CDC Director and Prominent Anti-Smoking Researcher Appear to Be Fabricating Scientific Evidence to Oppose Electronic Cigarettes

The issue of electronic cigarettes is a complex one and there is plenty of room for - and in fact a need for - vigorous discussion and debate on both sides of the issue. However, what I don't believe there is room for is tobacco control scientists and government agency leaders making up scientific evidence to support pre-determined positions. Science, not ideology, should be guiding the complex decisions that need to be made regarding the handling of the electronic cigarette issue.

Unfortunately, it appears that last week two prominent public health and tobacco control figures fabricated scientific evidence to bolster their opposition to electronic cigarettes.

1. CDC Director Dr. Thomas Frieden Stated that Many Youths Have Started Smoking Because of Electronic Cigarettes

In an interview with Medscape, CDC Director Dr. Thomas Frieden stated that many youth have become cigarette smokers because they experimented with electronic cigarettes, which then led to their smoking initiation.

Specifically, Dr. Frieden stated:

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

The Rest of the Story - #1

Dr. Frieden shares two pieces of data from the CDC's tracking of electronic cigarette use among youth. First, he reports that the use of e-cigarettes in youth doubled in the past year. This statement is true, as the CDC survey did in fact show a doubling of experimentation with electronic cigarettes among youth.

The second piece of data from the survey that Dr. Frieden shares is that many of the youth smokers in the survey started as pure electronic cigarette users and that the electronic cigarette use ultimately led to their initiation of cigarette smoking.

This statement, sadly, appears to be a fabrication. The CDC survey did not show that many youth smokers actually started with e-cigarettes. In fact, the survey did not even assess that question. It measured the prevalence of smoking and electronic cigarette use among youth, but it was a cross-sectional survey and it did not track youth over time to determine their vaping and smoking patterns. Moreover, it did not collect complete smoking and vaping histories from the youth so that it could answer this question.

In other words, Dr. Frieden apparently just fabricated this evidence and presented it as being a result of the CDC's surveillance of youth e-cigarette use.

If you examine the methodology and questionnaire for the National Youth Tobacco Survey, you'll note that:

1) It is a cross-sectional survey, so it did not examine the trajectory of smoking initiation in relation to electronic cigarette use; and

2) The questionnaire only assessed ever use and past 30 day use of conventional and electronic cigarettes and it did not ascertain the longitudinal history of smoking initiation in relation to experimentation with electronic cigarettes.

Thus, in contrast to Dr. Frieden's statement, the survey provides no evidence that "many kids are starting out with e-cigarettes and then going on to smoke conventional cigarettes."

Moreover, I am aware of no other scientific evidence that many youth who started out with e-cigarettes then initiated smoking.

Unfortunately, the rest of the story is that this piece of scientific evidence appears to have been fabricated to support the CDC's opposition to electronic cigarettes.

Here, I am not criticizing the CDC for its position on electronic cigarettes (that is a separate issue), but instead, I am criticizing the apparent fabrication of scientific evidence to support that position. If the evidence does not support the CDC's assertions, then the agency should not make up evidence to support those assertions. Perhaps it should instead re-think those assertions.

I believe that one of the core ethical principles of public health is honesty and transparency. Here, it appears that the CDC is being neither honest nor transparent.

2. Anti-Smoking Researcher Dr. Stan Glantz Stated that Electronic Cigarettes Present 10% to 20% of the Risk of Tobacco Cigarettes

In an article on electronic cigarettes in TIME magazine, Dr. Glantz is quoted as asserting that electronic cigarettes pose 10% to 20% of the risk of tobacco cigarettes, and therefore, since the risks of cigarette smoking are enormous, electronic cigarette use is a major health risk.

Specifically, Dr. Glantz is quoted as stating:

"The studies that the e-cigarette people point out, claiming that these things are harmless, are really, really, really crappy. It is probably about 10% to 20% of what a cigarette puts out, so looked at that way, they are really nice. On the other hand, if you look at absolute levels of risk, they are pretty bad, because a cigarette is just ridiculously toxic and ridiculously polluting. ... If you say an electronic cigarette is only 10% to 20% less polluting than a massive forest fire, that's not so good."

The Rest of the Story - #2

Here, Dr. Glantz has essentially fabricated scientific evidence that doesn't exist. He asserts that electronic cigarettes pose 10% to 20% of the risk of conventional cigarettes. However, no such evidence exists. Basically, he is just making this up.

If you examine the constituents in electronic cigarette vapor compared to tobacco smoke, Dr. Glantz' assertion holds no water. Cigarette smoke contains between 10,000 and 100,000 chemicals, including more than 60 known human carcinogens. Electronic cigarette vapor contains about 15 chemicals, of which only about five are of any significant health concern, and the levels of those five chemicals in electronic cigarettes are comparable to those in nicotine replacement products like the nicotine inhaler, nicotine gum, or nicotine patch.

I have argued that there are a few potential health risks associated with vaping, including long-term respiratory health effects of propylene glycol, carcinogenic effects of formaldehyde, and cardiovascular and reproductive health effects of nicotine. However, so far there is no actual scientific evidence that electronic cigarettes are causing any significant health harm to users. To assert that the risk is 10% to 20% of that of cigarettes is not only absurd, but it is just a fabrication.

If what Dr. Glantz is asserting is true, then if used over many years at the same prevalence as cigarettes, electronic cigarettes would eventually cause between 40,000 and 80,000 deaths per year. Obviously, that's a fabrication as there is no current evidence that vaping poses any significant mortality risk. What specific diseases does Dr. Glantz assert that e-cigarettes cause and what specific chemicals cause those diseases?

I would readily acknowledge that we don't have enough scientific evidence to precisely quantify the absolute risk levels associated with vaping. But that's quite the point. By asserting that the risk is 10% to 20% of that of cigarette smoking, Dr. Glantz is essentially just making up a risk estimate, without any scientific justification, support, or evidence.

Once again, the rest of the story is that another prominent tobacco control scientist appears to be fabricating scientific evidence to support a pre-determined position against electronic cigarettes. There is no room for tobacco control scientists and government agency leaders to make up scientific evidence to support pre-determined positions. Again, science, not ideology, should be guiding the complex decisions that need to be made regarding the handling of the electronic cigarette issue.

New Study Finds UK Graphic Cigarette Warning Labels to be Ineffective

A new study published in the journal Tobacco Control reports that the graphic cigarette warning labels implemented in the UK have had no effect on smokers.

The study methodology was as follows: "The UK (UK) became the third country in the European Union to require pictorial warnings on the back of cigarette packs, in October 2008. A repeat cross-sectional survey was conducted with 11–16-year-olds in the UK between August and September 2008 (N=1401) and August and September 2011 (N=1373). At both waves the same text warnings appeared on the front and back of packs, with the only difference being the inclusion of images on the back of packs to support the text warnings in 2011. Warning related measures assessed were salience (noticing, looking closely at warnings), depth of processing (thinking about warnings, discussing them with others), comprehension and credibility (warning comprehensibility, believability and truthfulness), unaided recall, persuasiveness (warnings as a deterrent to smoking), avoidance techniques (eg, hiding packs) and a behavioural indicator (forgoing cigarettes due to warnings)." 

The results were as follows: "For never smokers, warning persuasiveness and thinking about what warnings are telling them when the pack is in sight significantly increased from 2008 to 2011, but warning comprehensibility significantly decreased. For experimental smokers, there was a significant increase from 2008 to 2011 for warning persuasiveness, believing warnings and considering them truthful. For regular smokers, there were no significant changes from 2008 to 2011, except for an increase in hiding packs to avoid warnings and a decrease in warning salience." 

The Rest of the Story

This research adds to the growing body of literature which suggest that graphic cigarette warning labels are largely ineffective, having a negligible effect on smokers. In this study, the warning labels were found not to have increased smoking cessation or even smoking reduction among smokers. Among nonsmokers, there was actually a decrease in warning comprehensibility, although persuasiveness increased.

Overall, these results suggest that the graphic warning labels had only marginal effects, with no effect on smokers.

This is not the kind of evidence that the FDA is going to need in court to support its plan to impose graphic warning labels on cigarettes.

New Study Shows that Regular Use of Electronic Cigarettes by Nonsmoking Youth is Extremely Low

A new study published in the journal Addictive Behaviors confirms the conclusion of last week's CDC study: the use of electronic cigarettes among nonsmoking youth is extremely low.

In fact, of a high school population of 1,345 students, the survey could find only 5 nonsmokers who had experimented with e-cigarettes in the past 30 days.  

In the first wave of the survey (February 2010), a total of 1,719 students were surveyed. The total number of nonsmokers who had experimented with e-cigarettes in the past 30 days was 2.

In the second wave of the survey (October 2010), a total of 1,702 students were surveyed. The total number of nonsmokers who had experimented with e-cigarettes in the past 30 days was 5.
 
In the most recent wave of the survey (June 2011), a total of 1,345 students were surveyed. The total number of nonsmokers who had experimented with e-cigarettes in the past 30 days was 5.

Thus, the percentage of nonsmoking e-cigarette users among this high school sample was 0.1% at wave 1, 0.3% at wave 2, and 0.4% at wave 3.

