New Study Provides More Evidence that Vaping is Much Safer than Smoking and Finds Few Hazardous Chemicals in "Secondhand" Vapor

A new study published in this month's issue of the journal Inhalation Toxicology provides more evidence - from laboratory analysis of the constituents in "secondhand" vapor from electronic cigarettes - that vaping is much safer than smoking and that "secondhand" vapor is much less hazardous than secondhand smoke.

(see: McAuley TR, Hopke PK, Zhao J, Babaian S. Comparison of the effects of e-cigarette vapor and cigarette smoke on indoor air quality. Inhalation Toxicology 2012; 24(12): 850-857.)

According to the study: "Four different high nicotine e-liquids were vaporized in two sets of experiments by generic 2-piece e-cigarettes to collect emissions and assess indoor air concentrations of common tobacco smoke by products. Tobacco cigarette smoke tests were conducted for comparison. Comparisons of pollutant concentrations were made between e-cigarette vapor and tobacco smoke samples. Pollutants included VOCs, carbonyls, PAHs, nicotine, TSNAs, and glycols."

The chief results of the study were that:

1) Very few of the chemicals present in secondhand smoke were detected in the electronic cigarette vapor.

2) Of the few chemicals that were detected, the levels were substantially lower than those present in secondhand smoke.

The only compound of significant concern was formaldehyde, but its levels were much lower in the electronic cigarette vapor than in the tobacco smoke. One hypothesis is that formaldehyde may result from the heating of propylene glycol. While this is enough concern to warrant efforts to try to find ways to reduce the formation of formaldehyde in the vaporization process, this finding is consistent with previous research which also detected low levels of formaldehyde and does not alter the basic conclusion that these products are much safer than cigarettes.

In a press release accompanying the study, I am quoted as stating: "This study demonstrates that the risks of secondhand vapor from electronic cigarette use are very small in comparison to those associated with secondhand tobacco smoke. While secondhand smoke must be eliminated in workplaces and public places, the current data provide no justification for eliminating electronic cigarette use in these places."

Bill Godshall of Smokefree Pennsylvania is quoted as stating: "For more than 25 years Smokefree Pennsylvania has been advocating indoor smoking bans. Based on the results of this study I see no reason for e-cigarettes to be included in smoking bans."

Dr. Murray Laugesen of Health New Zealand is quoted as stating: "The results of this study confirm the findings of my last 4 years of research. E-cigarettes pose no discernible risk to public health."

The Rest of the Story

While I wouldn't go as far as Dr. Laugesen to say that this study confirms that there is "no discernible risk" to public health from electronic cigarettes, I do believe that the results confirm the previous evidence demonstrating that vaping is much safer than smoking and that there are few concerns related to the safety of secondhand vapor from electronic cigarettes.

It is important to keep in mind that the electronic cigarette vapor in this study was produced by machines, not by humans. Thus, none of the constituents of the vapor were absorbed in the lungs as they would be normally. So the study is going to overestimate the actual levels of these constituents that would be produced by actual vaping.

There are three reasons that I would not say electronic cigarettes pose no risks. First, they contain nicotine, which has adverse cardiovascular effects. So we are not expecting that electronic cigarettes will ever be viewed as being absolutely safe. Second, there are some acute respiratory irritant effects of propylene glycol inhalation. The implications of these effects for chronic use are not yet understood, but more research needs to be done before we know whether there might be some long-term respiratory effects. Third, there are low levels of a few specific volatile organic compounds. Of most concern is formaldehyde.

Nevertheless, given the thousands of chemicals in tobacco smoke, there is no doubt that vaping is much safer than smoking and that secondhand vapor is far less hazardous than secondhand smoke.

Before efforts to ban vaping in public places are justified, there need to be studies that document levels of actual human exposure to the vapor constituents in real-life settings using measurements in ambient air under realistic conditions. This laboratory study is useful in helping to define the maximum possible exposure levels, but real-life exposure is likely much lower. Before we can state that there is any risk of secondhand vapor to nonsmokers, we need to actually measure the exposure under realistic conditions.

Hence, my position is that there is currently no evidence to warrant banning vaping in public places.

The bottom line is that while further research is needed to precisely characterize any long-term risks that may be associated with vaping, the current evidence is sufficient to conclude that vaping is much safer than cigarette smoking. Health advocates should encourage, rather than dissuade, the use of electronic cigarettes as a smoking cessation or smoking reduction tool among current smokers, especially those who have failed to quit using traditional smoking cessation drugs.

CASAA Blasts Americans for Nonsmokers' Rights for Shamelessly Promoting Continued Smoking

Last week, I criticized a statement from Americans for Nonsmokers' Rights (ANR) that falsely claimed there is no evidence that electronic cigarettes can be useful tools for smoking cessation. This week, The Consumer Advocates for Smoke-free Alternatives Association (CASAA) is taking aim at ANR for promoting continued smoking by discouraging the use of electronic cigarettes for smoking cessation.

The original press release by ANR was entitled "Electronic (e)-cigarette manufacturers shamelessly promote untested product for use in "smokefree" environments; make false claims about efficacy as cessation device too." In a twist on who is acting shamelessly, the CASAA press release reads: "Americans for Nonsmokers' Rights shamelessly promotes continued smoking; makes false claims about hazards of electronic cigarettes."

According to the CASAA press release: "Americans for Nonsmokers' Rights (ANR), a proponent of the "quit or die" approach to smoking cessation, is misleading the public about hazards of electronic cigarettes, according to Elaine Keller, President of The Consumer Advocates for Smoke-free Alternatives Association (CASAA). A recent ANR press release also falsely claims that there is "a lack of independent peer-reviewed scientific evidence demonstrating the safety or efficacy" of electronic cigarettes for smoking cessation."

"FDA-approved nicotine patches, gum, lozenges, nasal sprays, and oral inhalers are referred to as Nicotine Replacement Therapy (NRT) products, but all these products are aimed at reducing the daily intake of nicotine to zero, and all have a 93% mid-year failure rate. In contrast, a growing body of scientific evidence is showing that providing smokers with a low-risk alternative such as electronic cigarettes is a much more effective way than nicotine-abstinence to achieve abstinence from smoking."

"BMC Public Health, a peer-reviewed scientific journal, published the results of an Italian pilot study that monitored modifications in smoking habits of 40 smokers not interested in quitting smoking. The researchers observed a 50% reduction of smoking in 32.5% of subjects and an 80% reduction in 12.5% of subjects. But they were astonished to discover that at the end of the 6-month study, 22.5% of these unwilling-to-quit subjects had completely stopped smoking." ...

"E-cigarette users report improvements in their health ranging from a reduction in COPD and asthma symptoms to better markers of cardiovascular health such as blood pressure and lipid measures." ...

"What I find most egregious about the ANR's recent press release," stated Keller, "is their claim that e-cigarettes 'pollute indoor air with detectable levels of carcinogens and other toxic chemicals,' when there is absolutely no indication that e-cigarettes pose any appreciable risk to bystanders. Tragically, these kinds of devious tactics may actually prevent smokers from saving their health and their lives by switching to this low-risk alternative."

The Rest of the Story

I agree that by scaring smokers about the health effects of electronic cigarettes, ignoring the evidence that these products have helped many smokers quit, and turning the other way towards clear evidence that many electronic cigarette users have experienced an immediate improvement in their lung function and respiratory symptoms, ANR is indeed "shamelessly promoting continued smoking." If they take ANR's advice, many smokers will be discouraged from trying to quit smoking using electronic cigarettes, and therefore will continue to smoke instead of either quitting or greatly reducing their cigarette consumption.

There is strong evidence that electronic cigarettes can play a useful role in smoking cessation or cigarette reduction. In the Italian study, 54% of smokers who were not motivated to quit were able to cut down on their smoking by at least half or quit completely within six months after trying electronic cigarettes.

There is also strong evidence that electronic cigarettes are much safer than regular ones. Instead of the more than 10,000 chemicals and more than 60 carcinogens in cigarette smoke, electronic cigarette vapor contains only a few chemicals, and those present are at much lower levels than in cigarette smoke. Thus, we know that vaping is much safer than smoking.

Of course we need more research to more precisely describe the exact health effects of electronic cigarettes and more importantly, to help find ways to reduce the levels of the few chemicals that have been detected. However, ANR's approach of scaring smokers about these products, without even mentioning the terrible hazards associated with cigarettes, is irresponsible.

ANR, along with much of the rest of the tobacco control movement, has lost its sense of perspective. Afraid of trace levels of carcinogens that have been detected in electronic cigarettes, the major national tobacco control organizations have gone overboard to condemn these products and discourage their use. The upshot of this approach is that these groups are essentially endorsing cigarette smoking over vaping. Better that smokers should continue using a deadly product whose risks are known than that they quit smoking by switching to a product whose risks have not been completely characterized, even though we know it is much safer than smoking.

That logic eludes me. In the case of most other groups that oppose electronic cigarette use, a readily apparent explanation exists: the financial connection of these organizations with Big Pharma. In ANR's case, there is no financial tie with Big Pharma that I am aware of. Instead, I believe the explanation is ideolgical.

Henry Ford Health System: A Role Model for Hypocrisy; Health of Patients and Employees is Self-Admittedly Not a Priority

According to an article at MLive.com, the Henry Ford Health System and Beaumont Health System - which employ a combined 42,000 people - have announced that they will no longer hire anyone who uses nicotine, including smokers and smokeless tobacco users, as well as electronic cigarettes.

