pneumonia, and having a mammogram all increase your risk of a heart attack.

By the way, the same analysis reveals that compared to vaping only occasionally, you reduce your risk of a heart attack substantially if you vape every single day.

In fact, daily vapers are at lower risk of having reported a heart attack than people who never vaped!

Junk Science Exposed: New Study Purports to Show that E-Cigarettes Increase Heart Attack Risk

According to the headline of a UPI news story from last week, vaping has been linked to an increased risk of having a heart attack. This research finding was reported worldwide, including a scary headline in London's Sunday Express reading: "New research claims vaping raises risk of deadly heart attacks and strokes."

This finding is profoundly important because if e-cigarette use does indeed increase heart attack risk, then the role of vaping in harm reduction comes into serious question.

The news headline stems from a paper that is being presented this week at the American Stroke Association’s International Stroke Conference in Hawaii.

According to the news coverage, the researchers used cross-sectional data from the 2016 Behavioral Risk Factor Surveillance Survey (BRFSS) and found that ever use of e-cigarettes increased the risk of reporting ever having had a heart attack, while controlling for age, gender, body mass index, history of diabetes, and smoking status. The same was true for the risk of reporting ever had a stroke.

While the abstract itself does not appear to be publicly available, the news articles report that the study found a 59% increase in heart attack risk associated with the use of e-cigarettes. According to one article: "The American Heart Association has subsequently cautioned the public against using e-cigarettes."

The Rest of the Story

It is irresponsible to use the results of this cross-sectional study to conclude (or even suggest) that e-cigarette use increases heart attack or stroke risk. Why? Because the study only assessed the relationship between "ever" having used e-cigarettes and "ever" having had a heart attack. The study has no information on which came first. In other words, it is entirely possible (and in fact quite likely) that the majority of respondents who reported having used e-cigarettes and having had a heart attack actually suffered the heart attack first and then subsequently started using electronic cigarettes because they were desperate to quit smoking after experiencing this life-threatening event.

A similar study (this one using cross-sectional data from the National Health Interview Survey) was published in the American Journal of Preventive Medicine last year and is subject to the same fatal flaw: it is highly likely that people who experienced a heart attack began using e-cigarettes in an attempt to quit smoking.

Trying to Quit Smoking Increases Your Risk of Having a Heart Attack

Using the same methodology as these studies, I examined the relationship between trying to quit smoking and heart attack risk. I used the 2016 BRFSS and modeled the risk of having had a heart attack as a function of having tried to quit smoking (and succeeding for at least one day). I controlled for age, gender, body mass index, diabetes, and smoking status.

The results:

Making a serious quit attempt is associated with a significant increase in heart attack risk. It actually increases your heart attack risk by 41%.

Obviously, what is going on here is not that quitting smoking increases your risk of having a heart attack. Instead, what is happening is that smokers who experience a heart attack are more likely to try to quit smoking.

But the same reasoning used by researchers to conclude that vaping increases heart attack risk supports the conclusion that trying to quit smoking increases heart attack risk.

For that matter, one could show that use of asthma inhalers is associated with an increased risk of having asthma, that use of insulin is associated with an increased risk of diabetes, or that the consumption of gluten-free food increases your risk for Celiac disease (caused by gluten allergy).

For those who are curious, trying to quit smoking is associated with a 38% increase in the risk of stroke.

Clearly, physicians should warn their smoking patients not to try to quit, as quitting appears to be associated with an increased risk of heart disease and stroke.

Sadly, we don't have to recommend that physicians counsel smokers not to try to quit -- the American Lung Association is already doing that.

Saturday, February 02, 2019

Does the American Lung Association Really Hate Smokers So Much that They Discourage Quit Attempts Using E-Cigarettes Despite New Clinical Trial Evidence of their Superiority to NRT?

On Wednesday, the New England Journal of Medicine published a new study that reported the results of a one-year randomized, clinical trial in which e-cigarettes were compared to nicotine replacement therapy (NRT) to aid smoking cessation. The study was conducted in the UK, and both treatments were accompanied by behavioral counseling. The result: "The 1-year abstinence rate was 18.0% in the e-cigarette group, as compared with 9.9% in the nicotine-replacement group (relative risk, 1.83; 95% confidence interval [CI], 1.30 to 2.58)."

This is the most definitive study yet on the effectiveness of electronic cigarettes for smoking cessation. It found that one-year smoking cessation rates with e-cigarettes were nearly twice those obtained using NRT. Although one must exercise caution in generalizing the results to the U.S., this evidence pretty much blows out of the water the claim being made by some anti-nicotine advocates that vaping actually inhibits smoking cessation.