The estimated percentage of nonsmoking e-cigarette users among youth nationally in the CDC survey was approximately 0.5%, suggesting that we are not seeing a substantial increase in the use of electronic cigarettes among nonsmoking youth.

Not surprisingly, the study does not actually directly mention the very low use of electronic cigarettes by nonsmoking youth and does not point out that the evidence it presents suggests that there is currently no reason for major concern that e-cigarettes are serving as a gateway to youth smoking.

The Rest of the Story

This study adds to the evidence that electronic cigarette use among nonsmoking youth is not currently a significant problem and that these products are not serving as a gateway to cigarette smoking, as claimed by many anti-smoking groups as well as policy makers.

Last week, Senator Ed Markey (D-MA) stated: "These e-cigarettes are a gateway to tobacco use by children and teens and should not be marketed to youth."

Connecticut Senator Richard Blumenthal stated as follows: "“Electronic cigarettes as marketed today – with flavors like bubblegum and strawberry – are targeted at young people with the very clear intent of creating a new generation of smokers. Without question, tobacco companies are using the same despicable tactics with e-cigarettes that they used in previous decades with traditional cigarettes to lure youth down a path of nicotine addiction and eventual death."

And CDC Director Dr. Thomas Frieden proclaimed: "The increased use of e-cigarettes by teens is deeply troubling....Nicotine is a highly addictive drug. Many teens who start with e-cigarettes may be condemned to struggling with a lifelong addiction to nicotine and conventional cigarettes."

This study, along with CDC's own study, demonstrates that these public health advocates and politicians are merely blowing smoke. They are not basing their statements on scientific evidence but are apparently jumping at the opportunity to lash out at electronic cigarettes, about which they presumably have reached a pre-determined conclusion based on ideology, not science.

The 0.4% prevalence of nonsmoking youth who have experimented with e-cigarettes in the past 30 days is even less concerning when you consider that this merely represents the use of an e-cigarette in the past month. It does not necessarily indicate regular use of the product, adoption of vaping as a regular behavior, or addiction to nicotine. In fact, the absence of major observed increases in the prevalence of e-cigarette use among nonsmoking youth suggests that at the current time, this behavior holds little appeal for them.

It is now clear that neither of the two potential drawbacks to the promotion of e-cigarettes - the inhibition of quitting by smokers and the initiation of smoking by nonsmokers - are significant problems at the present time. Therefore, it is quite clear that the net public health impact of electronic cigarettes is a positive one.

While FDA regulation is necessary to make sure that e-cigarettes remain out of reach and/or out of favor among nonsmoking youth, the scientific evidence supports the contention that the FDA, along with anti-smoking groups and advocates, should embrace electronic cigarettes as an important strategy in their efforts to reduce smoking and its related health consequences.

Financial Analyst Predicts that E-Cigarette Sales Will Surpass Tobacco Cigarette Sales by 2021; Primary Obstacle to this Dream Come True: The Anti-Smoking Movement

Bonnie Herzog, a tobacco financial analyst with Wells Fargo, has predicted that by 2021, sales of electronic cigarettes will actually surpass those of tobacco cigarettes, according to an article at NACS Online.

According to the article: "Herzog said that U.S. e-cigarette sales will reach roughly $2 billion by the end of this year and up to $10 billion by 2017. She expects Altria, R.J. Reynolds and Lorillard to take an increasing presence in the category, which will accelerate its growth. Herzog based her projection on three factors: The manufacturers’ ability to invest in the electronic cigarettes; their supply chain relationships with retailers and distributors; and their expertise at building successful brands. ... However, Herzog’s predictions can be upset by the FDA’s decision to regulate electronic cigarettes, said Carl Philips, scientific director for Consumer Advocates for Smoke-free Alternatives Association. 'We remain cautiously optimistic that the regulations will favor consumers and public health, which will mean not imposing the restrictions that favor large manufacturers.'"

The Rest of the Story

If Herzog's prediction is true, then electronic cigarettes may be one of the most effective public health interventions of all time. to reduce the sale of tobacco cigarettes so much that it is surpassed by electronic cigarettes would represent a drastic reduction in cigarette consumption and a tremendous accomplishment in terms of disease averted and lives saved.

Ironically, as Carl Phillips points out, the primary obstacle to this positive scenario is the anti-smoking establishment and its efforts to derail the electronic cigarette movement. If embraced by the FDA, this could result in a major obstacle for the expansion of the e-cigarette market, and therefore, for the decrease in the tobacco cigarette market.

Already, the sale of electronic cigarettes has resulted in unexpected declines in cigarette sales. What I don't understand is why anti-smoking groups continue to fail to appreciate that this is a demonstrable public health gain. The burden of cigarette-related disease and death is directly proportional to levels of cigarette consumption. Some of the major anti-smoking groups and advocates fail to understand that basic equation.

While there is no question that appropriate regulation of electronic cigarettes is necessary to keep these products out of the hands of minors and to ensure uniform quality and safety standards, the current evidence strongly suggests that electronic cigarettes have the potential to greatly benefit the public's health. It is unfortunate that such gains are going to be realized despite the efforts of anti-smoking groups rather than because of their efforts.

American Heart Association Not Sure if There are Any Benefits of Quitting Smoking if You Continue to Use the Nicotine Inhaler

Apparently, the American Heart Association is not sure if there are benefits to quitting smoking if you continue to inhale nicotine, such as you would do if you quit by using electronic cigarettes or a nicotine inhaler and then continued to use those devices.

According to the chief medical officer of the American Heart Association, as quoted at WebMD: "They [electronic cigarettes] are nicotine delivery devices intended to be used like a cigarette. What happens to someone who stops inhaling the tars of cigarettes and inhales only nicotine? We don't know."

This is quite clearly a caution against quitting smoking using nicotine inhalers because smokers doing so are stopping inhaling the tars of cigarettes but still inhaling nicotine. The same is true with electronic cigarettes.

The Rest of the Story

The American Heart Association would have us believe that there is not enough scientific evidence to know what happens to a person who quits smoking - thus eliminating their exposure to cigarette tars - but who continues to obtain nicotine (but in a "clean" fashion).

The rest of the story is that we know full well what happens to that person: they greatly reduce their risk of disease and death and quite possibly, they save their life.

How in 2013 the American Heart Association could not be aware that it is the tar (with the tens of thousands of chemicals and more than 60 known carcinogens), not the nicotine, which causes the overwhelming bulk of smoking-related disease is completely beyond me.

Shockingly, in 2013, it is the anti-smoking groups - not the tobacco companies - which are misleading the public about the health effects of smoking and undermining the public's appreciation of those hazards. Ironically, and quite sadly, the tobacco companies historical efforts to lie to and mislead the public in order to undermine the public's appreciation of the severe hazards of smoking have been replaced by the efforts of major anti-smoking groups.

And all this because these anti-smoking groups are so blinded by ideology that they are unable to endorse a behavior that looks like smoking, even though it protects the user from virtually all of its associated health effects.

FDA Doesn't Want Public to Think that Cigarette Smoking is More Hazardous than Vaping

I hate to start another post with "Yes, you read that headline correctly," but indeed, you did read the headline correctly.

The FDA has acknowledged that it does not want the public to think that cigarette smoking is any more hazardous than using a non-tobacco e-cigarette.

According to an FDA spokeswoman, as quoted at WebMD: "We don't want the public to perceive them (e-cigarettes) as a safer alternative to cigarettes."

The Rest of the Story

Why in the world does the FDA want the public to think that cigarette smoking is no more hazardous than vaping?

Even the tobacco industry, in 2013, acknowledges that smoking is more harmful than vaping.

In fact, if a tobacco company made the very same assertion that the FDA is making, they would immediately be dragged back into Judge Kessler's courtroom and would have to issue yet another corrective statement.

To be sure, then, the FDA should be ordered to issue a corrective statement of its own. Here is my suggestion:

Proposed Corrective Statement #1: (for the FDA)
Corrective Statement for FDA's Deception Regarding the Relative Safety of Electronic Cigarettes Compared to Real Tobacco Cigarettes

We are being required to tell the truth about the safety of cigarettes compared to electronic cigarettes. We told you that electronic cigarettes were no safer than tobacco cigarettes, that we didn't want you to think that e-cigarettes were safer. But that was a lie. Here's the truth:

• We found only trace levels of tobacco-specific nitrosamines in electronic cigarettes, comparable to those found in FDA-approved nicotine replacement products like nicotine patches and nicotine gum. In contrast, cigarettes have high levels of tobacco-specific nitrosamines and pose a substantial cancer risk.
• The levels of carcinogens we detected in electronic cigarettes are orders of magnitude lower than in regular cigarettes, indicating that electronic cigarettes are likely much safer than regular cigarettes in terms of cancer risk.
• The minute levels of tobacco-specific nitrosamines in electronic cigarettes are a necessary result of the extraction of nicotine from tobacco. Overall, these devices deliver nicotine with only a few other chemicals, compared to the delivery of nicotine plus tens of thousands of chemicals and more than 60 proven carcinogens in regular cigarettes.
• Recent studies have shown that in contrast to  smoking, e-cigarette use does not cause acute impairment of the coronary circulation. Thus, the risks of heart disease are likely to be much lower.
• Smokers who switch to electronic cigarettes have been shown to have an immediate improvement in their respiratory symptoms. E-cigarettes almost certainly lower the risk of COPD compared to continued smoking.