According to the article: "Starting Jan. 1, 2013, the systems will not hire anyone who fails a nicotine screening. Applicants can reapply after six months, said Jay Holden, Beaumont’s vice president of human resources. 'We just felt this was the next step to take in terms of being a role model for health and wellness in our community,' Holden said. The hiring policies don’t apply to current employees, but now they are no longer allowed to use tobacco or smell of smoke during the workday. Employees who violate the policies can be disciplined or lose their job. Tobacco products include but are not limited to cigarettes, cigars, pipe tobacco, snuff, chewing tobacco and e-cigarettes. ... Henry Ford CEO Nancy Schlichting said in a statement that the 'health and well-being of our patients, employees and visitors is our top priority.'"

The Rest of the Story

Apparently, the health and well-being of its patients, employees and visitors is not its top priority. If that were the case, then by its own reasoning, the Henry Ford Health System would be getting rid of all of its smoking staff and replacing them with nonsmokers. After all, the reasoning behind its action is that it harms employees and patients to have staff who smoke. So if that's the case, then how can Henry Ford justify continuing to employ tobacco users?

By its own admission, Henry Ford is not making the health of its employees and patients a priority because it is refusing to replace its tobacco-using employees with smoke-free employees.

Why would Henry Ford continue to allow smokers to have interactions with its patients? Presumably, it would be a tiresome process to have to hire so many new employees. Well, then, health is apparently not the priority.

Moreover, Henry Ford is being highly hypocritical in its actions. It states that hiring only nonsmokers is critical to "being a role model for health and wellness" in the community." Fine, but by that very logic, Henry Ford is admitting that it is a terrible role model for health and wellness in the community because it continues to employ large numbers of smokers and other tobacco users.

After all, the Henry Ford Health System is discouraging people from trying to quit smoking. The mainstays of quitting smoking involve nicotine use, and by using nicotine, prospective applicants are not eligible for employment. If this were actually about health, Henry Ford should be encouraging electronic cigarette use and rewarding prospective employees who have succeeded in quitting smoking, not disqualify them and throw their job applications in the garbage.

Frankly, all of its talk about being a good role model and making health a priority is a bunch of crap. On the contrary, Henry Ford is sacrificing health, acting hypocritically, failing to make health a priority, and by its own admission, serving as a poor role model for health in the community.

Faulty Scientific Conclusions in Published Research: Top Two Papers of the Week

Paper #1 -  Restaurant Smoking Bans and Youth Smoking Rates

Our first paper is a study of the relationship between national restaurant smoking bans and youth smoking rates in 15 European countries. The purpose of the study was to determine whether the enactment of restaurant smoking bans at a national level leads to a reduction in youth smoking.

(see: Vuolo M. Placing deviance in a legal and local context: A multilevel analysis of cigarette use in the European Union. Social Forces 2012; 90(4): 1377-1402.)

The investigator used data from the Eurobarometer survey, administered in 2002, to determine the smoking status of a probability sample of 450 youth ages 15-24 in each of the 15 countries. At the same time, he used data from the World Health Organization to determine whether or not each of these countries had a restaurant smoking ban in place in 2002. Such bans were in place in 7 of the 15 countries.

The paper uses a multilevel model to determine the relationship between the presence of a smoking ban and the proportion of youth smokers, while accounting for the clustering of respondents by country and while controlling for a range of individual-level, regional, and national factors that might influence youth smoking.

Using a logistic regression, the paper finds a statistically significant odds ratio of 0.65 for smoking associated with living in a country with a smoking ban. This means that the sampled youth were 0.65 times as likely to smoke (i.e., they were significantly less likely to be regular cigarette smokers) if they lived in a country with a restaurant smoking ban.

The paper concludes that restaurant smoking bans cause a reduction in youth smoking.

The conclusion of this study was disseminated through the media, with the help of a press release entitled "Restaurant smoking bans help snuff out European youth smoking." The press release stated: "Teenagers and young adults are less likely to smoke when faced with restaurant smoking bans."

The Rest of the Story

Does anybody see the flaw in the study conclusion? Do you see why this conclusion is flawed? Can you identify a plausible alternative explanation for the observed findings?

The answer lies in the classic distinction between correlation and causation. While the paper undoubtedly demonstrated a correlation between the presence of restaurant smoking bans and lower smoking prevalence among youth, one cannot conclude that smoking bans cause lower smoking rates. 

Why? Because this is a cross-sectional study and the direction of causation is not clear. It is certainly possible that restaurant smoking bans lead to a reduction in youth smoking, but is it not also plausible that countries with lower smoking rates are the ones which are more likely to enact restaurant smoking bans in the first place? In other words, is it not possible that countries with stronger anti-smoking sentiment (as evidenced by having fewer smokers) are the ones most likely to lead the pack in banning smoking in restaurants?

There is, in fact, evidence that localities with stronger anti-smoking sentiment and lower smoking prevalence are indeed more likely to adopt smoking bans. We found this to be the case in our study of the diffusion of restaurant smoking bans in Massachusetts.

Unfortunately, the cross-sectional nature of the study precludes the opportunity to determine the direction of causality: do the smoking bans precede a drop in youth smoking, or do low rates of youth smoking predict which countries will adopt smoking bans?

The paper does not mention this limitation. Despite its fancy statistical analyses and use of complex, hierarchical, generalized linear models, the interpretation of the study findings fails to take into consideration the basic distinction between correlation and causation.

By the way, there is strong evidence that restaurant smoking bans do reduce youth smoking. In a study I published with colleagues in the Archives of Pediatrics & Adolescent Medicine in 2008, we reported the results of a longitudinal study which examined the behavior of nonsmokers over a 4-year period in towns with and without restaurant smoking bans. We also controlled for the baseline levels of anti-smoking sentiment in each town. Because of the longitudinal nature of the study, we were able to rule out the possibility that any observed association between smoking bans and youth smoking was due to the tendency of towns with lower youth smoking to begin with to adopt such bans. We found that youth were about 0.6 times as likely to have progressed to established smoking over the 4-year follow-up period if they lived in towns with strong restaurant smoking bans. 

Paper #2 - Using Cell Phones in the Middle of the Night and Youth Depression

Our second paper is a study of the relationship between the use of cell phones in the middle of the night and depression and suicidal thoughts among youth. While not related to smoking, it demonstrates the same principles as our first case study.

In this study, the authors conducted a cross-sectional investigation of the use of cell phones after having gone to sleep and the presence of depression or suicidal ideation among a sample of adolescents using a self-administered questionnaire.

(see: Oshima N, et al. The suicidal feelings, self-injury, and mobile phone use after lights out in adolsecents. Journal of Pediatric Psychology 2012.) 

Nocturnal mobile phone use was defined as use of a cell phone to talk or send e-mails after lights out. Self-reported symptoms of anxiety or depression were measured, as were the presence of suicidal feelings or self-harm behaviors.

The paper reports a significant association between nocturnal mobile phone use and mental health symptoms, suicidal feelings, and self-harm behaviors, even after controlling for length of sleep. It reports that: "Logistic regression showed significant associations of the nocturnal mobile phone use with poor mental health, suicidal feelings, and self-injury after controlling for sleep length and other confounders."

How do the authors explain this relationship? They conclude that it is the cell phone use that causes the poor mental health, suicidal feelings, and self-harm. Specifically, they hypothesize that: 

1. "looking at the bright display of mobile phone might have critical physiologic effects on sleep."

2. "The combination of looking at a bright display and doing an exciting task (e.g., playing a shooting game) may change the secretion of melatonin and therefore the quality of sleep."

3. "the electromagnetic field ... emitted from mobile phones could have an effect on noctural melatonin secretion."

4. "Another mechanism could be negative emotions or stress by the mobile phone use."

The paper concludes: "The present study indicates that the mobile phone use might make a focus of the psychological education to improve mental health in adolescents. ... focusing on change in nocturnal use might be feasible, for example, through health education in high schools."

The article's conclusions were disseminated by the media, and included headlines such as: "Using cell phones after lights out may put teens at risk for depression, suicide."

The Rest of the Story

Before we start invoking theories regarding the effect of electromagnetic fields and melatonin secretion, do you see an alternative explanation for the study findings?

Once again, the answer lies in the distinction between correlation and causation. And once again, the cross-sectional nature of the study introduces the possibility that reverse causation is present here. It might be that cell phone use in the middle of the night causes depression and anxiety, but might it also be the case that youths who are depressed or anxious have more trouble sleeping and are therefore more likely to be awake in the middle of the night to use their cell phones?

In other words, might nocturnal cell phone use be a signal of mental health problems such as depression or anxiety, rather than the cause?

We do know that disturbed sleep is a very common symptom of depression and anxiety. Thus, it is entirely plausible that youths with mental health problems would be more likely to exhibit nocturnal cell phone use because of their depression or anxiety.

The distinction here is of great importance because if we get the direction of causation wrong, we may deliver the wrong intervention. If the cell phone use is the cause of the depression, then yes, taking the cell phones away from teenagers may cure their depression problems and lower the rates of self-injury among adolescents. However, if it is the underlying depression or anxiety that is signalling nocturnal cell phone use, then taking the cell phones away is not going to have any effect and we risk wasting resources on an intervention that won't work and which may distract us away from addressing the real problem.

