Sunday, July 21, 2019

Claim that Vaping Causes Heart Attacks is Completely Debunked

A study published last month in the Journal of the American Heart Association electronic cigarette use concluded that vaping is a cause of heart attacks, raising the risk of having a heart attack about two-fold. One of the co-authors publicized the study on his blog under the title "More evidence that e-cigs cause heart attacks."

This was a cross-sectional study using data from the baseline survey of the Population Assessment of Tobacco and Health (PATH) Study collected in 2013-2014. The investigators examined the relationship between respondents reporting that they ever had a heart attack and that they currently vaped. They found that people who vape were more likely to report ever having had a heart attack in the past.

The problem with drawing a causal conclusion from this cross-sectional study is that there is no way to know which came first: the vaping or the heart attack. As I have previously argued, it is entirely possible that most of the vapers who reported having had a heart attack were people who experienced a heart attack and then began vaping in an effort to stay off of cigarettes. If this is the case, then it is not the vaping that is causing the heart attacks; instead, it is really the heart attacks "causing" the vaping. In epidemiology, we call this "reverse causation," and it is a common limitation of cross-sectional studies, especially when they do not ask about the time course of exposures and outcomes.

Based on what I saw as a likely possibility of reverse causation and on the inability of the study to determine whether the vaping actually preceded the heart attacks, I argued that the investigators went too far in their conclusion and that, in fact, the study does not provide evidence that vaping causes heart attacks.

The Rest of the Story

I was wrong. I have to admit it ...

... I was wrong.

Specifically, I had argued that "there is no way to know which came first: the vaping or the heart attack."

However, Dr. Brad Rodu -- a professor at the University of Louisville -- noticed that in fact, we do know which came first.


Because the PATH survey actually asked respondents not just whether they had ever experienced a heart attack, but when they had the heart attack.

And similarly, the survey asked respondents not just whether they vaped, but when they started vaping.

So Dr. Rodu was able to analyze the same PATH data that the study authors used. Lo and behold, he found that the majority of the 38 vapers who reported having ever had a heart attack experienced that heart attack before starting to vape. In fact, he found that on average, "the heart attacks preceded first e-cigarette use by almost a decade."

There are two major problems here.

The first is that the unsupported, and now debunked, conclusions of the study have influenced many policy makers in their decision to ban the sale of e-cigarettes (while leaving real cigarettes on the shelves, which do cause heart attacks). For example, before voting to ban the sale of e-cigarettes in San Francisco, city council members were told that e-cigarettes are associated with heart attacks.

The second problem is the question of why the study investigators failed to look at whether the vaping preceded the heart attacks, even though they had the information in the survey to make that determination. It would have been easy for them to determine that the majority of the vapers who reported having had a heart attack actually experienced the heart attack before they even started vaping.

The rest of the story is that this new information calls into question not only the conclusions of the research, but also the objectivity of the researchers.

With local, state, and federal policy makers and regulators all considering legislation to regulate vaping, it would be damaging for their decisions to be informed by the now-debunked conclusion that vaping causes heart attacks. The problem is that this conclusion has already been spread widely through the media, and it is very difficult to retract information once it is already out there.

Tuesday, July 16, 2019

Based Solely on Quotes from Anti-Tobacco Groups, Big Tobacco Tells America's 3 Million Nonsmoking Vapers They Would Be Healthier Going Back to Smoking

The tobacco industry is taking advantage of a rare and unprecedented marketing opportunity being offered to it by none other than the anti-tobacco movement. Based solely on statements made by tobacco control organizations, Big Tobacco (@BigTobaccoUS) is urging America's 12 million vapers (3 million of whom do not use cigarettes at all) to return exclusively to smoking in order to protect their health.

Cleverly, Big Tobacco is not making any statements of its own. It is simply relying on statements already made by anti-tobacco groups. For example, Big Tobacco stated: "Most public health experts agree that vaping is dangerous and you're better off if you keep smoking. We share their opinions."

To support its claims, Big Tobacco cited a Twitter headline from Clear Way Minnesota, which said: "Switching from vaping to smoking does reduce your carcinogens."

It would be absurd to think that Big Tobacco, in 2019, would have the gall to make such a preposterous claim -- that switching from vaping to smoking will improve a person's health. But Big Tobacco isn't directly making that claim. They are simply repeating statements made by supposedly anti-smoking organizations.