Paid for by the Food and Drug Administration by order of The Rest of the Story.

Anti-Smoking Researcher Promoting "Anti-Smoking" Campaigns that Discourage Smokers from Quitting

Believe it or not, you did not misread that headline.

A prominent anti-smoking researcher and advocate is promoting "anti-smoking" campaigns that actually discourage many smokers from quitting.

Specifically, Dr. Stan Glantz wants anti-smoking campaigns to include anti-e-cigarette messages as well. He has called for anti-smoking campaigns that actively discourage smokers from quitting - at least those smokers who are thinking of quitting using e-cigarettes.

On his tobacco blog, Glantz offers the following recommendation: "States need to include ecigs in their anti-tobacco marketing campaigns, especially the fact that they pollute the air."

The effect of this message would be to discourage all electronic cigarette use, hindering or preventing literally thousands of smokers from quitting.

The Rest of the Story

You know that your movement is deteriorating when one of its prominent advocates wants anti-smoking campaigns that actively discourage thousands of smokers from quitting just because he has some sort of ideological opposition to a smoking cessation device that looks like a cigarette.

Look - there are many legitimate areas of uncertainty and disagreement about electronic cigarettes, including details about how they should be regulated, their long-term effects, the extent of their use by minors, whether they should be allowed in places where smoking is banned, etc. However, so far, only anti-smoking groups have actively discouraged people from quitting smoking using these devices. Only anti-smoking groups have condemned people who have literally saved their lives by quitting smoking, condemning them simply because they didn't quit "the right way." Only a movement that has become divorced from its public health objectives could be so blinded by ideology that it begins promoting policies and programs that will destroy its own goals.

How Low Can We Go? Basis of Anti-Smoking Researcher's Conclusion About Overall Health Consequences of E-Cigarettes: Two Anonymous Blog Commenters

In a recent blog post, Dr. Stan Glantz argues that heavy promotion of electronic cigarettes will increase, rather than decrease, the toll of nicotine addiction.

Question for my readers: Which of the following is the evidence upon which Dr. Glantz puts forward his argument?

A. A review of clinical trials on the effectiveness of electronic cigarettes.
B. A review of laboratory studies of the chemical constituents of electronic cigarette vapor.
C. A review of survey evidence of youth use of electronic cigarettes.
D. All of the above.
E. A weighing of the potential health benefits and costs of promoting electronic cigarettes.
F. Comments made by two anonymous blog commenters.

The Rest of the Story

To see how low we have gone, the answer to the question is:

F. Comments made by two anonymous blog commenters.

It is sad to me that this is where we are at now. A major anti-smoking researcher offers a widely-disseminated public opinion about the net benefits of electronic cigarettes to the overall public health of the nation, and his opinion is based on the rantings of two anonymous blog commenters!

Clearly, this is someone who has drawn a pre-determined conclusion about electronic cigarettes and their net impact on the public's health and who is not interested in serious consideration of this issue on anything close to a scientific basis.

It truly saddens me to see to depths to which the anti-smoking movement has deteriorated.

The issue of the net impact of the marketing of electronic cigarettes on the public's health is a complex one that, at a minimum, involves a consideration of:

• the likely number of smokers who will quit smoking as a result of electronic cigarette promotion;
• the safety advantages of electronic cigarettes over continued smoking;
• the natural history of smoking in the absence of an electronic cigarette trial;
• the uptake of electronic cigarettes by nonsmoking youth and the extent of progression to established smoking.

But apparently it's a lot simpler for some anti-smoking researchers. The whole question can be answered by two blog rants by Patricia and Stig.

Anti-Smoking Advocates Continue to Make Ridiculous Statements that E-Cigarette Companies are Promoting Smoking

A number of anti-smoking advocates continue to make the assertion that electronic cigarette company marketing is promoting cigarette smoking.

For example, in response to a CDC report on youth experimentation with e-cigarettes, Connecticut Senator Richard Blumenthal stated as follows: "“Electronic cigarettes as marketed today – with flavors like bubblegum and strawberry – are targeted at young people with the very clear intent of creating a new generation of smokers. Without question, tobacco companies are using the same despicable tactics with e-cigarettes that they used in previous decades with traditional cigarettes to lure youth down a path of nicotine addiction and eventual death."

Stan Glantz continues to argue that electronic cigarette marketers are promoting smoking.

In an article published in JAMA, Benowitz and Goniewicz argued that marketing of electronic cigarettes may promote "continued smoking of cigarettes and renormalizing cigarette smoking behaviours."

The Philippines health director stated that: "the electronic cigarette promotes smoking among children and the youth. It makes them less fearful of hazards and risks of smoking. It is opposed to the DOH’s health goal to stop cigarette smoking and tobacco use."

These are just a few examples of the many anti-smoking advocates and groups which are claiming that electronic cigarette companies are marketing their products in order to promote smoking.

The Rest of the Story

I have already pointed out how ridiculous this assertion is. But I think it deserves some more emphasis.

The clear intention of electronic cigarette marketers is to sell as many electronic cigarettes as they can, not as many cigarettes as they can. In fact, of the more than 250 companies now on the general market, only one even sells cigarettes in the first place. Thus, it is preposterous to assert that electronic cigarette marketing is intended to promote cigarette smoking.

The truth is exactly the opposite. What electronic cigarette companies want is to get smokers to quit smoking and switch to electronic cigarettes instead. The greater the degree of substitution of e-cigarettes for the real ones, the more money the e-cigarette companies make. Thus, they have no incentive to encourage smokers to maintain their smoking behavior.

In short, at least for 249 of the 250 electronic cigarette companies that are currently selling on the general market, there is zero incentive for them to promote continued smoking and none of them are doing that.

My examination of marketing for the only company (Blu cigs, owned by Lorillard) which could conceivably have an incentive to promote continued smoking - in addition to e-cigarette use - confirms that they are not in any way promoting smoking. What they are promoting is electronic cigarette use.

This has to be one of the most inane assertions being made by anti-smoking groups and advocates that I have ever heard.


(Jacob Sullum nicely summarizes the issue here.)

"On Point" Segment on Electronic Cigarettes

Yesterday, I had the pleasure of appearing as a guest on "On Point" with Tom Ashbrook, along with my mentor, Dr. Stan Glantz. The segment featured a general discussion of the potential role of electronic cigarettes in relation to public health. You can listen to the segment here.

The Rest of the Story

The most surprising aspect of the segment to me was Dr. Glantz' assertion that not only are electronic cigarettes ineffective for smoking cessation, but that they actually inhibit smoking cessation. He based this assertion on a study that he has misinterpreted, as I have explained previously. Moreover, he made this assertion in the face of his own acknowledgment that a clinical trial published just last week showed that electronic cigarettes are as effective as the nicotine patch for smoking cessation. If electronic cigarettes are equally effective as NRT for smoking cessation, then how can he possibly claim that e-cigarettes inhibit smoking cessation?

The most disappointing aspect of the segment, in addition to Dr. Glantz' misrepresentation of the Vickerman study, was his attempt to scare the public about the dangers of e-cigarettes by noting that they contain tobacco-specific nitrosamines. But what Dr. Glantz did not tell listeners was that these are trace levels, that they are an inevitable artifact of the derivation of nicotine from tobacco, that the same levels of tobacco-specific nitrosamines are present in nicotine gum and nicotine patches, and that these trace levels pose no health threat, just as they pose no health threat to users of nicotine patches and gum.

The most disturbing aspect of the segment was Dr. Glantz' dismissal of the tremendous health accomplishments made by the many callers (and thousands of similar people in the same situations) who have literally saved their lives by quitting smoking using e-cigs, or who have taken a serious step towards quitting smoking by greatly reducing their cigarette intake.

The saddest aspect of the segment was hearing my mentor support the availability and marketing of FDA-approved cigarettes which are killing hundreds of thousands of Americans each year, yet wanting to restrict or eliminate access to electronic cigarettes, a much safer alternative that contains no tobacco and involves no combustion.

Unlike Dr. Glantz, I think we should be promoting electronic cigarettes and discouraging the real ones rather than ensuring that people continue to assume the known risks of tobacco cigarettes rather than take a chance on the assuredly much safer fake ones.

Senators Complaining About Electronic Cigarette Flavors are Full of Baloney; Their Desire to Protect Kids from Addiction Only Goes as Far as Cigarette Company Profits

A group of U.S. Senators earlier this week lambasted electronic cigarettes and their flavorings, calling them a gateway to cigarette use and proclaiming themselves public health champions who will do what is necessary to protect kids from cigarette addiction.

For example, Senator Dick Durbin (D-IL) boasted: "This scientific report provides conclusive evidence that the use of e-cigarettes among our nation’s kids is both on the rise and closely linked to the deadly use of cigarettes. This information is a call to action – tobacco companies continue to find new ways to target America’s young people and we need to actively prevent it. I commend the Centers for Disease Control for shedding light on this important issue, and look forward to working with my colleagues to continue work to curb tobacco use amongst our kids. With the right commitment we can spare future generations of young people from this deadly epidemic."