Thus, in this case, making a causal attribution error could actually have substantial adverse public health consequences.

Anti-Smoking Groups that Oppose Electronic Cigarettes Received an Additional $1.4 Million from Big Pharma, Beyond the $2.8 Million Revealed Earlier; Groups Repeatedly Failed to Disclose this Conflict of Interest

Previously, I revealed that anti-smoking groups which opposed electronic cigarettes received payments from Pfizer to the tune of $2.8 million. Today, I expose further financial links between Big Pharma and these anti-smoking groups, this time from the pharmaceutical company GlaxoSmithKline, maker of the smoking cessation drugs Zyban, Wellbutrin, Commit, NiQuitin, CQ/Nicoderm, CQ/Nicabate, and Nicorette.

According to GlaxoSmithKline's disclosure of contributions for the years 2009, 2010, 2011 and for the first two quarters of 2012, eight anti-smoking groups which have all called for a ban on electronic cigarettes received nearly $1.4 million during the period 2009-2012 from GlaxoSmithKline alone.

The contributions by organization are as follows:

American Cancer Society: $602,010
American Lung Association: $143,461
Association for the Treatment of Tobacco Use and Dependence: $5,000
Campaign for Tobacco-Free Kids: $400,000
American Heart Association: $115,000
American Medical Association: $15,000
American Academy of Pediatrics: $65,075
American Legacy Foundation: $10,000

Total: $1.36 million

To the best of my knowledge, these contributions were not disclosed in the public statements made by these organizations in opposition to electronic cigarettes.

The Rest of the Story

In my view, it is unethical for these organizations to make public policy pronouncements about electronic cigarettes - calling for their removal from the market - without disclosing their significant conflict of interest with pharmaceutical companies that manufacture competing products. Yet these groups have repeatedly made such statements without revealing that they have received money from Big Pharma.

For example, in this policy statement calling for the removal of electronic cigarettes from the market, the American Heart Association, American Cancer Society, American Lung Association, and Campaign for Tobacco-Free Kids fail to disclose that all of these groups have received money from pharmaceutical companies that manufacture competing smoking cessation products. Nowhere in the policy statement does it reveal that all four of these organizations have been heavily funded by Big Pharma, as exposed above.

In its own fact sheet on electronic cigarettes, the American Legacy Foundation also supports a ban on these products, but fails to disclose its own financial connections with Big Pharma. The fact that Legacy has a substantial financial conflict of interest is hidden from the public in this document.

Similarly, the Association for the Treatment of Tobacco Use and Dependence wrote a letter to the FDA and issued a press release demanding that electronic cigarettes be taken off the market, but failed to disclose that this organization has received money from Big Pharma and that at least two members of its executive board had financial relationships with pharmaceutical companies that manufacture nicotine replacement products and stand to lose out in a major way if electronic cigarettes become popular

The American Medical Association also issued a press release calling for the removal of electronic cigarettes from the market, and guess what? The AMA also failed to disclose the tens of thousands of dollars it has received from Big Pharma. Thus, readers and the media have no way of knowing that the AMA has a severe conflict of interest in making its policy recommendation.

Not to be outdone, the American Academy of Pediatrics also issued a press release calling for the removal of electronic cigarettes from the market, and it too failed to disclose its significant financial conflict of interest with Big Pharma.

Thus, it is a clean sweep. Every one of these eight anti-smoking organizations that have called for the removal of electronic cigarettes from the market has received money from Big Pharma companies that make competing smoking cessation products, yet none of these organizations disclosed these conflicts in making their public statements.

Why are these organizations hiding this critical information from the public?

And incidentally, these are some of the very same organizations that have blasted tobacco industry-affiliated scientists or organizations for not revealing their financial ties to the industry when making policy statements of their own.

Had the FDA or other policy makers at the federal or state level heeded these groups' advice, it would have been a public health tragedy, as thousands upon thousands of ex-smokers would have essentially been forced to return to cigarette smoking. The gains that they experienced in their health would have been reversed, and the policy would undoubtedly have resulted in disease and death for many relapsing smokers.

The rest of the story is that every one of the nine major anti-smoking groups that has called for the removal of electronic cigarettes from the market (Action on Smoking and Health was discussed earlier) has a significant financial conflict of interest with Big Pharma companies that manufacture competing smoking cessation products, yet every one of these nine organizations hid these conflicts from the public. Not only were these recommendations inappropriate and detrimental to the public's health, but the issuing of the recommendations was unethical because of the failure to disclose these important conflicts of interest.

New Commenting System in Place as Haloscan Will Be Discontinued as of Monday

The good news is that as my previous commenting system - Haloscan - will be defunct as of Monday, we now have a new commenting system in place: Disqus, which has received excellent reviews.

The bad news is that although Disqus advertised that comments from Haloscan could be migrated over, it has not worked so far. I have a request in to the support team and hopefully will be able to resolve it.

Fortunately, I've been able to save the XML file with all the comments, so I can search them if anyone has specific things they are looking for and I can even share the file with those who are interested, as a last resort if we are unable to get them imported.

The new commenting system required that I change the template, so we have a new look as well.

Potential Elimination of Early Childhood Programs in Kansas Demonstrates Folly of Tying Program Funding to Cigarette Revenues

Rather than spend the money on tobacco-related programs, as it was originally intended, most states have been diverting money from the Master Settlement Agreement to fund other essential government programs, plugging budget shortfalls and avoiding having to find other sources of revenue. As a result, I have been arguing that the Master Settlement Agreement was a public health disaster because it tied state fiscal solvency to continued high levels of cigarette consumption. If cigarette consumption falls substantially, then funding for essential government programs evaporates.

Yesterday, the Kansas City Star reported that the bulk of funding for early childhood programs in Kansas may go up in smoke because of an expected decrease in cigarette company revenues from the Master Settlement Agreement.

According to the article: "The Kansas Children's Cabinet and Trust Fund, which promotes early-childhood programs in the state, has been warned that it could lose up to 75 percent of its budget next year because of a drop in money from a national lawsuit against tobacco companies. Amanda Adkins, chairwoman of the cabinet, told the board Wednesday to prepare two recommendations — one that would assume the group would continue to receive $56 million in tobacco funds, with a second assuming it would receive only $12 million, The Topeka Capital-Journal reported. "That is just the hard reality in which we find ourselves," Adkins said. Kansas and 30 other states are currently in arbitration over provisions in the tobacco case settlement, leading to speculation that funding for the trust will be cut." ...

"The cabinet receives its funding from a 1998 settlement with major tobacco companies. One of the provisions of that settlement required states to force smaller cigarette manufacturers to pay a $6 per carton fee to keep them from undercutting the bigger companies. The major manufacturers contend the states haven't enforced that agreement."

The Rest of the Story

This story illustrates the brilliance of the Master Settlement Agreement (from the perspective of the cigarette companies). The states are now fiscally dependent on a steady stream of cigarette revenues. Any substantial drop in cigarette smoking threatens the state's fiscal situation. Thus, there is no incentive to take any action that will substantially reduce cigarette sales. Perhaps this is why we haven't seen many major anti-tobacco initiatives at the state level since the Master Settlement Agreement was signed. We've seen mostly minor initiatives that dilly dally around the margins, but very few which actually aim to put a major dent in cigarette sales.

Big Tobacco could not have scripted a happier (more favorable) ending to the Master Settlement Agreement saga. If they had sat down and tried to figure out a way to institutionalize tobacco consumption and to find a way to make the states become dependent upon tobacco sales for their economic survival, they could not have come up with a better scheme than this.

Out of their greed for political and economic gain, the Attorneys General have done a tremendous service for the tobacco companies. They have created a financial partnership between their states and Big Tobacco, by which the fiscal solvency of the states depends on continued high levels of cigarette consumption. They have destroyed the incentive for states to take any action that might substantially reduce cigarette use.

This explains why so few states are running effective tobacco control programs, why so few states are allocating their MSA money to anti-tobacco programs, and why Congress (aiming to protect the states they represent) crafted tobacco legislation that does very little to actually make a dent in cigarette consumption

In direct contrast to what the Attorneys General predicted, the Marlboro Man isn't riding into the sunset on Joe Camel. Instead, they're both having a beer and a good laugh together as they enjoy their trip to the bank.

Americans for Nonsmokers' Rights Publicly Claims that Electronic Cigarettes are Not Useful in Smoking Cessation, Despite Any Scientific Support for Its Statement

In a press release issued yesterday, Americans for Nonsmokers' Rights (ANR) publicly claimed that electronic cigarettes are not helpful for smoking cessation, despite the lack of any scientific evidence to back up its assertion (and in the presence of much scientific evidence to contradict its statement).

According to the press release, entitled "Electronic (e)-cigarette manufacturers shamelessly promote untested product for use in "smokefree" environments; make false claims about efficacy as cessation device too":

"Proponents of electronic cigarettes, commonly known as "e-cigarettes," are misleading the public about these products through paid press releases, advertorials, and online social media by making unsubstantiated claims about their benefits and offering deep discounts and coupons to entice people to use them, despite their potential health risks. E-cigarette manufacturers and proponents appear to be the PR machine behind an onslaught of daily press releases that tout the benefits of e-cigarettes despite a lack of independent peer-reviewed scientific evidence demonstrating the safety or efficacy of the products for smoking cessation." ...