A previous clinical trial conducted in New Zealand had found that e-cigarettes were as effective as NRT for smoking cessation, but that trial used first-generation e-cigarettes that are not thought to be as effective as products currently on the market.

This is great news for smokers, as it suggests that switching to vaping is another smoking cessation option that can be added to those already available. Certainly, for smokers who try to quit but fail with other therapies--like NRT--trying e-cigarettes is a strong and viable option. It may also be appropriate at this point for physicians to encourage smokers who want to quit and are open to trying e-cigarettes to make an attempt to switch to vaping even if they have not failed with other cessation approaches.

The Rest of the Story

So here is what the American Lung Association had to say in response to the study:

"The US Food and Drug Administration has not found any e-cigarette to be safe and effective in helping smokers quit. We only support methods that are FDA approved and regulated. Switching to e-cigarettes does not mean quitting. Quitting means truly ending the addiction to nicotine, which is very difficult."

In other words, the American Lung Association is saying that despite this clinical trial demonstrating that e-cigarettes are probably much more effective than NRT for smoking cessation, they would rather smokers continue smoking than make a quit attempt using electronic cigarettes.

The American Lung Association is stating that it does not "support" the use of e-cigarettes by smokers. This means that if a smoker is not willing to try NRT or a pill, then the American Lung Association would not recommend that they try quitting with e-cigarettes as an alternative.

Not only that, but according to this statement, the American Lung Association will never support the use of e-cigarettes because it will only do so once the FDA approves vaping as a cessation method, which will not and cannot happen. The FDA cannot approve e-cigarettes for smoking cessation because they are recreational products and not drugs. No manufacturer has ever applied to the FDA for approval of a vaping product as a smoking cessation method, and it is unlikely that will happen any time soon.

What could possibly explain why a public health organization that is supposed to be committed to improving lung health would actually discourage smokers from trying to quit using e-cigarettes, especially in the light of strong clinical trial evidence of their efficacy?

The only way I can reconcile this is to question whether subconsciously, the American Lung Association has so much hatred for smoking and smokers that they would actually prefer that a smoker continue to smoke and get sick from that smoking if they are not willing to use an FDA-approved pharmaceutical product. This is, after all, exactly what the organization is expressing. And although the reasoning behind this position is clearly not conscious, the only reasoning that could possibly explain it is some sort of underlying hatred of smokers and a desire to punish them if they don't try to quit "the right way" -- the "right way", of course, being defined by the American Lung Association.

It is important to note that the American Lung Association had a number of alternatives to its recommendation that smokers refrain from using e-cigarettes to quit. They could have recommended that NRT or pharmacotherapy remain a first-line approach, but that those smokers who fail to quit using NRT or pharmacotherapy may want to consider trying electronic cigarettes. They could have recommended that smokers switch to e-cigarettes and then try to wean themselves off the nicotine. Instead, the American Lung Association chose to make a blanket statement urging smokers not to try to quit using e-cigarettes.

I had thought that the tobacco control movement had reached its lowest point, but I never could have imagined that it would come to this: a national tobacco control organization has told smokers that they are better off continuing to smoke than trying to quit using an electronic cigarette. I don't think we can get any lower than this.

Thursday, December 27, 2018

"Truth" Campaign to Kids: Better to Smoke 19 Cigarettes than to Vape One Juul Pod

And this "Truth" Campaign "Fact" Isn't Even True

One of the oft-repeated "facts" being disseminated by the "truth" campaign is that one Juul pod is equal to 20 cigarettes worth of nicotine.

More specifically, the "truth" campaign claims, as its #1 most important fact about Juul that: "The amount of nicotine in one JUUL cartridge is roughly equal to the amount of nicotine in a pack of cigarettes."

Joining the "truth" campaign in spreading this factual information is the Centers for Disease Control and Prevention (CDC), whose web site currently states that: "a single JUUL pod contains as much nicotine as a pack of 20 regular cigarettes."

This "fact" has spread like wildfire. Just as one example, a parenting article in a news magazine writes: "Each JUUL pod contains the approximate equivalent to 1 pack of cigarettes, or 200 puffs. So, if a user goes through one JUUL pod a day, that is the nicotine equivalent of smoking a pack of cigarettes a day."

Similarly, the appropriately named "Scary Mommy" web site warns that: "one Juul “pod” contains 20 cigarettes worth of nicotine (that’s a pack of regular cigarettes)."