At the same time, the Campaign for Tobacco-Free Kids jumped on the new CDC data and demanded instant action by the FDA to stop the marketing of these flavored products to children, complaining that "e-cigarettes are sold in an assortment of sweet, kid-friendly flavors including “vivid vanilla,” “cherry crush” and chocolate." The Campaign then boldly called for the federal and state governments "to take action to protect our kids."

The Rest of the Story

The rest of the story is that these politicians as well as the Campaign for Tobacco-Free Kids are full of baloney. While these politicians and anti-smoking groups are boasting about how committed they are to protect kids from a flavored product that might, through a tortuous pathway, eventually lead to cigarette smoking, these very same politicians and groups opposed protecting kids from addiction to cigarettes by banning the very flavored cigarettes that youth are actually smoking in huge numbers.

Yes, it is sadly true that Senator Durbin, along with the Campaign for Tobacco-Free Kids, led efforts to block the regulation of menthol cigarettes at the same time that Congress was banning every other cigarette flavor under the sun. Ironically, every one of these flavors except menthol was not actually smoked by youth. But menthol cigarettes were the flavor of choice among youth smokers.

Why did Senator Durbin and the Campaign for Tobacco-Free Kids oppose a ban on menthol cigarettes? Very simple: Because a menthol ban would have actually made a dent in cigarette sales. Unlike the enacted ban on cherry cigarettes which these groups endorsed, a ban on menthol cigarettes would actually have reduced youth smoking substantially.

So Senator Durbin and the Campaign for Tobacco-Free Kids and all of their friends in Congress who pretended to stand up against Big Tobacco actually did just the opposite: they fought the tobacco companies only to the point where it would have actually started hurting these corporations in the pocket book and thereby improving the public's health. It was an act of supreme hypocrisy and immense political cowardice.

While Durbin and the Campaign were busy flexing their muscles and touting their concern for kids, another piece of relevant data came out earlier this week. A study published in the journal Tobacco Control reported that 57% of youth smokers smoke menthol cigarettes and that menthol cigarettes are much more popular among youth smokers than among adults.

The report noted that while the smoking of non-menthol cigarettes among youth has declined, rates of menthol smoking have remained high and constant. The researchers concluded that the continued marketing of menthol cigarettes - facilitated by none other than Senator Durbin and the Campaign for Tobacco-Free Kids - has undermined progress in reducing youth smoking, writing that "Progress in reducing youth smoking has likely been attenuated by the sale and marketing of mentholated cigarettes, including emerging varieties of established youth brands."

Thus, instead of being champions for the public's health, firm opponents of Big Tobacco, and protectors of youth from cigarette addiction, Senator Durbin and friends along with the Campaign for Tobacco-Free Kids and its friends have actually been the cause of failure to make as much progress in reducing youth smoking. In other words, they are not public health champions, but hypocrites.

To make matters much worse, in caving in to Big Tobacco and protecting cigarette sales to youth, the Campaign for Tobacco-Free Kids advanced the racist and scientifically unsupported "justification" that African American smokers would turn to contraband. In fact, the Campaign for Tobacco-Free Kids advanced this argument before Lorillard did. In fact, Lorillard didn't have to make the argument because the Campaign for Tobacco-Free Kids already had. And it was this argument which the Campaign used to block an amendment which would have removed the menthol exemption.

The Campaign for Tobacco-Free Kids actually did Lorillard's dirty work for it. Part of its lobbying expenditures really should have been reported under Lorillard.

It is bad enough that politicians and a major tobacco control group have sold out the health of America's children, and in particular - African-American smokers - in order to protect the profits of tobacco companies. But seeing these same politicians and groups now pretend that protecting kids from addiction to flavored addictive products is their principled priority is too much for this stomach to handle.

University of Kentucky Cancer Center is Off Its Rocker: Testifies that Smoking is No More Harmful than Vaping

According to a press release issued Monday, the University of Kentucky Markey Cancer Center testified before the state legislature that smoking is no more harmful than vaping.

Yes, you read that correctly.

The University of Kentucky Cancer Center apparently testified that smoking - which kills 400,000 people each year in the U.S. - is no more hazardous than vaping, which involves no tobacco and no combustion and merely involves the vaporization of nicotine from a solution containing propylene glycol and glycerin.

According to the press release, which appears to have been issued by Kentucky Lung Cancer Research Program, the University of Kentucky Cancer Center director - Dr. Mark Evers - told a state legislative panel that e-cigarettes may be "every bit as dangerous" as smoking tobacco.

The Rest of the Story

Let's be very straight about this: if the tobacco companies said exactly the same thing before the legislature, they would probably be facing criminal charges for perjury, as well as civil liability charges for fraud.

For any tobacco company to defraud the American public by undermining the health consequences of smoking by stating that they are no more harmful than electronic cigarettes would be unheard of in 2013, and no tobacco company would ever do such a thing. They wouldn't be caught dead making such an outright lie.

Apparently, this is not so for the University of Kentucky Cancer Center, which stepped into territory that used to be occupied by Big Tobacco, lying before a state legislative panel, asserting that vaping is every bit as dangerous as smoking.

Even the tobacco companies agree that smoking is more hazardous than vaping. I don't understand how any scientist, especially a physician at a cancer center, could downplay the hazards of smoking so much as to suggest that they are no more harmful than a product that contains no tobacco and involves no combustion.

What is it about electronic cigarettes that causes its opponents to consistently lie to the public and make up scientific data to support their opposition? My guess is that the evidence is simply too strong for them to confront directly and honestly. Why else the need to resort to lying or misleading the public?

Electronic Cigarette Experimentation Increases Among Youth, But Use Among Nonsmokers Remains Low and Regular Use Rates are Still Unknown

The Centers for Disease Control and Prevention (CDC) reported last week that the prevalence of youth in grades 6-12 who have experimented with electronic cigarettes in the past month increased from 1.1% in 2011 to 2.1% in 2012. Among middle school students, the prevalence of past month use increased from 0.6% to 1.1%.  Among high school students, past-month use increased from 1.5% to 2.8%.

Based on these results, CDC Director Dr. Thomas Frieden proclaimed: "The increased use of e-cigarettes by teens is deeply troubling....Nicotine is a highly addictive drug. Many teens who start with e-cigarettes may be condemned to struggling with a lifelong addiction to nicotine and conventional cigarettes."

In response to the CDC report, Connecticut Attorney General Richard Blumenthal stated as follows: "“Electronic cigarettes as marketed today – with flavors like bubblegum and strawberry – are targeted at young people with the very clear intent of creating a new generation of smokers. Without question, tobacco companies are using the same despicable tactics with e-cigarettes that they used in previous decades with traditional cigarettes to lure youth down a path of nicotine addiction and eventual death."

Senator Markey responded: "“These e-cigarettes are a gateway to tobacco use by children and teens and should not be marketed to youth."

The Rest of the Story

The alarm calls being made by public health officials and politicians are premature. And their conclusions are unsupported by these data.

In no way do these data support the hypothesis that electronic cigarettes are a "gateway to tobacco use" by children and teens as Senator Markey claims. And there is no evidence provided that electronic cigarettes are being "targeted at young people with the very clear intent of creating a new generation of smokers" as Attorney General Blumenthal claims.

It is not at all surprising that youth smokers might experiment with electronic cigarettes. To the extent that these youth are able to switch over to electronic cigarettes, they are most likely reducing their long-term prospects of becoming cigarette smoking addicts. The danger is if nonsmoking youth start using these products and then end up becoming addicted to nicotine, causing them to transition to cigarette smoking.

But what do the CDC data tell us about whether the kids experimenting with e-cigarettes are smokers or nonsmokers?

Among youth who experimented with electronic cigarettes in 2012, the overwhelming majority - 90.6% - were smokers.Only about one in ten of the youths who experimented with electronic cigarettes were never smokers. And among the high school students who tried electronic cigarettes, only 7.2% were never smokers. Thus, it is quite clear that the overwhelming majority of the experimentation that is occurring among youth is happening among youth who already smoke cigarettes. This is not necessarily a bad thing, on its own, if it can reduce the chances of these youths becoming lifelong cigarette addicts.

The proportion of nonsmoking youth who experimented with e-cigarettes in the past 30 days remains small:

• Overall, only 0.5% of youth were nonsmokers using e-cigarettes in the past 30 days;
• Among middle school students, only 0.4% were nonsmokers using e-cigarettes in the past 30 days; and
• Among high school students, only 0.5% were nonsmokers using e-cigarettes in the past 30 days.

There are three other important points that make up the rest of the story.

1. The survey measured experimentation, but not regular e-cigarette use.

It is not surprising that about 2% of youth would try electronic cigarettes. But the important issue is what percentage of these youth enjoy them enough to become regular users? The CDC survey measured past month use (which is essentially experimentation), but it did not assess daily use, or anything close to regular use. So what we end up with is a measure of experimentation, but no idea of whether youth are actually taking up this behavior and becoming regular vapers.

