Sadly, this occurred in the Mayo Clinic's advice to the public about electronic cigarettes, which appeared in a column published in the Chicago Tribune on August 1.
The column consisted of the Mayo Clinic's answer to a very simple question (a yes or no question, in fact) posed by a reader: "I've been a smoker for years. I'm thinking about switching to electronic cigarettes or to a nicotine inhaler because I've heard they aren't as bad for you as regular cigarettes. Is that true?"
So the reader asks a simple and important question: are electronic cigarettes safer than regular cigarettes. This is a simple, yes-or-no question. Let's see what the Mayo Clinic had to say:
"Electronic cigarettes and nicotine inhalers both deliver nicotine to your body without tobacco. But that's where the similarity ends. The two are quite different when it comes to how they're used and how much doctors know about their safety. Nicotine inhalers are a proven safe and effective way to help people stop smoking. In contrast, very little is known about the health effects of electronic cigarettes. ... The manufacturers claim that e-cigarettes are a safe alternative to tobacco cigarettes. But there are significant questions about the safety of these products."
"When the U.S. Food and Drug Administration (FDA) analyzed samples of two popular brands of e-cigarettes, they found varying amounts of nicotine and traces of toxic chemicals, including substances that are known to cause cancer. The liquid inside many e-cigarettes contains a substance called propylene glycol. It creates the e-cigarette's vapor. Other common uses of propylene glycol are in cosmetics and as an ingredient in fog machines and antifreeze. The specific health effects of this product are not clear. No studies have been done to examine the safety of e-cigarettes. As a result, there is no evidence that doctors can use to assess the impact this product may have on a person's body. Also, no convincing evidence shows that e-cigarettes are useful in helping people to eventually stop smoking. ... As with e-cigarettes, nicotine inhalers give you a dose of nicotine when you puff on them. Unlike e-cigarettes, the amount of nicotine you receive is controlled and small. And with nicotine inhalers you receive only nicotine."
The Rest of the Story
As you can see, the Mayo Clinic has failed to answer this simple question. It refuses, in fact, to address the question of whether electronic cigarettes are safer than tobacco cigarettes. In fact, by its silence on this question, I think many readers will infer that the Mayo Clinic is answering with a "No." Instead of answering the question posed, the Mayo Clinic changes the question into a comparison of electronic cigarettes and nicotine inhalers. But sadly, this is where the lies and misinformation begin.
Lie #1: "The manufacturers claim that e-cigarettes are a safe alternative to tobacco cigarettes."
Not only does the Mayo Clinic fail to substantiate this claim, but it is largely untrue. Most electronic cigarette companies either do not make health claims about their products or if they do, they simple claim that e-cigarettes are safer than tobacco cigarettes. So it is demonstrably false that "the manufacturers" claim that e-cigarettes are a safe alternative. In fact, most of the electronic cigarette companies include disclaimers on their web sites informing consumers that their products contain nicotine which may be addictive and/or that their products have not been approved by the FDA and are not for the use of minors.
For example, let's look at the blu e-cigs web site.
Here is what blu says about its product: "blu can be purchased and used by anyone over the legal smoking age in the state where they reside. It should not be used by children, pregnant or breast feeding women, people with heart disease, high blood pressure, diabetes or people taking medicines for asthma or depression. Consult your physician before using any electronic cigarette product. CALIFORNIA PROPOSITION 65: Warning: This product contains nicotine, a chemical known to the state of California to cause birth defects or other reproductive harm. ... blu liquid is made in the U.S. with domestic and imported ingredients by Johnson Creek Enterprises in Hartland Wisconsin; we maintain an organization that inspects product lines at all facilities daily. blu simulates the smoking experience without the tobacco smoke, ash and smell associated with traditional tobacco cigarettes. blu should not be used as a quit smoking device as it has not been approved by the FDA as a cessation device. blu eCigs are not a smoking cessation product and have not been evaluated by the Food and Drug Administration, nor are they intended to treat, prevent or cure any disease or condition."
I defy the Mayo Clinic to identify where in this information blu is claiming that its e-cigarettes are "a safe alternative" to tobacco cigarettes.
Now let's look at the V2 Cigs web site. Here is what they say about their product in terms of its safety: "Nicotine is addictive and can be toxic if inhaled or ingested and may cause irritation if it comes into contact with your eyes or skin. Wash immediately with soap and water upon contact. Like other products with nicotine, you should not use this product if you are pregnant or breastfeeding, have or are at risk of heart disease, high blood pressure, diabetes, if you are taking medicines for depression or asthma or if you are allergic to nicotine, propylene glycol, or any combination of inhalants. Discontinue use and consult a physician if you experience symptoms of nicotine misuse such as nausea, vomiting, dizziness, diarrhea, weakness or rapid heartbeat. This product does not treat, diagnose or cure any disease, physical ailment or condition. This product is not marketed for use as a smoking cessation product and is not intended for use by non-smokers. This product and the statements made herein have not been evaluated by the FDA, or any other health or regulatory authority. WARNING: V2 Cigs products with nicotine contain a chemical known to the state of California to cause birth defects or other reproductive harm."
This hardly looks like V2 Cigs is claiming that their product is "safe." If they acknowledge that it can cause reproductive harm, I don't see how the Mayo Clinic can assert that they are claiming it is a "safe" alternative to smoking.
Lie #2: "And with nicotine inhalers you receive only nicotine."