It's not just scary mommy blogs that are disseminating this "critical fact" about Juul. The high tech-site "Inc." has this to say about Juul: "The secret is its uniquely potent formula--a single pod contains roughly as much nicotine as a pack of smokes."

I could go on and on with examples. The Chicago Daily Herald reports that: "Most of Juul's single pods contain the same amount of nicotine as a pack of cigarettes." Collegiate Times tells readers that "Engineered to be much more convenient than a cigarette, JUULs are arguably more addictive as one pod is the equivalent of 20 cigarettes (or a typical pack of smokes)...". Vogue magazine reported that even "Dan from Poison Control" apparently informed one concerned caller that the amount of nicotine in a Juul  pod is exactly the same as the total amount of nicotine in an entire pack of cigarettes: "Dan from Poison Control called me back to say that a fresh Juul pod has the same amount of nicotine as 20 cigarettes."

One respiratory therapist warned that because a single Juul pod contains as much nicotine as a pack of cigarettes, a youth who vapes is in danger of dying from nicotine poisoning: "Juul, which is one of the most popular brands on the market, contains the equivalent of 20 cigarettes. Many times, a bottle of e-liquid can contain the same amount of nicotine as a pack of cigarettes. That means kids, who might like the flavor and puff, puff, puff and go through the entire container, are taking in 20 cigarettes worth of nicotine. This sudden increase in nicotine can lead to nicotine poisoning, a potentially fatal condition."

The Rest of the Story

There are two severe problems with this claim by the "truth" campaign.

First, the message that it is sending to kids is that you are better off smoking 19 cigarettes than vaping one Juul pod. This comparison certainly makes it sound like Juuling is a lot worse than smoking. And if that's the case, then the clear message is that you are better off smoking than Juuling.

That's clearly the message that the "truth" campaign and other anti-tobacco organizations and health agencies are sending to public health practitioners. For example, the National Center for Health Research informed its readers that vaping is no safer than smoking. A magazine devoted to asthma and allergies told its readers that e-cigarettes are no safer than cigarettes for kids with asthma.

This message is a potentially damaging one from a public health perspective. It undermines the public's appreciation of the severe hazards of smoking and obviously, if any kids end up smoking instead of Juuling because of this information, it could have disastrous consequences.

Apparently, I'm not the only one who sees the problem with this message. A number of young people took to Twitter with the same message:

"This JUUL thing is so Dumb I wanna smoke 19 Cigarettes."

"Hey guys.. time to smoke 19 cigarettes instead of a juul pod cause it’s better for you!!!!"

"Okay I’ll just smoke 19 cigarettes instead of my Juul now, thank you for the advice!"

 "yeah f__k the juul go smoke 19 cigarettes instead."

But there's a second, possibly more subtle problem with the claim:

It's not true.

It doesn't take an advanced math degree to fact-check this claim. We just need two pieces of information:

1. The most highly concentrated Juul pod (there are two concentrations) contains 40 mg of nicotine.

2. An average cigarette contains about 12 mg of nicotine.

Thus, a Juul pod contains the amount of nicotine equivalent to that in about 3 cigarettes (not 20 cigarettes).

Moreover, there is nothing terribly unique about the Juul in terms of nicotine content. There are hundreds of varieties of e-liquids on the market that contain 24 mg of nicotine per cartridge, with a cartridge delivering about 200 puffs, similar to a Juul pod. So in reality, the Juul contains less than twice the amount of nicotine present in many other electronic cigarettes.

Focusing on the nicotine content obscures a more important factor, one which does actually separate out Juul from most other vaping products. That factor is the rate of absorption of nicotine into the bloodstream. Because of the nicotine formulation used in Juul (i.e., a nicotine salt), it is absorbed rapidly into the bloodstream and the pattern of nicotine levels in the blood over time mimics that of cigarette smoking. This is unlike the pattern for almost every other type of electronic cigarette on the market, which uniformly deliver nicotine quite ineffectively and therefore have a low addiction potential. By focusing on the nicotine content, rather than the formulation, the "truth" campaign and CDC are obscuring the most important information that people need to understand.

This commentary is not to minimize the addictive potential of Juul, the fact that there is a high level of nicotine absorption from Juul (much higher than from almost all other e-cigarettes), or that the pattern of nicotine in the bloodstream over time produced by the Juul does mimic that of cigarette smoking. It is just to highlight that there are a lot of exaggerated claims out there and in addition to just being incorrect, some of these claims could actually do public health harm.