The statements being made by Big Tobacco are also being supported by policy decisions announced in recent months by city councils and boards of health throughout the country. For example, the city of San Francisco recently banned the sale of e-cigarettes, while allowing Marlboros to stay on the shelves. The town of Brookline, Massachusetts recently banned the sale of nearly all e-cigarettes, while allowing the majority of cigarette brands to remain on the shelves. Similar laws have been enacted by at least 26 other cities and towns.

The Rest of the Story had an exclusive opportunity to interview a spokesperson for Big Tobacco. Here is a transcript of the interview:

Siegel: Thanks for taking the time to speak with me today. I have to just start by asking: Did you ever dream that one day, groups that you thought were anti-smoking organizations would be promoting smoking over a much safer, fierce competitor to your combustible products?

Big Tobacco: Never. We really believed, deep in our hearts, that anti-smoking groups were our enemies. Our opponents. Naturally ... they were calling themselves anti-smoking groups. So we assumed that they would be doing everything in their power to discourage people from smoking and to emphasize the severe health effects of cigarette smoking, effects that even we now acknowledge. It never occurred to us that these "anti-smoking" groups would one day be promoting laws to pull all of our competition off the shelves and allow our most toxic products - our combustible cigarettes - to remain on the market. This is a dream come true. And frankly, some days I wake up and think that I am dreaming.

Siegel: For years, the anti-smoking groups complained and attacked you for not doing anything to make your products safer. They condemned you for not doing any research on how to make a safer product. Now that you have actually gotten into the business of selling a much safer product (e-cigarettes), they immediately take that product off the shelves and force you to only sell your most toxic combustible product. Does that make any sense to you?

Big Tobacco: Not at all. We had recently announced plans to start converting our U.S. business portfolio from our most toxic products - the combustibles - to a range of vaping products, which are much safer and we assumed over time would become more and more popular. Based on the popularity of vaping products and statistics on the unprecedented number of people who were quitting smoking using these alternative products, market analysts were predicting that within about two to three decades, we would literally cut cigarette consumption in half. So much for that! We can now go back to business as usual: we'll actually be adding more Marlboro rolling machines, something that wasn't in our long-range business plan because we made the apparently errant assumption that the anti-smoking groups would actually want to see a lowering of cigarette consumption.

Siegel: The City Attorney of San Francisco and the Board of Supervisors said that they were standing up to Big Tobacco when they enacted a law that bans the sale of all e-cigarettes. I assume that your stock prices must have tumbled since then. How are you coping with those huge financial losses?

Big Tobacco: Oh, no, that's not what happened at all. From the day the mayor of San Francisco signed the ordinance, our stock has risen from $47.35 to $49.54. A consensus of the major analysts now rate us as a "Strong Buy."

Siegel: Ok. Well we've talked about your competition from vaping products, which have now been taken off the market or severely restricted in many cities. Let's talk now about your competition from other cigarette brands. Although your Marlboro brand has always been #1, Newport has long been your chief competitor at #2. What are your plans to decrease that competition and further improve your market position?

Big Tobacco: We have none.

Siegel: You have none! How could you possibly have no plans to help fight off competition from Newport cigarettes?

Big Tobacco: Well, we don't have to make any plans because the anti-smoking groups are doing all of that work for us. You are not going to believe this, but our so-called enemies are promoting ordinances and state laws throughout the country that essentially ban the sale of Newport cigarettes while allowing Marlboro cigarettes to remain on the shelves, unfettered and untouched. 

Siegel: Wait a second. You have me here. Why ban one cigarette brand but not another one that is equally dangerous?

Big Tobacco: They have somehow got it into their minds that Newport cigarettes - which have menthol - are a much greater threat to the public's health than Marlboro cigarettes ... [laughing] ... [laughing] ... [choking] ... So the Newports are coming off all the shelves and the Marlboros are staying put [laughing] ... And the irony is that for years, the anti-smoking groups attacked us for even insinuating that one cigarette brand was safer than another. Now those same groups are telling policy makers throughout the country that some cigarettes are safer than others. And we got the long end of the stick! [laughing almost out of control]. No pun intended.

Siegel: The "anti-smoking" groups are claiming that vaping is as dangerous as smoking. Now, how many people does smoking kill every year?

Big Tobacco: We no longer make up our own estimates. We now really on public health authorities. They estimate the number to be around 400,000.

Siegel: So I take it that vaping also kills around 400,000 people each year.

Big Tobacco: Not quite that many.

Siegel: Well then how many exactly?

Big Tobacco: So far zero.