"'What I find most egregious are the direct advertisements with false and misleading claims, including that e-cigarettes are effective smoking cessation devices' ... said Cynthia Hallett, MPH, Executive Director."

ANR goes further than this, however. It links to its fact sheet about electronic cigarettes, which claims that: "E-cigarettes are widely promoted as a way for people to quit smoking, but ... there is no scientific evidence that e-cigarettes are an effective cessation tool."

The Rest of the Story

There are two major problems with ANR's statements. First, ANR claims that e-cigarette companies are lying when they argue that these products can be helpful in smoking cessation. Thus, ANR is asserting that we know that e-cigarettes are not useful in smoking cessation. The problem is that ANR has no evidence to back up this assertion.

Can ANR cite a single study which demonstrates that electronic cigarettes are not useful in smoking cessation? If not, then how can it claim that e-cigarette companies are lying when they suggest to customers that these products may be able to help them with smoking cessation?

The second major problem is that ANR is lying when it states that there is no scientific evidence that e-cigarettes are an an effective cessation tool.

There is abundant evidence that literally thousands (if not tens of thousands) of electronic cigarette users have successfully used these products to either quit smoking or to cut down substantially on the amount that they smoke. A clinical trial has demonstrated that among smokers who were not motivated to quit, 54% were able to quit completely or to cut down by at least half on the amount they smoke.

In light of the existing clinical trial evidence, how can ANR deceive the public by asserting that there is no evidence for the potential of electronic cigarettes in smoking cessation? To do so is to completely ignore the results of the clinical trial evidence, as well as to ignore the multitude of anecdotal evidence based on personal reports of ex-smokers. Ignoring the anecdotal evidence may not be all that troubling, but ignoring the clinical trial evidence is gravely problematic.

Apparently, ANR either has not read or is ignoring the Polosa study, which provides exactly the kind of scientific evidence that it claims does not exist. In that study, electronic cigarettes were found to be useful in smoking reduction or smoking cessation in a majority of smokers who were not even motivated or attempting to quit.

If ANR had asserted that the effectiveness of electronic cigarettes in smoking cessation has not been proven, that would be fine. But to claim that there is no evidence that electronic cigarettes may be helpful in smoking cessation is simply a lie. 
 
The rest of the story is that ANR's press release complains about e-cigarette companies misleading or lying to the public, ANR itself is lying to the public in claiming that there is no evidence that e-cigarettes can help smokers quit and is misleading the public in asserting that electronic cigarettes are not useful for smoking cessation:

(1) It is incorrect to state that there is no evidence that these devices are useful in smoking cessation or reduction. Clinical trial evidence suggests that these products could be very useful, even among smokers with little motivation to quit.

(2) It is misleading to assert that electronic cigarettes have been shown not to be an effective smoking cessation aid. They are for many people. What remains to be seen is exactly what proportion of smokers will be successful in quitting or cutting down substantially.

No IVF for Smokers or Overweight Prospective Parents in Fife

According to an article in the Express, the National Health Service in Fife, Scotland is set to impose new rules by which couples will be denied in-vitro fertilization (IVF) treatment if either prospective parent smokes or if the woman has a body mass index of greater than 30.

Fife is apparently the first health board in Scotland to dictate that both partners must be nonsmokers in order to be eligible for IVF, as well as the first to dictate that the woman must be within certain body mass index parameters.

According to the article: "Dr Brian Montgomery, medical director of NHS Fife, said: 'Treatment criteria have been revised to improve the success of the treatment and the outcomes for mothers and babies. Both partners must be non-smokers and the female body mass index should be less than 30kg/m2.'"

The Rest of the Story

Well of course it will improve the success of the treatment and the outcomes if you limit the availability of the treatment to the healthiest couples. So why not also limit IVF to couples where both partners consume less than 150 grams of fat per day? And why just limit the BMI to 30? Why not set an age limit at 30 as well to improve the success and outcomes?

While the Fife National Health Service is at it, why not also limit IVF to persons who have a body mass index of at least 20, as underweight is known to reduce fertility? And why prohibit IVF for women who consume five or more drinks of alcohol per week, since that has been shown to significantly reduce fertility?

Other people who should not be eligible for IVF, in order to improve treatment success, include:

• those with autoimmune disorders, such as lupus, diabetes, and thyroid disease;
• those taking anti-depressants, which have an adverse effect on fertility; and
• those under high levels of mental stress, which severely impairs fertility.

Imagine the success rates and wonderful outcomes the Fife NHS could achieve with IVF therapy if it were only available to nonsmokers who were thin, but not too thin, consumed less than five drinks of alcohol per week, were less than 30 years old, consumed less than 150 grams of fat per day, did not have lupus, diabetes, or thyroid disease, were not taking anti-depressants, and were living relatively stress-free lives.

Revising the treatment criteria in that way would drastically "improve the success of the treatment and the outcomes for mothers and babies."

Not only that, but waiting times for treatment would decrease precipitously and lots of money would be saved. Plus, population growth would slow, which itself would yield significant societal benefits. It would truly be a win-win situation for all involved. 

Anti-Smoking Groups that Opposed Electronic Cigarettes Accepted Money to the Tune of $2.8 Million from Pfizer Alone in 2011-2012

The eight anti-smoking organizations that have opposed electronic cigarettes and called for their removal from the market pocketed a total of $2.8 million from Big Pharma's Pfizer during 2011 and the first half of 2012, according to figures being released today by The Rest of the Story.

Based on financial contribution reports published by Pfizer, the anti-smoking groups that have called for a ban on electronic cigarettes have received millions from the pharmaceutical manufacturer of Chantix, a smoking cessation product that stands to lose enormously if electronic cigarettes become increasingly popular. These organizations have repeatedly failed to disclose their financial interests in Big Pharma when making statements opposing electronic cigarettes.

The numbers compiled by The Rest of the Story are as follows (these represent Pfizer money received by each anti-smoking group during 2011 and the first two quarters of 2012):

American Academy of Pediatrics: $720,800
American Cancer Society: $252,750
American Heart Association: $136,000
American Lung Association: $190,250
Campaign for Tobacco-Free Kids: $100,000
American Medical Association: $857,500
American Legacy Foundation: $300,000
Action on Smoking and Health: $200,000

GRAND TOTAL: $2,757,300

The Rest of the Story

These figures illustrate how strong a financial interest the major national anti-smoking groups have in Big Pharma and help explain the entrenched position of these groups against electronic cigarettes. These data also help explain why these groups continue to promote drug therapy for smoking cessation despite evidence of its dismal rates of effectiveness.

These are the primary anti-smoking groups that called for the removal of electronic cigarettes from the market. Each of these groups, for example, submitted an amicus brief urging the D.C. District Court to allow the FDA to ban electronic cigarettes by regulating them under the Food, Drug, and Cosmetic Act, even in the absence of therapeutic claims made by product manufacturers. Had the recommended action of these groups been taken, literally thousands of ex-smokers would instead be smokers today because electronic cigarettes have been their means to achieve smoke-free status.

In their amicus briefs, none of these anti-smoking groups disclosed their financial ties to Big Pharma. Nor have they disclosed these severe financial conflicts of interest in public statements or website pages opposing electronic cigarette use.

Today, we find out that each and every one of these eight anti-smoking groups has accepted funding from Big Pharma and more importantly, from a Big Pharma company that manufactures a smoking cessation drug that is a direct competitor to electronic cigarettes.

Moreover, the amount of money involved is substantial. Each of these groups received at least $100,000 in an 18-month period alone, and the total amount of money received by the eight groups during this period from Pfizer alone exceeds $2.75 million.

Now it is starting to make sense why these groups opposed a product that is helping literally thousands of ex-smokers to remain smoke-free and helping hundreds of thousands more to greatly reduce the amount of cigarettes that they smoke.

When public health groups start to oppose public health measures, you need to start suspecting that money is playing a role. Today's revelation demonstrates that in the case of anti-smoking group opposition to electronic cigarettes, the money being received from Big Pharma is working to perfection. These groups are vigorously protecting pharmaceutical profits, even at the expense of severe harm to the public health and their abrogation of ethical integrity by failing to even disclose their conflicts of interest to the public.

ADA, AAP, AAFP, and ADA: Whose Side are You On? Rest of the Story Challenges Health Groups to Reject Big Soda Money After Coke and Pepsi Deny Link Between Sugar-Sweetened Beverages and Obesity

Today, the Rest of the Story has a question for the American Dietetic Association (ADA), American Academy of Pediatrics (AAP), American Academy of Family Physicians (AAFP), and American Diabetes Association (ADA2):

Whose side are you on?

The side of the public's health, or the side of helping to market sugar-laden soft drinks?

In response to a salvo of articles published in the prestigious New England Journal of Medicine which demonstrate -- using the most rigorous methodology available -- a strong link between the consumption of sugar-sweetened beverages and obesity, the Coca-Cola Company and PepsiCo, Inc. responded by denying that there is any link between sugar-sweetened beverage consumption and obesity.