Note: This post is dedicated to Kimberly Manor, the owner of Moose Jooce vape shops in Michigan: "Kim Shilling Manor smoked 2 1/2 packs of Marlboro reds a day. She smoked even after her husband died of lung cancer and her mother developed lung cancer. Kim quit smoking the FIRST time she tried vaping! It was life changing for her and she opened Moose Jooce so people could see just how easy it was to live smoke free!" It is because of Kimberly, and the literally 2 million other former smokers out there with similar stories, that I continue to try to reveal the "rest of the story."

Tuesday, November 20, 2018

Will Marijuana Become the Next Juul?

Yesterday, the first recreational marijuana facility opened in Massachusetts. Out of curiosity, I decided to check out its menu of offerings. Although I thought that this ballot initiative was all about allowing adults to use marijuana for recreational purposes, I was surprised to find a menu that is certain to appeal to youth.

The Rest of the Story

Here are some menu items - tell me that they are not going to be appealing to teenagers:

  • Strawberry-flavored chewy bites
  • Large, citrus gummy bears
  • Delectable Belgian dark chocolate bars
  • Assorted fruit-flavored chews
  • Assorted fruit-flavored cubes
  • Raspberry flavored confection
  • Raspberry flavored lozenges
  • Chewy, cocoa caramel bite-sized treats
  • Raspberry & watermelon flavored lozenges
  • Chocolate-chip brownies.”
My point here is that we are in complete hysteria because youth are using flavored e-cigarettes and health agencies want to ban e-cigarettes because they attract youth with gummy bear and cotton candy flavors, yet we are practically encouraging youth to enjoy kid-friendly flavors and varieties of marijuana, doing nothing to address the access of youth to real cigarettes in retail stores, and allowing the unfettered sale and marketing of flavored alcohol products which are used by more high school students than use the Juul and other e-cigarettes combined.

I can drive to a store within 10 miles and get flavored alcoholic beverages, menthol cigarettes, and chewy, cocoa caramel marijuana, but I can't buy a Juul flavor multi-pack to help me quit smoking?

This is public health in 2018?

Tuesday, November 13, 2018

FDA to Announce Ban on Sale of Most Cigarettes in Convenience Stores Due to Addiction of Hundreds of Thousands of Youth to Cigarettes

Tomorrow, the FDA is expected to announce the strictest regulation of cigarettes sales in decades. Spurred by the data showing that nearly 8% of high school students are current cigarette smokers, the FDA will announce that from now on, with just a few exceptions, cigarettes may not be sold in any convenience store or gas station. Online sales of cigarettes will still be allowed, but it will be subject to advanced age verification procedures. The only stores that will be allowed to sell cigarettes without restriction will be those which are only open to adults (or which establish an area that is only open to adults).

The FDA said it was forced to take this drastic action because it has evidence that: "a new generation is being addicted to nicotine, and we can’t tolerate that."

The tobacco companies intentionally make cigarettes more addictive by adding ammonia to the product, which enhances nicotine absorption. Cigarettes are the most effective known product to deliver nicotine in a pattern that is capable of quickly initiating and then sustaining addiction.

According to the CDC, every day more than 3,200 youth smoke their first cigarette. It has been estimated that it only takes four to five cigarettes for a youth to become addicted to smoking. One out of every two long-term addicted smokers will die prematurely, primarily from lung cancer, lung disease, heart disease, stroke, or other cancers. 

The Rest of the Story

Actually, I got it wrong.

The FDA is not banning the sale of most cigarettes at convenience stores; it is banning the sale of most fake (electronic) cigarettes at convenience stores.

Convenience stores and gas stations can continue to sell real cigarettes - which, despite lower smoking rates, continue to addict a new generation to nicotine - but they will no longer be able to sell electronic cigarettes (with only minor exceptions).

Somehow, we have completely lost all sense of public health perspective. Every argument that the FDA is making in justifying a ban on the sale of electronic cigarettes in convenience stores and gas stations applies even more strongly for real tobacco cigarettes: you know, the ones that kill hundreds of thousands of Americans each year. Something is terribly wrong with our sense of perspective when we take the fake cigarettes off the shelf but allow the real ones to remain.

So let me attempt to correct this skewed perspective.

First, we need to recognize that the problem of youth addiction to electronic cigarettes is not a broad problem of youth becoming addicted to e-cigarettes; it is a very specific and narrow problem of youth becoming addicted to Juul. It is one specific product that is causing the problem.

Other than Juul, all other closed system electronic cigarettes do not have high addiction potential because they are actually quite poor at delivering nicotine. Specifically, there is no nicotine spike in the blood, and the nicotine level drops off quite slowly. In contrast, the Juul uses a specially formulated nicotine salt that is absorbed much more rapidly into the bloodstream, and the pattern of blood nicotine levels from Juuling mimics that of a real cigarette. Youth are becoming addicted to nicotine not because they are vaping generally, but because there is an epidemic of Juul use occurring in middle schools and high schools across the nation.