Siegel: Well that doesn't seem possible. The anti-smoking groups, especially the American Lung Association, say that vaping causes popcorn lung. That is a rapidly progressive and fatal disease. With 12 million vapers in the United States, the product on the market for 13 years, and such a high risk of popcorn lung, there must be thousands of cases by now.

Big Tobacco: [laughing] ... Actually... [laughing] ... not a one!

Siegel: But a researcher at Harvard Medical School stated, and I'm quoting here, "Vaping can cause something called bronchiolitis obliterans, or popcorn lung."

Big Tobacco: [snicker] ... Not a one.

Siegel: Ok. But a physician and researcher from the University of North Carolina School of Medicine stated, and I'm again quoting here, "Yes, vaping can cause popcorn lung. The first thing to understand is that vape juice flavorings are not designed to be inhaled; they’re designed to be eaten. So these flavorings, when inhaled at higher temperatures, can be toxic to the lungs and cause damage, including the possibility of popcorn lung."

Big Tobacco: Not a one.

Siegel: And a specialist in substance abuse prevention stated, again I'm quoting, "The one thing we do know for sure in terms of long-term effects is that those who vape long term develop popcorn lung."

Big Tobacco: They're lying. Believe me, we know all about lying. We did it for years. And the anti-smoking groups attacked us for it. Even took us to federal court.

Siegel: Well that seems quite hypocritical of them.

Big Tobacco: If you say so.

Siegel: Let's talk for a minute about cancer risk. Tobacco smoke has more than 10,000 chemicals including more than 60 known human carcinogens. One carcinogen - formaldehyde - has been found to be present in some brands of e-cigarettes, although your own Mark Ten brand did not contain any detectable formaldehyde. How in your right mind could you possibly claim that vaping poses a greater carcinogenic risk than smoking?

Big Tobacco: Oh, simple. We're not the ones making that claim. That statement was made by researchers at Portland State University. And we are in no position to contest a conclusion made by academicians at a reputable university. If I recall correctly, and it's been a while, their exact statement was that "If we assume that inhaling formaldehyde-releasing agents carries the same risk per unit of formaldehyde as the risk associated with inhaling gaseous formaldehyde, then long-term vaping is associated with an incremental lifetime cancer risk of 4.2×10−3. This risk is 5 times as high ... or even 15 times as high ... as the risk associated with long-term smoking."

Siegel: Well if vaping poses a 15 times higher risk of cancer than long-term smoking, why would anyone in their right mind quit smoking by switching to vaping? And wouldn't ex-smokers who did quit smoking successfully by switching to vaping want to immediately go back to smoking?

Big Tobacco: That's precisely what the "anti-smoking" groups are telling them.

Siegel: Ok, one last question. The tobacco industry has a long history of reaching out to various groups to develop allies, or "friends" as you may call them. You had the Tobacco Institute, the National Smokers' Alliance, I can't recall the others. Who are your current allies?

Big Tobacco: There are a large number of groups that are working to promote laws that get rid of vaping products and leave retail stores with cigarettes as the only available nicotine product. The American Lung Association, the American Cancer Society, and the American Heart Association come to mind.

Siegel: Whoa. I thought those were anti-smoking groups. In fact, I spent two decades working closely with all 3 of those groups to pass smoke-free bar and restaurant laws throughout the country.

Big Tobacco: Yeah we know. You're in our files. Well, we now refer to those groups as our Marketing Department ... [laughs] ... Heck, with enemies like that, we really don't need friends.

Siegel: Thank you for taking the time to provide me with this exclusive interview.

Sunday, July 14, 2019

New Organization Forms to Confront the Epidemic of Popcorn Lung

Prompted by the statements of anti-tobacco groups throughout the country claiming that vaping causes popcorn lung, a new organization was launched this past Thursday to confront this new and alarming epidemic among young people. The organization is called the American Popcorn Lung Association (APLA) and it has a Twitter feed (@LungPopcorn).

"Popcorn lung" is a serious, progressive lung disease that is technically known as bronchiolitis obliterans. The disease results in obstruction of the smallest airways in the lung. The disease is irreversible and can be fatal. A lung transplant is the only definitive treatment. The most common cause of popcorn lung is inflammation following a lung transplant. But it has also been associated with exposure to toxic fumes, especially with extremely high exposure to the chemical diacetyl, which occurred in a group of popcorn factory workers (hence the name popcorn lung).