In the first study, investigators examined the interaction between genetic predisposition to obesity and consumption of sugar-sweetened beverages. Their findings were as follows: "In two prospective cohorts of U.S. women and men, we found that greater consumption of sugar-sweetened beverages was associated with a more pronounced genetic predisposition to an elevated BMI and an increased risk of obesity. The findings were further replicated in an independent large cohort of U.S. women. In all three cohorts, the combined genetic effects on BMI and obesity risk among persons consuming one or more servings of sugar-sweetened beverages per day were approximately twice as large as those among persons consuming less than one serving per month. These data suggest that persons with greater consumption of sugar-sweetened beverages may be more susceptible to genetic effects on adiposity. ... Our findings further underscore the need to test interventions that reduce the intake of sugary drinks as a means of reducing the risk of obesity and related diseases."

The authors conclude that "these data support a causal relationship among the consumption of sugar-sweetened beverages, weight gain, and the risk of obesity."

In the second study, normal weight children ages 4-10 were randomized to receive 8 ounces of either a sugar-sweetened or sugar-free beverage each day at school. After just 18 months of providing merely 8 ounces of this beverage a day, there was a significant weight difference between the two groups. The researchers conclude that: "Masked replacement of sugar-containing beverages with noncaloric beverages reduced weight gain and fat accumulation in normal-weight children." They note that: "Children in the United States consume on average almost three times as many calories from sugar-sweetened beverages as the amount provided in our trial. We speculate that decreased consumption of such beverages might reduce the high prevalence of overweight in these children."

In the third study, obese and overweight adolescents were randomized either to receive or not receive an intervention which consisted mainly of providing them with non-caloric beverages. Children in the intervention group greatly reduced their consumption of sugar-sweetened beverages and after one year, had significantly lower body mass indices. The effect was attenuated after two years, with children in the intervention group still having lower weights, but there was not a statistically significant difference between the groups.

An accompanying editorial which synthesizes the findings of all three studies emphasizes that: "These randomized, controlled studies — in particular, the study by de Ruyter et al. — provide a strong impetus to develop recommendations and policy decisions to limit consumption of sugar-sweetened beverages, especially those served at low cost and in excessive portions, to attempt to reverse the increase in childhood obesity. ... Taken together, these three studies suggest that calories from sugar-sweetened beverages do matter. ... The time has come to take action and strongly support and implement the recommendations from the Institute of Medicine, the American Heart Association, the Obesity Society, and many other organizations to reduce consumption of sugar-sweetened beverages in both children and adults."

The Rest of the Story

Despite this strong evidence that sugar-sweetened beverages contribute to obesity, two major corporations which produce such drinks - the Coca-Cola Company and PepsiCo, Inc. - continued to deny any link between consumption of sugar-sweetened beverages and obesity. The companies responded by stating: "Sugar-sweetened beverages are not driving obesity. By every measure, sugar-sweetened beverages play a small and declining role in the American diet."

The statement of the soft drink companies is analogous to the repeated denials of the tobacco industry in past decades that its products contribute to lung cancer, heart disease, and chronic obstructive lung disease. In light of evidence to the contrary, the tobacco industry continued to deny any link between smoking and disease.

Now, the soft drink companies are acting exactly like Big Tobacco. In the face of strong evidence - from multiple independent studies - published in a reputable medical journal, these companies publicly deny that there is any link between consumption of sugar-laden beverages and obesity. Furthermore, they have the chutzpah to suggest that sugar-sweetened beverages play a small role in the American diet and that their consumption is going down.

These claims are in stark contrast to the boasting proclamations of the Coca-Cola Company that its sales volume grew 4% last year in North America. It's funny because I don't see anything in this investment report about how sugar-sweetened beverage consumption is declining in America. These companies are talking out of both sides of their mouths: one side for the damage control due to the New England Journal studies; the other side for their investors.

There's More to the Story

It would be great if this were the end of the story. But it doesn't end here.

Four public health organizations - the American Dietetic Association, American Academy of Pediatrics, American Academy of Family Physicians, and American Diabetes Association - have accepted money from the Coca-Cola Company and/or PepsiCo and have forged corporate partnerships with these companies, in some cases going so far as to call these companies leaders in the movement to reduce obesity.

American Academy of Family Physicians

The American Academy of Family Physicians (AAFP) has entered into a corporate partnership with the Coca-Cola Company, in which Coca-Cola is providing money to AAFP in return for public recognition, improvement of its public image, distraction of public attention away from the role of Coca-Cola's products in the obesity epidemic, a lucrative marketing opportunity for Coke, and ultimately, an increase in its bottom line (Coke sales).

The large expenditure on the part of Coca-Cola is very well spent, and should be applauded vigorously by Coca-Cola stockholders. The corporation is already starting to reap the benefits of this rare marketing opportunity.

On the web site that is apparently being supported by Coca-Cola, the AAFP actually goes so far as cautioning people not to necessarily limit their consumption of soda: "Sugar-sweetened drinks, such as fruit juice, fruit drinks, regular soft drinks, sports drinks, energy drinks, sweetened or flavored milk and sweetened iced tea can add lots of sugar and calories to your diet. But staying hydrated is important for good health."

American Academy of Pediatrics

The American Academy of Pediatrics accepted funding from Coca-Cola to sponsor its "Healthy Children" web site. On that site, the AAP states that the Coca-Cola Company is committed: "to better the health of children worldwide."

Whatever Coca-Cola contributed to the American Academy of Pediatrics to garner that statement and recognition as a leader in the child health movement internationally was nowhere near enough. This is blatant prostitution, where the AAP is essentially selling its site to the highest bidder. Do you want to be recognized as a leader in children's health internationally? Simply pay off the AAP. Never mind the fact that you market a product which is a major contributor toward childhood obesity.

American Dietetic Association

According to a press release issued on August 31 by the Coca-Cola Company, the American Dietetic  Association has accepted $125,000 from Coca-Cola. This donation was originally reported over at the Fooducate blog in a post entitled "Here's How Coke is Buying the Silence of Health Organizations. For Pocket Change."


I defy anyone to find information on the ADA's web site about the billions of dollars that Coke is spending annually to market its sugar-laden products. Given the role of soda marketing in the obesity epidemic, that is what I call total silence.

In fact, the public's health would be better served if the ADA were completely silent. The media outreach that it is doing stands in opposition to what many of us in public health are trying to accomplish through policy measures to reduce soft drink consumption. Concurrent with its acceptance of money from Coca-Cola, the ADA has actually become an enemy of critical public health measures to reduce obesity, not merely an innocent bystander, and at the far extreme from being a leader in the nutrition policy movement.

American Diabetes Association

According to a press release issued on August 31 by the Coca-Cola Company, the American Diabetes Association has accepted $125,000 from Coca-Cola. This donation was originally reported over at the Fooducate blog in a post entitled "Here's How Coke is Buying the Silence of Health Organizations. For Pocket Change."

The Challenge

Today, I am issuing a challenge to the American Academy of Pediatrics, American Academy of Family Physicians, American Dietetic Association, and the American Diabetes Association:

Now is your chance to change sides on this issue. Right now, you have chosen to take the side of aiding in the marketing of sugar-laden soft drinks and other sugar-sweetened beverages by partnering with corporations that are spending millions of dollars to market these drinks and to oppose every reasonable measure introduced at the state and local level to improve school nutrition. You have chosen to serve as a pawn in the marketing and public relations efforts of corporations that to this day, are publicly denying that there is even a link between sugar-sweetened beverage consumption and obesity. And which even have the gall to publicly claim that sugar-sweetened beverages play a minor and declining role in the American diet, despite their investor reports which boast the exact opposite.

I challenge these four organizations to switch sides, and to come over to the side of the public's health by renouncing their corporate partnerships with Coca-Cola and Pepsi, returning their checks, and vowing not to accept funding from these companies.

Political Corruption in St. Louis Health Department Opens Door: Now All Bars and Restaurants Can Ask for Exemptions

The St. Louis health department's decision to cave in to pressure from wealthy and politically connected constituents at the Missouri Athletic Club by agreeing not to enforce the law as it regards that establishment has now opened the door to all St. Louis bars and restaurants to request similar arrangements. After all, a precedent has now been set that for no health-related justification at all, the City of St. Louis is willing to look the other way if your business complains loudly enough, or at least has the right political connections.

As our own Bill Hannegan has pointed out, the Missouri Athletic Club kicked off its negotiations with the city health department by actively flouting the ordinance. In how much better a position, then, are the hundreds of bars and restaurants that have been following the law? Should they not be in a better position to negotiate with the city, since they have taken the moral high ground and diligently followed the law? Should they City not consider their good behavior in negotiating with these establishments? And if the bad behavior of the MAC resulted in the city agreeing to look the other way, should not the good behavior of these other bars be rewarded by the city happily looking the other way?

Now that it has established that businesses can successfully negotiate with it to get out of having to follow health ordinances, the St. Louis department of health is going to need to set up an "Exemptions Department" to handle all these negotiations. The line will be out the door.

St. Louis is now the only city I am aware of where if you don't like a health regulation, you can negotiate with the city health department to be excused from having to adhere to the law.

The Rest of the Story

The irony of the situation was not lost to cartoonist Dan Martin of the St. Louis Post-Dispatch who mockingly depicts health director Pam Walker sitting at a desk signed "Smoking ban exemption application division," taking requests from local businesses to get out of having to comply with the smoking ban.