2. The survey found no evidence that e-cigarettes are a gateway to smoking.

In contrast to the alarming statements of the politicians and the CDC director (who was talking more like a politician), the survey provided no evidence whatsoever that electronic cigarettes are serving as a gateway to cigarette use. Not a single case was documented in which a nonsmoking youth began using electronic cigarettes, became addicted to nicotine, and then went on to become a regular cigarette smoker. So we're still in the realm of unsubstantiated claims.

3. The low rates of youth nonsmoker use of e-cigarettes in light of the high rates of experimentation with e-cigarettes among youth suggest that e-cigarettes are not currently a major problem that is creating a gateway to increased cigarette addiction.

Given that the rate of experimentation with electronic cigarettes is as high as 10% among high school students, the finding that only 0.5% of high school students are nonsmoking, current electronic cigarette users is actually somewhat reassuring. It suggests that this behavior has not caught on among nonsmokers -- at least not yet.

4. Neither this study, nor other evidence, supports the assertion that electronic cigarettes are being marketed with the intention of recruiting youth and/or creating new cigarette smokers from those youth.

It is difficult to refute a statement for which there is no evidence presented in support. Attorney General Blumenthal claims that electronic cigarettes "are targeted at young people with the very clear intent of creating a new generation of smokers." However, he provides not a shred of evidence to support this outcontention. Perhaps in political circles, that flies. But in science, it does not. I cannot make a statement like that with providing at least some supporting evidence.

In fact, the existing evidence refutes Blumenthal's contention, because the clear intention of electronic cigarette marketers is to sell as many electronic cigarettes as they can, not as many cigarettes as they can. In fact, of the more than 250 companies now on the general market, only one even sells cigarettes in the first place. Blumenthal's assertion, therefore, is not only unsubstantiated, but preposterous.

Summary

The rest of the story is that both health leaders and politicians (perhaps being one in the same) are using these data to make false and exaggerated claims that have no basis in science. There is no evidence that regular electronic cigarette use is becoming a substantial problem among youth nonsmokers and there remains no evidence that electronic cigarettes have become a gateway to cigarette addiction. These is also no evidence that these products are being marketed with the intention of turning youth into new cigarette smokers.

Nevertheless, I am in no way arguing here that regulation is not needed. Just the opposite. The FDA needs to step in and do everything it reasonably can to ensure that electronic cigarettes do not become popular among youth, and especially that they do not become a gateway to nicotine addiction and cigarette use.

Hour-Long Radio Times Segment Explores Electronic Cigarettes

I was honored to participate as a guest on the Radio Times (WHYY) hour-long segment this morning on electronic cigarettes. I thought that the issues raised were fascinating and that the comments and questions from the guests were outstanding. This is worth a listen, especially for the discussion of some of the interesting marketing issues involved.

Another Tobacco Control Practitioner Tells the Public That There is No Evidence Electronic Cigarettes are Safer than Real Ones

According to a story run by WDIO-TV (Duluth, MN), a tobacco control practitioner in Duluth is telling the public that there is no evidence vaping is any safer than smoking. She is also telling the public that there is no evidence that switching to electronic cigarettes can help a smoker quit smoking.

According to the story: "Brian Annis says he smoked for years and tried everything from nicotine gum to prescribed medication to quit.  But it wasn't until he found e-cigs that something actually stuck. "It helped me. It satisfies that oral fixation and that inhalation of something that I really missed with those other cessation devices," Annis said." ...

"However, not everyone is as enthusiastic as Annis. Cardiology Nurse Practitioner Jessica Zweifel helps people kick their smoking habit as the program director of Tobacco Free Services at Essentia Health. She says, like Annis, many smokers think of e-cigarettes as a less-harmful substitute to tobacco cigarettes. "Unfortunately for both of those options being less harmful or a successful cessation device, there is no evidence out there stating that these things are true," Zweifel said. She says she expects substantial research in the coming years, but until then she doesn't recommend e-cigs as a cessation tool to her clients.  Instead, she offers other traditional quit tools such as counseling and nicotine gum."

The Rest of the Story

It is unfortunate that many tobacco control practitioners continue to tell the public that there is no evidence that electronic cigarettes can help a smoker quit smoking. Multiple published surveys as well as literally thousands of personal testimonials from ex-smokers who have quit with these products make it eminently clear that for some smokers, electronic cigarettes are a successful strategy for quitting smoking. No responsible tobacco control practitioner should be denying that. Especially in August 2013 when such evidence is overwhelming.

What we don't know is the percentage of smokers who quit successfully with e-cigarettes. But to deny that there is any evidence that many vapers have successfully quit smoking is an attempt to deny reality. There are thousands of vapers out there who provide evidence that electronic cigarettes can be effective for quitting smoking.

Ironically, if the cigarette companies were making the same argument in order to protect cigarette profits from the threat of electronic cigarette sales, we could attack the companies for making fraudulent claims to protect their sales. After all, how could these companies deny that many smokers have quit successfully using electronic cigarettes when their are multiple surveys and online testimonials which document that many smokers have quit successfully using electronic cigarettes? Is this statement any less false just because it is being made by tobacco control advocates, instead of by cigarette companies?

Perhaps even more unfortunate is the assertion that there is no evidence that electronic cigarettes are less harmful than tobacco cigarettes. There is plentiful scientific evidence that electronic cigarettes are less harmful than tobacco cigarettes, including toxicology studies, laboratory studies, and clinical studies.

What we don't know is the absolute level of safety of electronic cigarettes. But that they are much safer than regular cigarettes is not in dispute. And that there is no evidence that e-cigarettes are safer than tobacco cigarettes is untruthful.

Once again, if the cigarette companies were making the exact same claim - arguing that there is no evidence that smoking is any more hazardous than vaping - we would certainly be attacking them for misleading the public and undermining the public's appreciation of the hazards of cigarette smoking. This assertion is no more truthful just because it is being made by tobacco control advocates, instead of by cigarette companies.

One thing I have learned in my public health career is that when the opposition resorts to lying, it is usually because their arguments are not strong enough on their own. This appears to be the case with the opponents of electronic cigarettes. The logic, as well as the evidence, is so overwhelming that electronic cigarettes are improving the public's health that it takes outright lies to counter it. And sadly, it is to dishonesty that much of the tobacco control movement is resorting.

Electronic Cigarettes Commentators Fail to Disclose Financial Conflicts of Interest with Big Pharma

The New York Times "Room for Debate" section Wednesday featured a debate about electronic cigarettes. I was one of six commentators who provided their perspectives on the issue. After reviewing the other commentaries, the first thing that struck me was the failure of one of the commentators to disclose an important financial conflict of interest: his receipt of funding from Big Pharma to study the effectiveness of a competitive product to electronic cigarettes.

The commentary was written by Dr. Andrew Strasser, an associate professor in the department of psychiatry at the University of Pennsylvania's Perelman School of Medicine, where he is the director of its Biobehavioral Smoking Laboratory. The commentary calls for more research and regulation of electronic cigarettes, a perspective with which I largely agree. It argues that electronic cigarettes are safer than tobacco cigarettes, a statement with which I completely agree. It calls for the FDA to set quality control standards for these products. I agree. However, the commentary goes on to assert that: "there is a paucity of research on how individuals actually use electronic cigarettes. What about those who might have a chance of quitting smoking altogether but instead end up replacing the tar and nicotine from traditional cigarettes with e-cigarettes?"

There actually has been considerable research on how vapers are using e-cigarettes and from that research, it is quite clear that the smokers using these products are not people who would otherwise have "quit smoking altogether." Most of the e-cigarette users have tried and failed to quit using traditional "FDA-approved" therapies. In fact, the reason they are attracted to e-cigarettes in the first place is that these products provide an alternative to the products which do not work or have not worked for them. So it is simply not the case that e-cigarettes are hindering smokers from quitting. In fact, it is quite the opposite as these products are providing a ray of hope to smokers who otherwise would probably not even be making further quit attempts, or at least not serious ones.

There is one other point made in the commentary with which I disagree. The column expresses concern over "the perception that electronic cigarettes are less harmful ... than traditional cigarettes." I don't understand why we should be concerned about the public holding a perception that e-cigarettes are safer than tobacco cigarettes. In fact, this is the truth. Why wouldn't we want the public to understand the truth. It would be a tragedy, in fact, if smokers were under the mistaken impression that their "real" cigarettes were as safe as the electronic ones. So I just don't understand why the public perception that e-cigarettes are safer than tobacco cigarettes is concerning.

The main problem with this commentary, however, is not the opinions it expresses, but the fact that it hides from the public an important financial conflict of interest of the author that I believe should have been disclosed.

The Rest of the Story

It turns out that the author of the commentary has received funding from a company which manufactures a competitive product to electronic cigarettes. Specifically, he has received research funding from Pfizer, the manufacturer of Chantix, a smoking cessation drug that stands to lose substantial sales if electronic cigarettes become increasingly popular. Therefore, this is a significant financial conflict of interest and I think it ought to have been disclosed in the article.

