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

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

Specifically, Dr. Frieden stated:

"What we are doing first is tracking, and we are seeing some very concerning trends. Use of e-cigarettes in youth doubled just in the past year, and many kids are starting out with e-cigarettes and then going on to smoke conventional cigarettes."

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

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

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

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

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

The Rest of the Story

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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