Popcorn lung is a very rare disease. Smoking is not recognized as a cause of popcorn lung and the disease is not observed in smokers (in the absence of other risk factors such as lung transplant).

The Rest of the Story

Despite the presence of electronic cigarettes on the U.S. market for 13 years and despite the fact that there are literally millions of vapers, there has never been a confirmed case of popcorn lung occurring in a vaper. The annual incidence of popcorn lung among electronic cigarette users between 2007 and 2018 was 0.0 per 100,000. The current prevalence of popcorn lung among current (past month) vapers (as of the end of 2018) was 0.0%.

Despite the complete absence of a single case of popcorn lung having been caused by vaping, the American Popcorn Lung Association is hard at work trying to discourage smokers from trying to quit smoking using e-cigarettes because of what it says is the severe risk of developing popcorn lung from vaping.

When asked to defend its statement that vaping can cause popcorn lung--even though there has never been such a case and even though smoking itself is not a cause of popcorn lung--a spokesperson for the American Popcorn Lung Association told The Rest of the Story that there is solid evidence that vaping causes popcorn lung because e-cigarette aerosol has been found to contain small amounts of diacetyl, 750 times lower than what is present in cigarette smoke, which is not a cause of popcorn lung.

The spokesperson referred me to multiple statements of anti-tobacco organizations and some physicians, including statements by, or quotes from researchers or staff at, the following:

Despite the absence of even a single case of popcorn lung in a vaper, APLA insisted that vaping has been demonstrated to cause popcorn lung, citing the current website of the American Lung Association, which contains an article whose headline states: "Popcorn Lung: A Dangerous Risk of Flavored E-Cigarettes."

APLA also pointed to a statement of Dr. Jonathan Winickoff, a physician and researcher at Harvard Medical School, who was quoted as stating: "Vaping can cause something called bronchiolitis obliterans, or popcorn lung."

In addition, APLA pointed to a University of North Carolina School of Medicine statement by Dr. Adam Goldstein that leaves no room for doubt: "Yes, vaping can cause popcorn lung. The first thing to understand is that vape juice flavorings are not designed to be inhaled; they’re designed to be eaten. So these flavorings, when inhaled at higher temperatures, can be toxic to the lungs and cause damage, including the possibility of popcorn lung."

APLA also cited what is perhaps the most definitive statement about the link between vaping and popcorn lung, made by a Rhode Island substance abuse prevention advocate: "The one thing we do know for sure in terms of long-term effects is that those who vape long term develop popcorn lung. Popcorn lung was first seen in popcorn plant workers who developed it from the chemicals in the butter flavor of popcorn. Popcorn lung is irreversible. Once you get it, there is no treatment to reverse it. Earlier diagnosis is better, but the longer you’re vaping … the worse it is. The only way to prevent popcorn lung is not to do it – no Juuling, no vaping."

Although I am still skeptical about the link between vaping and popcorn lung due to the fact that even lifelong, heavy tobacco smoke exposure has not been associated with the development of popcorn lung and not a single case has been confirmed in a vaper, the American Popcorn Lung Association convinced me not to worry, telling me that anti-vaping organizations throughout the country are working hard to produce evidence that vaping does cause popcorn lung. The spokesperson referred me to a recent statement by the American Lung Association, ensuring that: "Scientists have been working hard to debunk the belief that e-cigarettes are less harmful than traditional cigarettes." APLA pointed out that "among those harms is the dreaded POPCORN LUNG."

Last Friday, APLA reassured potential donors who may be skeptical about giving money to prevent a disease that does not exist: "We are taking time out from our busy schedule (assembling our professional team of popcorn lung experts and developing our strategy), to update you on the latest epidemiological research into the popcorn lung epidemic. Still no cases but we know they're out there."

A spokesperson for the newly created, multi-million dollar national organization called the "Campaign for Popcorn Lung-Free Kids" told The Rest of the Story that: "The precautionary principle is the foundation of public health. It is entirely appropriate for the American Popcorn Lung Association to advocate against a disease that does not exist. In fact, we would argue that is the ultimate in precaution."

The American Non-Vapers' Rights Association took it a step further. Their spokesperson told me they are concerned that secondhand exposure to vaping aerosol could increase a bystander's risk of developing popcorn lung, especially if the flavor being used is Juul's youth-friendly, highly popular cotton candy-flavored e-liquid. 

Just as we were about to achieve a nicotine-free generation, do you want to see that undermined by an epidemic of kids developing popcorn lung? If, like me, you want to do something about the popcorn lung epidemic, I urge you to follow my example and join the American Popcorn Lung Association.