This is not the only commentary which failed to disclose a significant financial conflict of interest. The American Lung Association offered a commentary which urged smokers not to use electronic cigarettes to quit smoking. This is a devastating recommendation that, if followed, will result in increased smoking, disease, and death as thousands of smokers who would otherwise have quit smoking using e-cigarettes will instead continue smoking.

But the larger problem with the commentary is that it fails to disclose a significant financial conflict of interest: the American Lung Association has received millions of dollars of support from Big Pharma; specifically, from Pfizer.

In the second quarter of 2009 alone, the American Lung Association received more than $1.5 million from Pfizer, manufacturer of Chantix and Nicotrol. Pfizer is a sponsor of the Lung Association's Freedom from Smoking program.

The financial connection is so strong that the American Lung Association goes so far as to promote Pfizer on its web site, boasting that: "Founded in 1849, Pfizer is the world's premier biopharmaceutical company taking new approaches to better health. We discover, develop, manufacture and deliver quality, safe and effective prescription medicines to treat and help prevent disease for both people and animals. We also partner with healthcare providers, governments and local communities around the world to expand access to our medicines and to provide better quality health care and health system support. At Pfizer, colleagues in more than 90 countries work every day to help people stay happier and healthier longer and to reduce the human and economic burden of disease worldwide."

In other words, the American Lung Association is allowing Pfizer to gain a huge public relations benefit out of its financial support. It is truly a partnership, not merely a charitable contribution from Pfizer. Clearly, the ALA has become beholden to Pfizer by virtue of the money it has received. No wonder the ALA finds it such a threat that thousands of smokers are quitting by virtue of a product that is not produced by Big Pharma. Electronic cigarettes are a real threat to Pfizer's profits.

Clearly, New York Times readers have the right to know about this conflict of interest so that they can properly interpret the validity of the arguments being made by the American Lung Association.

It is valuable to engage in public debate about the complex regulatory, research, and policy issues involved with electronic cigarettes and the public's health. However, it is essential that this debate include appropriate disclosures of financial conflicts of interest that might bias the opinions or conclusions expressed in these debates. In particular, when a commentator has received financial support from a corporation that manufactures a competitive product to electronic cigarettes, that should be disclosed. Readers deserve this information so that they can properly evaluate and interpret the opinions expressed by the authors. Failure to disclose this information is effectively hiding important facts from the public.

New York Times Features Debate on Electronic Cigarettes

The New York Times "Room for Debate" section yesterday featured a debate about electronic cigarettes. I was honored to be one of the commentators asked to provide a perspective for the debate. In subsequent posts, I will provide commentary on the debate and the other articles.

Duke a Willing Collaborator in Defrauding the American Public

In agreeing to accept funding from Philip Morris for its Center for Smoking Cessation, Duke acted willingly as a collaborator in the defrauding of the American public.

A review of news articles announcing the funding of the Duke Center for Smoking Cessation by Philip Morris revealed that Philip Morris used this funding as an opportunity to improve its poor public image by making the public believe that the company was committed to getting smokers off of its products. And Duke happily gave Philip Morris a platform to make these fraudulent statements.

According to a 2004 article in the Duke Chronicle: "Philip Morris USA, however, hopes to show with this grant that it recognizes this fact and wants to help smokers who want to quit. "One of our goals is to reduce the harm caused by our products," said Jennifer Golisch, a spokesperson for Philip Morris."

According to a 2008 article in the Duke Chronicle: "Bill Phelps, a spokesperson for Philip Morris, emphasized that the money was given without caveats that could influence the findings. For example, Philip Morris cannot veto publication of research from the center. "We give grants to universities for a variety of reasons," Phelps said. "Some [grants] in the past have been for smoking- and health-related research. We have given a grant to Duke... that is related to our program which is called cessation." ... Phelps ... said Philip Morris is assisting its patrons in whatever way possible. "We think that if smoking is addictive and causes serious issues... we can be helpful in that role of acquittance," he said."

The Rest of the Story

Acquittance is a perfect Freudian slip. I think the word that should have been used was "assistance." But what is behind the Philip Morris grant is actually "acquittance." The chief aim of Philip Morris in funding this research is to be acquitted for the harm it is doing in selling products that kills hundreds of thousands of people each year. And what a perfect way to achieve acquittance: by getting the Duke Center for Smoking Cessation to promote Philip Morris to the public and give it a platform for making it appear that the company is committed to getting smokers to quit using its products.

I need to make it clear that I am not blaming Philip Morris for seeking out these public relations opportunities. It is a brilliant strategy and a wise business decision. All successful companies have strong public relations as part of their marketing activities. The entity I am blaming is the Duke Center for Smoking Cessation, because without their willingness to collaborate, this defrauding of the American public could not take place.

The rest of the story is that Duke willingly is collaborating with Philip Morris in defrauding the American public by making it appear that the tobacco company is sincerely committed to getting smokers to get off its products. Of course, that is nonsense. It would be a very bad business decision, would send its stock spiraling down, would jeopardize its dominant market share, and would lead to the firing of the Philip Morris executives. The company's job is to sell cigarettes, not to convince consumers not to use its products.

However, the job of the Duke Medical Center is not to sell cigarettes. Sadly, by collaborating with Philip Morris in the defrauding of the American public, the Duke University Medical Center is actually doing more to market cigarettes than to prevent or reduce their use.

And even more sad is that they just don't get it. In defending the acceptance of Philip Morris money, the Center's director, Dr. Jed Rose, stated: "I recognize that there are widespread opinions that people have about using tobacco funding for research. But the source of the money is less relevant than the conditions [with which] the money is being given."

Baloney. It is the source of the money that is in question here, not the conditions with which it is being given. Philip Morris is not so stupid as to give money in the current decade with many strings attached. That would make it easy for the public to criticize. The brilliance of the company's public relations strategy is that it gives this money without strings attached. Thus, it has the appearance of being part of a sincere effort to undermine its business when it is actually a public relations effort.

That physicians in the Center and at Duke Medical Center are unable to see the role they are playing in undermining efforts to protect the public's health from the chief cause of preventable death is truly sad. And that they are defending it by noting that there are no strings attached is shameful.

One of the "strings" that is attached is that by accepting the money, The Center is aiding Philip Morris in deceiving the public into thinking that the company is committed to getting its customers off of its products. That would be a severe violation of their stockholders' interests and of course, the company wouldn't and arguably is not charged with the responsibility of doing that. However, as part of a medical center, the Duke Center for Smoking Cessation is charged with some important ethical responsibilities. And one of those is not collaborating with Big Tobacco in defrauding the American public. One of those is not playing a role in the public relations and marketing strategies of the deadliest consumer product.

Duke Center for Child and Family Policy is Aiding Public Relations Efforts of Big Tobacco

Earlier this summer, I revealed that the Duke Center for Smoking Cessation is still accepting Big Tobacco funding and not prominently disclosing it.

I wrote: "Since [Judge Kessler's] decision, it has become very difficult to find an academic medical or public health institution that is willing to accept tobacco funding. There is still, however, a last refuge for tobacco industry-sponsored research. There is a last bastion of acquiescence in the historical tobacco industry scheme to gain a public relations victory by allying itself with academia and pretending to be an objective, scientific voice in the smoking debate. There is still one academic center that is allowing itself to be used as a pawn in the marketing of cigarettes. That last bastion is the Duke Center for Smoking Cessation."

Today, I reveal that another center at Duke University - the Duke Center for Child and Family Policy - is also taking Big Tobacco funding.

The Rest of the Story

At the Duke Center for Child and Family Policy, "faculty and staff work together to discover and evaluate strategies to improve outcomes for children and families and to share their discoveries with policymakers and public agencies."

One of the strategies to improve outcomes for children and families that you won't see the Center sharing with policymakers is increasing cigarette taxes or imposing financial penalties on tobacco companies to fund aggressive anti-smoking media campaigns that demonstrate to youth the role of the tobacco industry in the smoking epidemic.

The Center's hands are tied because it is funded by Philip Morris.

Moreover, by accepting this funding, the Duke Center for Child and Family Policy is serving a public relations function for Philip Morris. It is helping Philip Morris to improve its public image by associating the tobacco company with the academic name and reputation of Duke.

In United States of America v. Philip Morris USA, Inc., et al. (Civil Action No. 99-2496 [GK]), the United States District Court for the District of Columbia found that tobacco industry funding of university research has long been part of an illegal enterprise that violates federal anti-racketeering law. The Court found that tobacco industry funding of university research was essentially a public relations ploy to undermine the public’s appreciation of the harms of smoking while making it appear that the tobacco companies were concerned corporate citizens interested in advancing objective scientific research.

The most important role of industry funding of research has been to refurbish the public image – especially the scientific image – of the tobacco companies: “Robert Seligman, Vice President of R&D of Philip Morris, described how Defendants used institutional grants to refurbish their scientific image. Seligman reported that … Shook, Hardy & Bacon attorney William Shinn had stated: “CTR began to lose their luster in the mid-60’s and the tobacco industry looked around for more beneficial ways to spend their research dollars on smoking and health. It was at this time that special projects were instituted at Washington University, Harvard University, and UCLA. … The industry received a major public relation ‘plus’ when monies were given to Harvard Medical school.” (page 148)

In fact, the chief public relations advantage gained by the industry granting money to an institution is the good will associated with the university’s name: “Arnold Henson of American [Brands Tobacco Company] acknowledged that one of the main reasons for the Harvard project was the ‘PR value of the Harvard name.’” (page 148)

In the opinion of the Court, the external research funding of the tobacco companies served as a way for the tobacco companies to coordinate their fraudulent activities, in violation of federal law (page 1541).