European Union Poised to Ban Electronic Cigarettes, Forcing Smokers to Be Able to Use Only the Most Hazardous Possible Nicotine-Containing Products

According to a working document leaked to the Tobacco Journal International, the European Union's revised Tobacco Products Directive contains a recommended ban on the marketing of all electronic cigarettes. More broadly, the Directive contains a ban on the marketing of all smokeless nicotine-containing products with the one exception of Swedish snus. This means that not only electronic cigarettes, but dissolvable tobacco products, orbs and strips, and all smokeless tobacco other than Swedish snus would also be banned.

According to the leaked draft of the Directive: "Only NCP [nicotine-containing products] that are authorised as medicinal products on the basis of their quality, safety and efficacy, and with a positive benefit/risk balance are allowed on the market. Otherwise, marketing of NCP is banned."

Because electronic cigarettes (as well as other nicotine-delivering products such as dissolvable tobacco products) have not been authorized as medicinal products (i.e., drugs), they would not be allowed on the market under this draft directive.

Christopher Snowdon first broke this story last Friday. At that time, no actual text of the document was available so I chose not to blog this. Now that Tobacco Journal International has released the text of the leaked document, I can confirm that the directive does indeed recommend a ban on all smokeless nicotine-containing products (other than Swedish snus).

The Rest of the Story

What the Tobacco Products Directive is basically saying is that the EU wants to make sure that the most hazardous nicotine-containing products (cigarettes) - and only the most hazardous nicotine-containing products - remain on the market and available to Europe's nicotine users. This is essentially a strategy to maximize disease and death in Europe.

Does it not make more sense to ensure the availability of the safest nicotine-containing products, allowing them to compete with cigarettes and to encourage smokers to quit? This is especially true of electronic cigarettes, which contain no tobacco, have a decent toxocological profile, and have been shown to result in high rates of cessation or smoking reduction, even among unmotivated smokers.

The strategy also ensures that the least effective smoking cessation products remain available to smokers in Europe and that more promising strategies (such as electronic cigarettes and any subsequent innovations based on the e-cigarette concept) do not see the light of day.

This proposal protects the interests of the cigarette and pharmaceutical industries at the expense of the public's health.

In a column entitled "Smokers only allowed to buy deadly tobacco cigarettes in New Zealand? – Ministry of Health moves to ban nicotine electronic cigarettes," Dr. Murray Laugesen explains why a similar proposal by the New Zealand Ministry of Health that would ban electronic cigarettes makes no sense and would harm the public's health. According to the article: "Dr Laugesen says it is clearly not in the public interest to run a prosecution against sellers of nicotine e-cigarettes which the Ministry of Health itself says are "far safer" than tobacco cigarettes, when banning them is expected to send hundreds of users back to smoking tobacco cigarettes.  In 2010 End Smoking NZ identified e-cigarettes as one of the top four policies for ending tobacco smoking in New Zealand in an article in the New Zealand Medical Journal."

Dr. Laugesen goes on to write: "Persistent tobacco smokers face a lifetime 50 percent risk of dying early, and according to End Smoking NZ are entitled to have access to buy whatever nicotine product would most help them quit. Nicotine products do not cause cancer or heart disease, unlike smoked tobacco products. If there is a tiny risk from nicotine, many smokers are prepared to take that risk, rather than run the deadly risks of smoking tobacco. Smokers interested in switching to nicotine electronic cigarettes should be able to buy them over the counter at any dairy or supermarket, just like tobacco cigarettes."

I can only echo Dr. Laugesen's comments and note that they apply equally well to the European Union.

Political Corruption in the Gateway City: If St. Louis Health Department Won't Stand Up for Health, Then What Will It Stand Up For?

In my 25 years in tobacco control, I have seen many cities and towns grant exemptions from smoking bans to certain types of establishments. But never have I seen a health department unlawfully exempt a particular establishment, thus willfully violating the law.

That all changed this week, when St. Louis city health department director Pam Walker decided to allow smoking at the downtown Missouri Athletic Club, in direct violation of the ordinance passed by the St. Louis City Council. That ordinance bans smoking in all bars and restaurants, including private clubs, unless there are no employees. Since the Missouri Athletic Club has multiple employees, it is subject to the smoking ban. However, after threatening a lawsuit (that would have no legal basis) and flexing its muscles, and after some apparent back-room deal-making, the health department announced that it would allow the Missouri Athletic Club to violate the law.

What is this? Chicago in the 1960's? Can wealth and prestige simply buy off policy makers? Apparently so.

David Hunn, the reporter who covers St. Louis government and politics for the St. Louis Post-Dispatch, covered this important story in yesterday's paper.

He wrote: "No other city in the country has enacted a smoking ban and then willingly broken the ban to make an exception for one business, said Dr. Michael Siegel, who has tracked tobacco laws for 25 years. Siegel, a professor at Boston University’s School of Public Health, said city health director Pam Walker’s decision to allow smoking at downtown’s Missouri Athletic Club is the first of its kind. “I’ve never seen a health department essentially fight to provide an exemption for an entity,” Siegel said. He doesn’t even consider Walker’s decision an exemption. If the city scrapped the existing law, wrote a new bill, added an exemption for the MAC, and got it passed into law by the Board of Aldermen, that’d be one thing, Siegel said. “This is simply looking the other way,” he said. “They’re essentially saying they’re not going to enforce the legislation for this particular business.” “It really sours the entire integrity of the health department, I think,” he said."

If you haven't already seen it, please read my previous coverage of this issue:

In Backroom Deal, St. Louis Health Director Agrees to Exempt Missouri Athletic Club from Smoking Ban (link)

St. Louis Health Director Shows that Money and Lawsuit Threats Do Talk, Suspends Smoking Ban for One Business Only (link)

The Rest of the Story

If the city of St. Louis wants to avoid being guilty of political corruption and the St. Louis Department of Health wants to retain any integrity, this decision needs to be revoked immediately and the law needs to be enforced as written. Otherwise, St. Louis is going to quickly become the laughing stock of public health nationally.

The rest of the story is that in one of the most egregious examples of political corruption affecting public health in my lifetime, the St. Louis Department of Health has succumbed to political pressure and agreed to knowingly look the other way in the face of recurrent and willful violation of city law.

In my opinion, not only is this a public health travesty, but the Department of Health and the Mayor's office need to be investigated by the Missouri Attorney General's office. Willful failure to enforce the law is in my view an abrogation of the responsibility to uphold the law.

Note: By stating that the health department was essentially "bought off," I am not suggesting that there was any payment of money in exchange for this agreement. Instead, I am arguing that by virtue of the wealthy status of the Downtown Athletic Club and its membership, this business was able to achieve the equivalent of an exemption, while other businesses that have less money and are less well politically connected, have no hope of getting the health department to look the other way. 

Providence Mayor Praises Himself for Banning Flavored Cigars, But He Fails to Remove Exemption for Most Flavored Cigarettes

Claiming that "we will not let our children be harmed by the tobacco industry’s deceitful tactics to attract new users," Providence's mayor and city council president praised themselves - in a letter to the editor of the New York Times - for closing a loophole in the FDA tobacco regulations which permit the sale of flavored cigars.

The FDA bans the sale of some flavored cigarettes, but this ban does not extend at all to cigars. To close part of that loophole, Providence enacted an ordinance that bans the sale of flavored cigars.

Praising themselves, the mayor and city council president wrote: "Like New York City and Maine, Providence, R.I., is fighting to protect our children from tobacco. We took the ruling by the Food and Drug Administration banning flavored cigarettes a step further by banning the sale of other candy- and fruit-flavored tobacco products. Tobacco products that entice children with flavors like bubble-gum and chocolate will no longer be sold in stores in Providence. Beyond cigars, there are many emerging tobacco products that deceive people of all ages with their mint and colorful candy-like packaging. Most smokers begin before they turn 18, and we will not let our children be harmed by the tobacco industry’s deceitful tactics to attract new users. The City of Providence is standing strong to protect the health and wellness of our youth. Although our efforts have drawn a lawsuit from the tobacco industry, we will not back down."

The Rest of the Story

If the city of Providence is standing strong to protect the health and wellness of its youth, then why did it not close the biggest loophole in the FDA tobacco law: the exemption of most flavored cigarettes, including those most favored by the youth of Providence, Rhode Island?

If the city of Providence is fighting to protect its children from tobacco, then why did it not choose to ban the sale of all flavored cigarettes, rather than to focus its efforts on cigars, which are far less of a long-term health problem for Providence's youth than cigarette smoking?

How can Providence continue to allow flavored cigarettes to attract, seduce, and addict the majority of its youth smokers, and at the same time, praise itself for putting an end to the tobacco industry's attempts to attract new users?

The rest of the story is that the mayor and city council president are not truly standing up to Big Tobacco. They are not truly protecting their children from tobacco. They are not truly putting an end to the tobacco industry's attracting new users.

Instead, they are taking a politically easy step that ignores the larger problem: about 50% of Providence's youth smokers are using flavored cigarettes -- namely, menthol cigarettes. And about this problem, the Mayor and City Council chose to look the other way.

Rather than close the loophole which exempted menthol cigarettes from the FDA's flavored cigarette "ban," the Providence City Council chose to look the other way, while distracting attention from its decision to ignore the problem by praising itself for getting rid of chocolate cigars.