This is an irresponsible lie. It is simply not true that people who use nicotine inhalers are only inhaling nicotine. Many other chemicals have been identified in the nicotine inhaler vapor, including a number of known toxins and carcinogens. 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
- Lead
Lie #3: "No studies have been done to examine the safety of e-cigarettes."
There have been many studies that examined the safety of electronic cigarettes. According to the Mayo Clinic, these studies are a figment of the authors' imaginations. Apparently, the Mayo Clinic must believe that someone must have hacked into the Pub Med web site and created these fictitious studies:
Levels of selected carcinogens and toxicants in vapour from electronic cigarettes
Health-related effects reported by electronic cigarette users in online forums
Metal and silicate particles including nanoparticles are present in electronic cigarette cartomizer fluid and aerosol
Acute impact of active and passive electronic cigarette smoking on serum cotinine and lung function
Comparison of the effects of e-cigarette vapor and cigarette smoke on indoor air quality
Comparison of electronic cigarette refill fluid cytotoxicity using embryonic and adult models
Acute effects of electronic and tobacco cigarette smoking on complete blood count
Short-term pulmonary effects of using an electronic cigarette: impact on respiratory flow resistance, impedance, and exhaled nitric oxide
EffiCiency and Safety of an eLectronic cigAreTte (ECLAT) as Tobacco Cigarettes Substitute: A Prospective 12-Month Randomized Control Design Study
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.
Lie #4: "There is no evidence that doctors can use to assess the impact this product may have on a person's body."
There is an abundance of evidence that doctors not only can use, but must use in assessing the likely health impact of electronic cigarettes, especially in relation to tobacco cigarettes. Responsible physicians should be examining the abundant existing evidence and actually answering their patients' questions regarding these products, unlike the Mayo Clinic, which is lying about the evidence.
To start physicians off, here are just nine studies to begin with. There are a lot more, including more than 20 which have characterized the components of electronic cigarette liquids or vapor.
Levels of selected carcinogens and toxicants in vapour from electronic cigarettes
Health-related effects reported by electronic cigarette users in online forums
Metal and silicate particles including nanoparticles are present in electronic cigarette cartomizer fluid and aerosol
Acute impact of active and passive electronic cigarette smoking on serum cotinine and lung function
Comparison of the effects of e-cigarette vapor and cigarette smoke on indoor air quality
Comparison of electronic cigarette refill fluid cytotoxicity using embryonic and adult models
Acute effects of electronic and tobacco cigarette smoking on complete blood count
Short-term pulmonary effects of using an electronic cigarette: impact on respiratory flow resistance, impedance, and exhaled nitric oxide
EffiCiency and Safety of an eLectronic cigAreTte (ECLAT) as Tobacco Cigarettes Substitute: A Prospective 12-Month Randomized Control Design Study
Why this Need to Lie?
Why must such a reputable organization like the Mayo Clinic lie about electronic cigarettes and the scientific evidence regarding the relative safety of these products in relation to the tobacco cigarettes which are killing so many of their patients? Smokers, including the one who posed this question, deserve honest and factual answers. In fact, I would argue that telling patients the truth about the scientific evidence is one of the central ethical tenets of the practice of medicine.
While it is difficult for me to understand why lies are necessary when providing medical answers to the public, I have two hypotheses about why we are seeing so much of this going on with regards to the electronic cigarette issue.
First, many anti-smoking physicians and researchers appear to be blinded by an ideology that views anything that even looks like cigarette smoking to be evil. This leads to a pre-determined conclusion that electronic cigarettes must be harmful and that any promotion of e-cigarettes is going to lead people to smoke, rather than the opposite. When a conclusion is pre-determined, one looks only for evidence that supports one's position and discounts or discredits any evidence which doesn't support the pre-existing position.
Second, many anti-smoking physicians and researchers have financial conflicts of interest with pharmaceutical companies that manufacture smoking cessation drugs, like nicotine inhalers. Thus, there is an inherent bias whenever they make a comparison of electronic cigarettes and drug company products, such as nicotine inhalers.
It is possible that this is the case even here with the Mayo Clinic column, because the author - Dr. Jon Ebbert - has apparently participated in research that was funded by Pfizer, which markets the nicotine inhaler. In fact, Dr. Ebbert has apparently participated in a second study that was funded by Pfizer; and in a third study that was funded by Pfizer. And a fourth one as well.
Dr. Ebbert is also listed as a Principal Investigator on a clinical trial that is sponsored by Pfizer or in which Pfizer is collaborating. In a 2012 article, he acknowledges as follows: "Jon O. Ebbert has received support to conduct clinical trials with varenicline from Pfizer."
It is also important to disclose that the Director of the Nicotine Dependence Center (Dr. Ebbert is an Associate Director of the Center) apparently serves or served on the Advisory Board for Pfizer. And another Associate Director of the Center acknowledges receiving research funding from Pfizer.
Unfortunately, the Mayo Clinic article in the Chicago Tribune fails to disclose the conflicts of interest of Dr. Ebbert and of the Nicotine Dependence Center's other leadership. That Dr. Ebbert and the other leadership of the Center have or have had financial conflicts of interest with Pfizer - which markets the nicotine inhaler discussed in the article - is not disclosed. Thus, this creates the appearance that the article's misrepresentation of the research in which the chemicals delivered by nicotine inhalers were identified was influenced by this conflict of interest.
The rest of the story is that not only is this Mayo Clinic article packed with lies about the science, but it also fails to disclose a relevant conflict of interest that has the appearance of shaping the misinformation in the article.
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