Brown & Williamson was quite explicit in acknowledging that the Council for Tobacco Research - the major research funding arm of the tobacco industry for many years - was essentially a public relations ploy, saying that “CTR was organized as a public relations effort” (page 50).

By accepting funding from Big Tobacco, the Duke Center for Child and Family Policy is allowing itself to serve as a pawn in Philip Morris' public relations strategy.

The rest of the story is that rather than being a model for child and family policy for the nation, Duke is instead an example of exactly the opposite. It is perhaps a model, but a model for the most egregious violation of academic ethics. Duke is allowing itself and its reputation and good name to be used as a public relations ploy for a tobacco company. Duke is allowing itself to be used as a pawn in the public relations and marketing strategy of Philip Morris.

By associating its name with that of Duke University, Philip Morris is using Duke to gain public relations marketing value from that association. This is public relations 101. Using corporate funding to secure public credibility and respect. It was part of Philip Morris' (and the other tobacco companies') playbook for decades.

The rest of the story is that Duke continues to undermine its own scientific integrity and that of academia as a whole by allowing itself to serve as a pawn in the tobacco industry's public relations and marketing strategy. A university - and especially a child policy center - should not play a role in marketing the most deadly consumer product. But that is exactly what Duke is doing.

Rather than being recognized as a model for child and family policy, the Duke Center for Child and Family Policy should instead be entered into the Hall of Shame as a center that puts money over ethical integrity.

American Heart Association Accused of Accepting Payments to Allow Undeserving Products to Use "Heart-Healthy" Label

The American Heart Association has been accused, in a lawsuit filed against the Campell Soup Company, of allowing products that are not heart-healthy according to its own standards to display the "Heart-Healthy" label in exchange for financial payments.

According to the AP story: "A new lawsuit is contesting the validity of the heart-healthy claims on some cans of Campbell’s soups. At the center of the federal lawsuit is the ‘‘Heart-Check’’ certification by the American Heart Association, and whether it rightfully conveys that a product carries particular health benefits. The lawsuit says the nonprofit group lets Campbell and other companies use the ‘‘Heart-Check’’ label on products that run counter to its stated mission, in exchange for fees. The American Heart Association says its goal is to fight cardiovascular diseases and stroke."

"To earn its ‘‘Heart-Check’’ certification, the group’s website states that products must have no more than 480 milligrams of sodium per serving. But the website also notes elsewhere that ‘‘low sodium’’ is defined as having 140 milligrams or less per serving, the lawsuit notes. ‘‘The AHA, for a fee, abandons its general, non-commercial dietary and nutritional guidelines,’’ the lawsuit states. A can of Campbell’s ‘‘Healthy Request’’ condensed Chicken Noodle Soup, which bears the certification mark in question, is listed as having 410 milligrams of sodium per half-cup serving. The lawsuit notes that there are two or more servings per can, meaning there would be at least 820 milligrams of sodium in a can. ... The lawsuit states that the AHA’s seal of approval misleads people into thinking in that products made by Campbell ‘‘possess some cardiovascular benefit not enjoyed by products that have not been certified by the AHA.’’ It states the only difference is that Campbell pays money for the certification."

The Rest of the Story

What the American Heart Association is doing is nothing short of fraud. And the most despicable part of their behavior is that they are essentially being paid off to partner with corporations to commit this fraud. Money, not the public's health, is apparently the driving force behind the American Heart Association's actions.

I'm sorry, but there is simply no way that a can of soup that contains 820 milligrams of sodium (one half of an entire day's limit for "heart health") should have a heart-healthy label. The fraud, of course, is that the American Heart Association allows corporations to base the label on one serving of the product, rather than one can. But how many people do you know who pour out half a bottle of Campbell's soup and then put the remainder away for a different day?

By allowing companies to use very small amounts of food (in this case, just one cup) as a serving size, the American Heart Association is defrauding the American consumer. This might not be so bad if it weren't the case that the Heart Association is apparently being paid off. What a scam.

Despite Best Efforts of Anti-Smoking Groups, Cigarette Sales Were Down 600 Million Units in First Quarter of 2013

Despite the best efforts of many anti-smoking groups, cigarette sales were down 600 million units in the first quarter of 2013. Why? Because electronic cigarettes competed successfully with tobacco cigarettes and drove their sales down.

According to an article in the Wall Street Journal: "The market for e-cigarettes, which includes more than 250 brands, has grown from the thousands of users in 2006 to several million world-wide. Analysts estimate sales could double this year to $1 billion. Some go as far as saying consumption of e-cigs could surpass consumption of traditional cigarettes in the next decade. Tobacco company executives even noted that e-cigarettes drove total industry cigarette volumes down about 600 million cigarettes, or about 1 percent, during the first quarter, excluding Internet sales—a major avenue for e-cig purchases."

This effect, which is going to reduce smoking-related disease, occurred despite the best efforts of many anti-smoking groups, which have been vigorously discouraging smokers from quitting smoking or cutting down on their cigarette consumption using e-cigarettes.

In other words, if the anti-smoking groups had their way, there would have been 600 million more cigarettes smoked in the first quarter of 2013.

The Rest of the Story

You may be wondering if you read this story correctly. It states that the anti-smoking groups are acting in a way to increase cigarette consumption, rather than decrease it. This seems ironic, if not absurd.

Nevertheless, this is not a mistake. It is true. The anti-smoking groups did everything they could to prevent this 600 million unit decline in cigarette sales. Fortunately, many smokers didn't listen to the anti-smoking groups and instead, decided to put their health first and to decrease their consumption of cigarettes.

It is sad that a successful intervention that is decreasing cigarette consumption is occurring not as a result of the actions of tobacco control groups, but in spite of their actions. In fact, the cigarette companies are playing more of a role in this substantial public health success story than the anti-smoking groups.

It's time for the anti-smoking groups to go back to the drawing board and remind themselves that they are trying to improve the public's health, not harm it.

American Legacy Foundation-Proclaimed "Leader" in Tobacco Control is Now Advertising Camel Cigarettes to Millions of Youth Readers

In 2007, the American Legacy Foundation, according to its website, honored Glamour and Vogue with a corporate partnership: Legacy listed Conde Nast Publications - the publisher of these magazines - as being its corporate partner. According to a Legacy report, the Foundation reaped a significant financial benefit from this corporate partnership: substantial advertising discounts in the company's magazines.

Moreover, the American Legacy Foundation called Conde Nast Publications - its corporate partner - a "leader" in the tobacco control movement.

The Rest of the Story

In 2013, while most cigarette advertising in magazines has gone by the wayside, Conde Nast Publications is featuring, in several of its magazines with large youth readerships, a 3-page spread advertising Camel cigarettes. According to the Campaign for Tobacco-Free Kids, these ads are reaching a total youth audience of at least 12.9 million teenagers: more than 2.2 million youth readers through Glamour and nearly 1.2 million teens through Vogue.

According to the Campaign for Tobacco-Free Kids: "The August 2013 issue of Glamour magazine features the world’s most popular boy band, One Direction, on the cover.  Inside the magazine, and placed just before the story and photos on the band, there’s a huge, three-page spread of ads for R.J. Reynolds’ Camel cigarettes. The magazine’s cover no doubt is attracting many teens and tweens who make up the band’s fan base, exposing them to messages encouraging them to smoke.  Glamour has more than 2.2 million teen readers, according to GfK MRI, a consumer research firm."

So thanks largely to Conde Nast Publications, we have now turned the clock back more than a decade and recreated the problem of youth exposure to cigarette advertising in magazines - a problem that had almost disappeared.

The unforgivable part of this story is that it was the American Legacy Foundation that honored Conde Nast Publications with a corporate partnership and called Conde Nast a "leader" in the tobacco control movement.

Back in 2007, I wrote: "The rest of the story is that while the American Legacy Foundation's mouth is busy complaining about how Vogue and Cosmopolitan are carrying these malicious advertisements which are directly targeting girls [the Camel No. 9 ads], the Foundation has done something very different with its financial interests: maintained a corporate partnership with these very magazines. ... So the truth of the matter is that the American Legacy Foundation is, or at least was, a corporate partner of the very companies which are carrying these supposedly despicable Camel No. 9 advertisements to our nation's girls."

"If Legacy were sincerely interested in ending the advertising of Camel No. 9 cigarettes, I should think that the first thing it would do is to end its corporate partnership with Hearst and
Conde Nast (and do so in a very vocal manner), or at very least, to issue an ultimatum to these companies that they either halt the advertising of Camel No. 9 cigarettes or Legacy will end its partnership and stop honoring these companies as public health contributors."

"While Legacy is easily able to write a stinging letter demanding that magazines cease their advertising of Camel No. 9, it does not appear to be so willing to risk its financial benefits by threatening or ending its corporate partnership with the very same magazines."