St. Louis Health Director Shows that Money and Lawsuit Threats Do Talk, Suspends Smoking Ban for One Business Only

Proving that policy makers can still essentially be bought off by wealthy and influential individuals and scared off by the veiled threat of lawsuits, City of St. Louis Health Director Pam Walker has granted an exemption to a private club that serves wealthy people in the city, while requiring all other bars, restaurants, and private clubs to remain smoke-free as called for by a city ordinance.  

A smoking ban went into effect in St. Louis in 2011, barring smoking in all restaurants and other places of employment, but not including bars whose square footage is less than 2000 or private clubs without employees. The Missouri Athletic Club in St. Louis does not qualify as a small bar, nor as a private club without employees. Thus, it is subject to the smoking ban, or at least it is supposed to be subject to the ban.

However, after threatening the city with a lawsuit and apparently holding backroom meetings with the city, the downtown Missouri Athletic Club was able to win an exemption from the smoking ban from the City Health Department.

City health department director Pam Walker acknowledged that she was granting an exemption to the aristocratic club earlier this week.

The Rest of the Story

There is no ambiguity about the law and whether it applies to the Missouri Athletic Club. It applies. The Club is neither a private club without employees nor is it a bar. Thus, it is subject to the ban. Or ... it should be.

Clearly, what happened here is exactly what Bill Hannegan (one of our own Rest of the Story readers and commenters) said happened: This is the result of a backroom deal that, with no legal basis, excluded one establishment from the law in order to appease a privileged and influential sociopolitical class of individuals: the city's politicians.

This is the worst kind of political elitism. It is exactly the kind of back-door negotiating between government officials and private aristocracy that democratic polity despises.

And it therefore the worst kind of hypocrisy. The St. Louis Health Department is basically saying that employees and the public need to be protected from the hazards of secondhand smoke, but not if the establishment is an elitist one which serves politicians. Then, public health principles go out the window and a backroom deal can buy you an exemption from the law.

In St. Louis, the law only applies, I guess, to "lower-class" establishments that serve the 99%. Elitist joints that serve the 1% aren't subject to the same laws. They can essentially buy their way out of having to follow the law by using their political, economic, and legal clout. Threaten a lawsuit and be able to back up the threat with money and the public health department will back down. No longer will the public health principles of protecting people from the hazards of secondhand smoke be paramount.

This is hypocrisy at the highest level. If the Missouri Athletic Club is granted an exemption when there is no lawful exemption written into the city ordinance, then why shouldn't Pat's Bar & Grill and hundreds of other establishments in the city be allowed to negotiate for exemptions through their own backroom deals?

As Hannegan asks: "It opens the door for bars to petition for their own exemption. If she can do this for the MAC, why can’t she do this for other establishments?"

Why didn't the ordinance simply specify (in a new section - section 17) that any establishment with political and economic clout could apply for an exemption from the law through a special exception that could be arranged through a backdoor deal? That's exactly what the Health Department is doing, and that is why its director - Pam Walker - has joined a private club of her own - the Colonel Benjamin Church Hypocrisy Hall of Shame - as a gold club member.

Note: By stating that the health department was essentially "bought off," I am not suggesting that there was any payment of money in exchange for this agreement. Instead, I am arguing that by virtue of the wealthy status of the Downtown Athletic Club and its membership, this business was able to achieve the equivalent of an exemption, while other businesses that have less money and are less well politically connected, have no hope of getting the health department to look the other way.

Campaign for Tobacco-Free Kids' Argument that Sixth Circuit Validated Graphic Warning Labels is Not Entirely Correct; Supreme Court Will Never Affirm Sixth Circuit's Reasoning on the Actual Proposed Warning Labels

Last month, I reported on the U.S. Court of Appeals for the District of Columbia upholding a district court decision that invalidated the graphic cigarette warning labels proposed by the Food and Drug Administration (FDA).

The Campaign for Tobacco-Free Kids has argued that the D.C. Circuit's ruling is "wrong on the law" and "wrong on the science" and urged the FDA to appeal to the Supreme Court.

The Campaign wrote: "The Justice Department should quickly appeal today's ruling by the U.S. Court of Appeals for the D.C. Circuit that struck down the large, graphic cigarette warnings required by the landmark 2009 law giving the FDA authority over tobacco products. Today's ruling is wrong on the science and law, and it is by no means the final word on the new cigarette warnings. The only other appellate court to consider the issue, the U.S. Court of Appeals for the Sixth Circuit, upheld the graphic warnings requirement in March. ... The Sixth Circuit found that the law's requirements for graphic warnings "are reasonably related to the government's interest in preventing consumer deception and are therefore constitutional." That court found that the warnings "do not impose any restriction on Plaintiff's dissemination of speech, nor do they touch on Plaintiffs' core speech. Instead, the labels serve as disclaimers to the public regarding the incontestable health consequences of using tobacco."

There seems to be a widely-held perception that the D.C. and Sixth Circuit court rulings are in direct contradiction. Because of this, many anti-smoking groups have played down the significance of the D.C. Court's ruling, asserting that the Sixth Circuit upheld the graphic warning labels and that there is therefore a good chance that the Supreme Court will side with the Sixth Circuit's opinion.

The Rest of the Story

Not so fast.

While there clearly is a discrepancy in the two Circuit Court rulings, making it very likely that the Supreme Court would take the case if the FDA appeals, it is not as simple as arguing that the Sixth Circuit approved the graphic warning labels proposed by the FDA.

Importantly, the Sixth Circuit was ruling on the general principle of the use of graphic warning labels on cigarette packages, rather than on the specific warning labels proposed by the FDA. The Court ruled that warning labels, even those that incorporate pictures to enhance the understandability of the warning, are factual and non-controversial disclosures that are subject to only light scrutiny under Zauderer. There must only be a rational basis for the requirement, which there clearly is with regard to warning people about the hazards associated with cigarette use.

However, the Court did not rule on the specific warning labels proposed by the FDA and perhaps did not even see the labels that FDA proposed, which are not mentioned in the decision. Instead, the decision relates to textual warnings that are accompanied by pictures used to illustrate the warnings, such as one might encounter in a medical textbook.

The Court writes: "Without any specific graphic images to challenge, Plaintiffs’ argument is and must necessarily be that the graphic warning requirement on its face violates the First Amendment." Thus, the Court is making it clear that it is only evaluating the general concept of requiring a graphic component to a warning label, not the specific warning labels proposed by the FDA.

Furthermore, the district court made it clear that it, too, was ruling just on the general concept of requiring pictures to accompany a warning: "In finding that the new warnings were permissible under the First Amendment, the court stated that it “does not believe that the addition of a graphic image will alter the substance of [the new warnings], at least as a general rule. Accordingly, . . . the Court finds that the warning requirement is [constitutional]."

Moreover, the Court writes: "Supreme Court precedent dictates that we review Plaintiffs’ challenge to
the Act’s warnings as a facial one." Again, the Sixth Circuit makes it exquisitely clear that it is ruling only on the idea of requiring pictures as part of a warning, not on the specific graphic warning labels designed by the FDA.

The actual meaning - and limited scope - of the Sixth Circuit decision is made explicit by the Court's own language: "Because Plaintiffs bring a facial challenge to the warning requirements, our concern is not the specific images the FDA chose—those are under review elsewhere—but rather whether
Plaintiffs can show that “ no set of circumstances exists under which [the statute] would be valid, or that the statute lacks any plainly legitimate sweep.”"

Obviously, this is a very broad criterion, and it is almost certainly possible to demonstrate at least one example of a pictorial warning label that would convey factual and non-controversial information. In fact, the Sixth Circuit court is able to imagine such a situation: the use of pictures such as in a medical textbook.

Here is what the Sixth Circuit is imaging in upholding the graphic warning label requirement: "Students in biology, human-anatomy, and medical-school courses look at pictures or drawings in textbooks of both healthy and damaged cells, tissues, organs, organ systems, and humans because those pictures convey factual information about medical conditions and biological systems."

What the Sixth Circuit has in mind is a textual warning accompanied by a simple demonstrative picture: "a picture or drawing of a nonsmoker’s and smoker’s lungs displayed side by side; a picture of a doctor looking at an x-ray of either a smoker’s cancerous lungs orsome other part of the body presenting a smoking-related condition; a picture or drawing of the internal anatomy of a person suffering from a smoking-related medical condition; a picture or drawing of a person suffering from a smoking-related medical condition; and any number of pictures consisting of text and simple graphic images."

The actual graphic warning labels proposed by FDA go far beyond these simple descriptive pictures. Moreover, they include a 1-800 telephone number designed to refer smokers for medical treatment, something that was clearly not an example conjectured by the Sixth Circuit.

The FDA is not going to win any argument that its actual proposed graphic warning labels, accompanied by the 1-800-QUIT-NOW placard, are merely pieces of factual information. The FDA itself admits that the warnings are intended to convince smokers to quit, and the inclusion of the 1-800 referral number cinches this fact.

In other words, the Supreme Court will never apply the Zauderer standard to the actual warning labels proposed by the FDA, rendering the Sixth Circuit's decision almost moot with respect to the Supreme Court's review.