"Big Tobacco Lies. So Does Juul." ... And So Does Americans for Nonsmokers' Rights

A July 11 column by the American Nonsmokers' Rights Foundation (ANRF) is entitled "Big Tobacco Lies. So Does Juul." A large image shows a graduating college student with the quote: "We were literally going to be the first generation not addicted to nicotine. And then they made it taste like cotton candy and everyone is vaping and ADDICTED to nicotine."

The Rest of the Story

The headline should more appropriately say: "Big Tobacco Lies. So Does Juul. And So Does the American Nonsmokers' Rights Foundation."

ANRF is lying here because they are implying that Juul created cotton candy-flavored e-cigarettes which have attracted youth and gotten large numbers of them addicted to nicotine. However, there's just one problem with that assertion ...

... Juul does not make cotton candy-flavored pods.

The truth is that it is not cotton candy-flavored products that have gotten youth addicted to vaping. In fact, the cotton candy products are not particularly addictive, and if youth were actually using cotton candy vapes, they would most likely not be addicted to nicotine.

Moreover, the cotton candy flavors are not manufactured by either Juul or by any tobacco company.

It is also not true that the generation of students graduating from college now was going to be the first generation not addicted to nicotine. The prevalence of current smoking in 12th grade among this year's college graduating class was approximately 11%. While that's obviously much better than in the past, it is hardly a generation that is not addicted to nicotine.

So why is ANRF lying? Well, I guess it is more alarming and makes for a more shocking story to try to fool the public into thinking that Juul is targeting kids with cotton candy flavoring, and that deception helps with donations to the organization. Heck, if Juul was enticing kids with cotton candy e-liquids, I would donate because that is so obviously an attempt to appeal to youth.

It's a more shocking story, but it's not true. And I don't believe that the ends justifies the means. Lying in an effort to enhance the story to solicit more donations is not justified. Especially in a column that is criticizing the tobacco industry and Juul for ...

... lying!

Saturday, July 13, 2019

American Lung Association Inadvertently Reveals the Truth About Many Vaping Opponents

An article published recently by the American Lung Association claims that vaping causes popcorn lung and COPD. There is no evidence to support either of these assertions. In fact, I'm not aware of a single case of either popcorn lung or COPD that has ever been diagnosed in a vaper without a history of cigarette smoking. Even active smoking itself is not associated with popcorn lung, and cigarette smoke contains about 750 times the amount of diacetyl (the putative cause of popcorn lung) than e-cigarette aerosol. So the American Lung Association is lying about the health risks of vaping.

The Rest of the Story

However, that's not what this commentary is about. This commentary is about something very interesting that the American Lung Association inadvertently revealed about the way they think about science.

In the very first sentence of the article, the American Lung Association writes: "Scientists have been working hard to debunk the belief that e-cigarettes are less harmful than traditional cigarettes."

So this is how the American Lung Association thinks about science? According to them, scientists are not doing objective research to compare the health effects of vaping and smoking. Instead, they have come up with a pre-determined conclusion that vaping is more dangerous than smoking and they are frantically trying to come up with evidence to prove that conclusion. The truth, of course, is that there is no legitimate scientific debate about whether vaping is less harmful than smoking. It is much safer and no credible scientist can deny that based on a multitude of evidence.

So what the American Lung Association is basically saying is tantamount to its stating that "Scientists have been working hard to debunk the belief that global warming exists."

It's obvious that the writers of this article didn't think about what they were writing very carefully. So what we were left with is a revelation of the true thinking of the American Lung Association. Apparently, their true thinking is that they want to be able to claim that vaping is more dangerous than smoking, they have come to a pre-determined conclusion that vaping is more dangerous than smoking, and now they are hoping that scientists will somehow come up with evidence that vaping is more harmful than smoking.

This is no less damaging and no less unethical than the behavior of groups that are denying global warming or claiming that vaccines cause autism.

This is painful for me to watch because I have a long history of working with and for the American Lung Association and have many dear colleagues with whom I have worked over the years, especially in the movement to achieve smoke-free workplaces, bars, and restaurants.

Sadly, the scientific integrity of the American Lung Association has apparently deteriorated to the point that they have become just another denialist organization - like the global warming deniers or anti-vaxxers. Their actions are completely undermining the public's appreciation of the severe health hazards associated with smoking, something I worked for decades with the American Lung Association to achieve.