"Interestingly, while Legacy mentions that Vogue and Cosmopolitan are carrying the Camel No. 9 ads, it is careful not to mention the names of the companies that publish these magazines. Apparently, this is one benefit of a corporate partnership with Legacy: protection from public criticism."

While the rest of the tobacco control movement was working in the mid-2000s, and for decades before that - to reduce or eliminate cigarette advertising in magazines - the American Legacy Foundation was working on the opposite side of the issue, undermining the work of the rest of the tobacco control community. Sadly, they have never acknowledged this serious error. Today, given what Conde Nast is now doing, Legacy should acknowledge its mistake and issue an apology.

Today, I cannot find any evidence that Legacy is criticizing Conde Nast for its actions in helping promote Camel cigarettes to its youth readers. I've seen no evidence that Legacy is remorseful for putting its financial interests ahead of the public's health.

But I suppose it's not surprising that Legacy would not criticize Conde Nast. It's difficult to bite the hand that feeds you, and even the one that fed you.

Gallup Poll Shows that Cold Turkey is Overwhelmingly the Most Successful Quitting Strategy, With NRT Making Little Contribution

A July Gallup poll asked former smokers to identify the strategies or methods they used to successfully quit smoking. Based on their smoking cessation recommendations to the public, if you ask any anti-smoking organization what they think would be the most common answer to this question, they will most likely say:

a. Nicotine patch;
b. Nicotine gum;
c. Nicotine inhaler; or
d. Prescription drugs.

But the public's answer to the question was essentially "None of the above." Overwhelmingly, the method identified by ex-smokers as most effective for quitting was "cold turkey."

Nearly half of successful quitters (48%) identified cold turkey quitting as the most effective strategy for them. In contrast, only 5% identified the nicotine patch, 1% identified nicotine gum, no one identified the nicotine inhaler, and 2% identified prescription drugs.

Interestingly, despite discouragement from anti-smoking groups, 3% of successful ex-smokers identified electronic cigarettes as being the most effective smoking cessation strategy, higher than the proportion identifying Chantix, Buproprion, nicotine gum, or the nicotine inhaler and only slightly behind the nicotine patch.

The Rest of the Story

There are two important findings of this survey.

First, it is very clear that despite the findings of clinical trials, when you examine the question on a population basis, cold turkey quitting is the most effective strategy and the "recommended," "FDA-approved" quitting methods are not particularly useful.

What does this mean? It demonstrates what I've been arguing for months: that although clinical trials have found that NRT and drugs are effective, the absolute cessation rates are dismally low. Thus, these approaches cannot be said to be "effective" strategies for smoking cessation on a population basis.

It also demonstrates that most clinical trials results are meaningless because they involve not just NRT or drugs but intensive intervention involving multiple medical visits, assessments, counseling, etc. When used in real-life settings, these products are not nearly as effective. And of course, that is what matters most, not the clinical trial results.

Second, these findings suggest that electronic cigarettes are an effective smoking cessation tool for many smokers. Anti-smoking groups which continue to argue that there is no evidence that electronic cigarettes can be effective for smoking cessation are ignoring the evidence and misleading the public.


(Thanks to John Polito for the tip.)

Why is the CDC Taking Research Funding from a Pharmaceutical Company?

When I worked at the Centers for Disease Prevention and Control (CDC) from 1993-1995, I always considered it to be an independent, objective source of public health scientific research and policy analysis. I can attest that all of the research I conducted there was independent and free of any influence from corporate interests. None of the research I conducted was funded by, or conducted in partnership with any tobacco or pharmaceutical companies, nor did we farm out any research to be funded by or associated with corporations.

It's remarkable how much things have changed since I left the agency in 1995.

Last week, the CDC published an article in its journal "Preventing Chronic Disease" that assessed the economic impact of smoke-free bar and restaurant laws. The research found that there was no adverse economic impact of these laws in the nine states studied.

This may sound innocent enough.

Consider, however, that the research was funded through the CDC Foundation, which contracted with RTI International to conduct the study. And who actually funded the study?

The Rest of the Story

The study was funded by a drug company: Pfizer.

And Pfizer wasted no time in boasting about its partnership with CDC. In the very press release that was supposedly intended to announce the important scientific results of the study, the CDC Foundation was sure to include this public relations statement from the corporation:

"Pfizer is proud to have partnered with the CDC Foundation and CDC on this important research initiative and we are very encouraged by the results,” said Freda C. Lewis-Hall, MD, FAPA, executive vice president and chief medical officer, Pfizer."

So now you know the truth. The real story behind this research is that its true purpose - from the perspective of Pfizer - was to create the public perception that Pfizer and CDC are partners.

That's all very charming, but there's just one problem. It is not appropriate for a government public health agency to partner with the very corporations about whose drugs or products that agency issues recommendations about their approval, disapproval, or use.

Suppose I were a corporation that manufactured a vaccine about which CDC was going to make a recommendation for either approval or disapproval. Wouldn't I just love the opportunity to partner with the CDC so that I could influence their decision with money, and to do it legally no less?

Well, this is exactly what the CDC is now allowing corporations to do by accepting their donations in return for the opportunity to partner with, and thus influence, the agency's decisions. And the CDC Foundation acknowledges this right on its web site, writing that two of the "added values" to corporations of partnering with the agency are:

• creating "mutually beneficial collaborations with world-renowned CDC scientists"; and
• simplifying "the process of partnering with a complex federal agency."

The collaboration with CDC scientists is mutually beneficial because the scientists get funding with which to conduct additional research and the corporation gets a perfectly legal opportunity to exert an influence on federal public health policy at the highest level.

For example, the CDC makes recommendations regarding the use of vaccines. One vaccine about which the CDC deliberated was Pfizer's Prevnar. The CDC Advisory Committee on Immunization Practices (ACIP) regularly makes recommendations regarding the use of vaccines.

Furthermore, CDC makes recommendations regarding a wide range of other drugs, related to the prevention and treatment of all sorts of infectious and chronic diseases.

Through its partnership with CDC and the CDC Foundation, Pfizer has the potential to gain an increased corporate image among CDC staff, and therefore, to influence decisions that the CDC makes about the approval or disapproval of Pfizer products. I am not arguing that the influence is a conscious one. I’m not saying that CDC will consciously say to itself: we received money from Pfizer so let’s be extra nice to them in our formulation of public recommendations. However, I do believe that the receipt of this funding from Pfizer, which the CDC Foundation praises heavily in its press release, will have the effect of improving the company’s image within the agency, and that it could potentially have a subconscious effect on the agency and therefore influence its actions. This is precisely how conflicts of interest work.

If this were an individual researcher rather than an agency, there is no question that the partnership with Pfizer and other pharmaceutical companies would represent a conflict of interest. I see no reason why it is not a conflict just because the CDC is an agency rather than an individual. The conflict of interest would be expected to work in exactly the same way.

The CDC Foundation has a large number of partnerships with Big Pharma companies, including GlaxoSmithKline, Bristol-Myers Squibb, Eli Lilly, Johnson & Johnson, Novartis, and Sanofi-Aventis. So the problem is not restricted to this one partnership with Pfizer.

The CDC Foundation also partners with the Coca-Cola Company. According to the CDC Foundation, partnerships are only accepted with "Corporations whose goals or philanthropic interests align with CDC’s work...".

In what way do Coca-Cola’s goals align with those of CDC? The CDC is in the business of trying to improve the public’s health. Coca-Cola is in the business of trying to market and sell sugar-laden soft drinks that contribute to the obesity epidemic. The CDC presumably favors school nutrition improvement. Coca-Cola has opposed virtually every piece of state legislation to improve school nutrition. The CDC presumably wants to decrease the consumption of sugar-laden soft drinks. Coca-Cola is working to sustain the sales of its sugar-laden soft drinks.

Don’t get me wrong. I’m not criticizing Coca-Cola. They are not in business to reduce obesity. They are in business to sell soft drinks and I wouldn’t argue that they should do otherwise. If anything, I commend Coca-Cola for being brilliant enough to use its money in a way that may soften the CDC’s stance on sugar-laden soft drinks.

The CDC Foundation also partners with Abbott Laboratories.

How could the CDC’s partnership with Abbott Laboratories not constitute a violation of its corporate partnership policy? Abbott Laboratories is one of the leading manufacturers of infant formula, which it is pushing to pregnant women through programs such as the giveaway of infant formula in hospitals. Presumably, the CDC has a vested interest in promoting increased breastfeeding and reduced use of infant formula. This certainly appears to represent a conflict of interest.

The CDC Foundation also partners with Georgia Pacific.

How could CDC’s partnership with Georgia Pacific not constitute a conflict of interest? Georgia Pacific is one of the nation's leading corporate polluters. In what way does that align with CDC's mission and goals?

The rest of the story is that through its corporate partnerships with companies which either produce products that are causing harm to the public or which are within the scope of CDC’s public recommendations, the CDC Foundation is creating significant conflict of interests that conflict with its stated policy of avoiding such conflicts. I believe that these partnerships taint the scientific objectivity of the agency, are inconsistent with the stated mission and policy of the CDC and CDC Foundation, and represent a disservice to the public’s interest.