The rest of the story is that the Sixth Court's opinion was merely a facial review of the general idea of requiring a simple picture as part of a textual warning, not an evaluation of the actual graphic warning labels proposed by the FDA. The simple, pictorial, graphic warning labels envisioned by the Sixth Circuit appeals court are far removed from the emotion-invoking, medical referral-providing warnings promulgated by the FDA. The U.S. Supreme Court will never apply the Zauderer standard to these graphic warning labels. While the Sixth Circuit decision does make it more likely that the Supreme Court will take the case, it does not in any way provide legal reasoning that can play a role in the Supreme Court's consideration of the issue at hand. It is the Campaign for Tobacco-Free Kids, then, that I believe is "wrong on the science" and "wrong on the law."

American Dietetic Association to Hand the Microphone to Coca-Cola at Its Annual Conference; It's Like an Anti-Smoking Group Inviting Philip Morris to Present on Its Initiatives to Reduce Youth Smoking

On Sunday, October 7th, the American Dietetic Association will hold a press conference at its annual meeting in Philadelphia to highlight the work of groups which it claims are upholding the organization's "vision of optimizing the nation's health through food and nutrition."

Naturally, many of you are now curious as to who these groups are which are upholding the vision of optimizing the nation's health. The answer, according to the American Dietetic Association, is:

The Coca-Cola Company: A company which sells 1.25 billion bottles of Coke each year and spends $4.5 million annually lobbying against public health measures to improve nutrition and reduce obesity

PepsiCo: A company whose signature sugar-laden soft drink is responsible for $20 billion in annual sales and which spends $1.7 million annually lobbying against public health measures to improve nutrition and reduce obesity.

The Rest of the Story

What do these two companies have in common? Why are they being honored as champions of the public's health rather than one of the leading organizations that actually fights soft drink consumption and obesity, such as the Rudd Center for Food Policy and Obesity or one of the hundreds of other organizations devoted to improving nutrition and fighting obesity?

The answer is simple...

... money.

Both the Coca-Cola Company and PepsiCo are heavy funders of the American Dietetic Association. This money has not only purchased the ADA's silence on the corporate role in the obesity epidemic and the importance of policy change, but has also purchased a marketing endorsement from the ADA and a golden opportunity to address the media - with the ADA's help - as a leader in the movement to improve nutrition.

Had these sponsorships by Coca-Cola and Pepsi merely bought the ADA's silence on the role of these corporations in the obesity epidemic, it would have been bad enough. But far from being silent, the ADA is now serving as an active marketing arm for these soft drink companies, and therefore, for soft drinks.

This is a dream come true for Big Soda. They now have the ADA as a marketing partner.

vision of optimizing the nation's health through food and nutrition. Read more: http://www.eatright.org/FNCE/content.aspx?id=6442469221&terms=coca-cola

vision of optimizing the nation's health through food and nutrition. Read more: http://www.eatright.org/FNCE/content.aspx?id=6442469221&terms=coca-cola

American Diabetes Association and American Dietetic Association Sell Themselves Out, Sacrificing their Health Mission for Money

Two national organizations that were previously committed to improving the public's health by fighting unhealthy eating have sacrificed their health missions, selling out to Big Soda in order to yield tens of thousands of dollars, while at the same time allowing themselves to be used as a public relations and marketing tool for the Coca-Cola Company.

According to a press release issued on August 31 by the Coca-Cola Company, the American Diabetes Association has accepted $125,000 from Coca-Cola and the American Dietetic Association has accepted $100,000 from Coca-Cola. These donations were originally reported over at the Fooducate blog in a post entitled "Here's How Coke is Buying the Silence of Health Organizations. For Pocket Change."

In the Fooducate post, Hemi Weingarten writes: "This is simply unfathomable. How can the American Diabetes Association in its right mind take money from the company that contributes the most to this terrible disease? More than 20 million Americans suffer from Type 2 diabetes, and most of them acquired it from overloading their bodies with junk foods and drinks. Liquid candy like Coke shares the responsibility. Another 75 million Americans are well on their way to diabetes because of excess consumption. Please, please, please, don’t bring up the “moderation” angle, or tell us that there are no bad foods (drinks). Sugary soft drinks cannot be consumed in moderation when they are pushed into our faces with $10,000,000,000.00 worth of marketing spend every year. Do you really think a measly education pamphlet or 30 minute community center class has a chance against the marketing might of Coke’s top notch ad agencies?"

"Coke has paid less than a hundredth of a percent of its marketing budget to buy the silence of these organizations and their leaders. How can they now be firm and adamant when they shook hands with Coke executives and took their money? The American Dietetic Association has an annual budget of around $100 million. Does it really need to take money from Coca Cola?"

According to the Fooducate blog, the American Dietetic Association responded to the post, arguing that the Coca-Cola donation is not buying their silence: "Ryan O’Malley, spokesperson for the American Dietetic Association (now know as the Academy of Nutrition and Dietetics) emailed us with the following response:

…to say that Coca-Cola’s donation is buying our silence is just factually inaccurate and irresponsible. To demonstrate, here are several examples from the Kids Eat Right website itself encouraging families to limit and stop their consumption of sugary beverages and soft drinks.

http://www.eatright.org/kids/article.aspx?id=6442468566,  
http://www.eatright.org/kids/article.aspx?id=6442467733
You just cannot honestly say that their support buys our silence, as we always have and will continue to encourage consumers to reduce and even omit sugary beverages from their diet."

The Rest of the Story

Actually, Weingarten has understated the case against the American Dietetic Association (ADA) and the American Diabetes Association (ADA2). Not only has their silence been bought, but they now have effectively become marketing arms of the Coca-Cola corporation. By accepting Coca-Cola's money, the ADA and ADA2 are allowing Coca-Cola to use them as part of its marketing plan. Corporate sponsorships not only buy silence from public health organizations, but they also allow the companies to boast about their support of "health causes," thus boosting their public image and ultimately, their bottom line: sales.

While O'Malley tries to argue that the ADA's silence has not been bought because the organization is apparently "bold" enough to come out publicly and suggest that families limit their consumption of soft drinks, the ADA has never supported evidence-based policies that have been shown to actually reduce soft drink consumption, such as taxes on soft drinks. In fact, the ADA has virtually opposed soft drink taxes. Moreover, the ADA has been silent on Coca-Cola's role in lobbying against almost every effective school nutrition bill in state legislatures. And I defy anyone to find information on the ADA's web site about the billions of dollars that Coke is spending annually to market its sugar-laden products. Given the role of soda marketing in the obesity epidemic, that is what I call total silence.

In fact, the public's health would be better served if the ADA were completely silent. The media outreach that it is doing stands in opposition to what many of us in public health are trying to accomplish through policy measures to reduce soft drink consumption. Concurrent with its acceptance of money from Coca-Cola, the ADA has actually become an enemy of critical public health measures to reduce obesity, not merely an innocent bystander, and at the far extreme from being a leader in the nutrition policy movement.

The American Diabetes Association's acceptance of money from Coca-Cola is perhaps even more mind-boggling. If there is a way that the ADA2 could more effectively undermine its message about the role of diet in diabetes prevention and treatment, I certainly can't think of one.

Corporate marketing - including the billions of dollars spent annually by Coca-Cola - undeniably contribute significantly to the public health problems of poor nutrition, obesity, and diabetes. The silence of the American Dietetic Association and American Diabetes Association has been effectively bought by Coke because these organizations are not going to highlight the role of this corporate marketing in the causation of the public health problems which they purport to be fighting. Instead, they will continue to focus on education: an approach we know is failing as sugar-sweetened beverage consumption increases yearly despite all of the education we are doing.

Hemi Weingarten said it best: "Sugary soft drinks cannot be consumed in moderation when they are pushed into our faces with $10,000,000,000.00 worth of marketing spend every year. Do you really think a measly education pamphlet or 30 minute community center class has a chance against the marketing might of Coke’s top notch ad agencies?"

We can now rule out the American Dietetic Association and American Diabetes Association as public health partners in the fight to take on the Big Soda industry and counteract its marketing. Instead, these organizations are now serving as pawns in Big Soda's marketing strategy. And even worse, the ADA is praising Coca-Cola and helping market its sugar-laden soft drinks by helping to improve the company's public image.

The American Diabetes Association now pays homage to Coca-Cola on its web site: "Like ADA, Coca-Cola understands that a healthy lifestyle involves balancing many different elements — staying physically active, consuming a balanced diet, getting enough rest — and even keeping a positive attitude. We are proud to partner with ADA to help provide Americans with information that allows them to make informed decisions about their personal well-being."

Yes - Coca-Cola, the company that spends billions of dollars promoting sugar-laden soft drinks, opposes school nutrition legislation, and lobbies against taxes that would reduce soda consumption is truly providing Americans with what they need to make healthy decisions.

What crap! The American Dietetic Association has sacrificed all semblance of public health principles, and it's clear that the money from Coca-Cola has contributed to its defection from public health to becoming a marketing partner for the sugar-laden soft drink industry.

And now, standing shoulder to shoulder with Coca-Cola and the ADA in the marketing of soft drinks through their participation in its corporate sponsorship initiatives is the American Diabetes Association. With enemies like these, the corporations that are contributing to deteriorating diet and increased obesity and diabetes do not even need friends. These so-called health groups are playing a greater role in the marketing of soft drinks than soft drink companies could ever imagine. The $225,000 or so that the Coca-Cola company has spent to silence the American Dietetic Association and American Diabetes Association was well-spent. It has resulted in health organizations joining with Coca-Cola in the marketing and public relations activities of the Coca-Cola corporation.