However, just four days ago, Juul announced that it would voluntarily stop selling flavored Juul products in all convenience stores and gas stations. In fact, Juul has agreed to stop selling flavored Juul products in any brick-and-mortar establishment. These products will only be available online and with age verification procedures.

So this sweeping action by the FDA is not necessary. It will not result in the elimination of flavored Juul sales from convenience stores because that is already occurring.

So the rest of the story is that what the FDA's action is doing is to make it much more difficult for adults who have quit smoking to continue to stay smoke-free using their favorite brands of electronic cigarettes, which will be taken off the shelves. Youth will not be able to purchase flavored Juul products from stores, but that was going to happen anyway. The other e-cigarettes that are being sold at these stores (i.e., products other than Juul) have low nicotine addiction potential. It makes no sense to take them off the shelves but to allow real cigarettes, which have extremely high addiction potential, to remain available for sale and distribution to the 3,200 youth who try these products every day.

I believe this action will have a net negative impact on the public's health because it will almost certainly result in many ex-smokers returning to smoking as their products disappear from convenience store shelves.

What the FDA should have done is to deal directly with Juul and demand that they voluntarily remove their flavored products from the shelf and bolster their age verification procedures for online purchases. But since Juul has already agreed to this, there is no need for this drastic regulation, especially because cigarette sales are being left unencumbered.

One might argue that the reason that Juul agreed to remove their flavored products from the shelf is that they anticipated this FDA regulation. If that is the case, then perhaps the threat of regulation was successful in achieving this result. But now that Juul has agreed to take most of their products off the shelves, the FDA should not proceed with the regulation. Unless it is sincerely concerned about youth becoming addicted to nicotine, in which case it should ban all cigarette sales in brick-and-mortar establishments that are not restricted to adults.

Monday, June 18, 2018

USC Ended Partnership with Anheuser-Busch InBev in April; Ohio State and San Diego State Should Follow Suit

I have been informed by the USC Suzanne Dworak-Peck School of Social Work that the School and its research team that had been involved in the Smart Drinking Goals project terminated its involvement with the project in April 2018 and that they are no longer associated in any way with the project.

The USC team had prepared toolkits summarizing the best current scientific thinking regarding environmental strategies for alcohol prevention. Although the team's involvement was apparently slated to last at least through 2018, they terminated their involvement in April and have completely disassociated themselves from the Smart Drinking Goals project.

I applaud USC and this research team for dissociating from the project.

The Rest of the Story

To the best of my knowledge, the Ohio State University is still involved with the Smart Drinking Goals program, and in addition, since yesterday I have learned that San Diego State University also seems to be involved with the program. Both of these institutions should immediately follow the lead and example set by USC and terminate their involvement with this project and their partnership with Anheuser-Busch InBev.

While public-private partnerships are sometimes tenable, in this case, you cannot have a credible partnership when the private corporation is bullying and disrespecting the autonomy of governments to implement their own public health measures to prevent excessive alcohol use and its associated harms. I cannot fathom an academic institution partnering with a company that went so far as to threaten a lawsuit against the city of Rostov in order to force it to allow the sale of beer at the World Cup soccer matches in Rostov Arena. Obviously, this completely undermines the supposed "smart drinking goals" initiative and exposes it for what it really is: a public relations hoax.

I have since learned that San Diego State University has apparently also partnered with Anheuser-Busch InBev to aid this public relations initiative. According to the university, it accepted a $200,000 grant from the alcohol corporation to be a part of the "implementation planning" for the Smart Drinking Goals project.

This grant completely exposes the hypocrisy of the alcohol company and demonstrates why this whole project is a hoax. Ironically, part of the San Diego State University project is to develop programs to reduce excessive alcohol consumption in sports arenas! Now you can see why this is a complete joke. At the same time that the company is, out of one side of its mouth, proclaiming that it cares about reducing alcohol consumption at sports arenas, from the other side of its mouth it is threatening to sue cities in order to force them to sell alcohol and facilitate excessive alcohol consumption in their sports arenas!

This hypocrisy boggles the mind, and it demonstrates that the Smart Drinking Goals program is not a sincere effort to address public health concerns but instead, a public relations hoax.

Hopefully, Ohio State and San Diego State will follow the example set by USC and immediately terminate their partnerships with Anheuser-Busch InBev.