Monday, March 31, 2014

Laboratory Study Shows No Detectable Carcinogens or Metals in High-Technology Electronic Cigarette Brand, Suggests that Minimal Risk E-Cigarette is Technologically Feasible

A laboratory study presented last week at the annual meeting of the Society of Toxicology provides important new evidence that electronic cigarettes have the potential to deliver nicotine with a high degree of relative safety. Specifically, the study reports that a high-technology brand of electronic cigarette (VUSE) delivers an aerosol that has no detectable carcinogens or metals - compounds that were of concern in a number of other e-cigarette brands.

(See: Theophilus EH, et al. VUSE electronic cigarette aerosol characterization (poster). Presented at the Annual Meeting of the Society of Toxicology, March 24-27, 2014.)

In the study, researchers from R.J. Reynolds Tobacco Company and the Eurofins-Lancaster Laboratories in Winston-Salem examined the constituents in the aerosol produced by VUSE electronic cigarettes. Of particular concern were a number of carcinogens, metals, and volatile compounds found in previous studies of different electronic cigarette brands. The study chromatigraphically profiled the chemical constituents of VUSE aerosol.

Among the compounds specifically examined were the following:

Tobacco-specific nitrosamines



Volatile Organic Compounds
Propylene oxide
Vinyl chloride

Poly-aromatic amines

Poly-aromatic hydrocarbons


The study reported that none of the above chemicals were detected: all were below the limit of detection or limit of quantification of the laboratory methods used. In contrast, most of these compounds were detected in tobacco cigarettes.

The study concluded that the composition of VUSE aerosol is much less complex than that of tobacco smoke, that the main compounds detected are those predicted to be present (i.e., those present in the e-liquid), and that none of the toxicants of specific concern were detectable in the electronic cigarette aerosol.

The Rest of the Story

This research is important because it suggests that it is technologically possible to produce an electronic cigarette that delivers nicotine with an excipient, but essentially without any other toxic or carcinogenic chemicals. How R.J. Reynolds is able to avoid the hydrolysis products of propylene glycol is not clear. Perhaps it is related to the quality of the heating mechanism and/or the temperature regulation. The avoidance of metal contamination may have to do simply with the quality of the manufacturing process. At any rate, this is an important study because it suggests the great promise of the electronic cigarette as perhaps the most important smoking cessation product of the future.

Of course, this is only a study of one brand of electronic cigarette. But it shows what is technologically possible. I believe that one of the FDA's priorities in regulating these products should be to discover and articulate the specific manufacturing processes or features that allow nicotine to be delivered in as clean a fashion as VUSE appears to deliver it. Quality assurance and quality control standards should be the centerpiece, I believe, of the FDA's regulation of electronic cigarettes, rather than strict regulation of these devices in a manner similar to that of tobacco cigarettes.

While we still don't know the effects of long-term inhalation of propylene glycol, this study suggests that outside of the nicotine, VUSE poses minimal health risks. Obviously, this research helps to confirm that VUSE is much safer than tobacco cigarettes.

It is also important to note that this study also suggests that "secondhand" exposure to VUSE e-cigarettes is unlikely to pose any substantial health risks.

This research should cause tobacco control practitioners to embrace electronic cigarettes as a promising device that could permanently alter the nature of the combustible tobacco product space, potentially saving more lives than any previous smoking cessation product. We have a long way to go, but embracing the promise of these products and committing to use our public resources and policies to maximize the benefits while minimizing the risks of these products is the first step.

Monday, March 24, 2014

New Study on Electronic Cigarettes by UCSF Researchers is Not Only Bogus Science, But is Also Dishonest

Researchers from the Center for Tobacco Control Research and Education at UCSF have published a research letter in JAMA Internal Medicine which purports to show that electronic cigarettes are ineffective for smoking cessation.

(See: Grana RA, Popova L, Ling PM. A longitudinal analysis of electronic cigarettes use and smoking cessation. JAMA Internal Medicine. Published online March 24, 2014. doi:10.1001/jamainternmed.2014.187.)

The study involves a survey of 949 adult smokers who were interviewed at baseline in 2011 and followed up one year later. Of these smokers, at baseline, 88 had tried electronic cigarettes in the past month (that is, they had used electronic cigarettes at least once).

The study reports that at one year follow-up, the rate of smoking cessation among the baseline non-e-cigarette users was 13.8%, compared to 10.2% for the 88 electronic cigarette users, a difference that was not statistically significant. On this basis, the study concludes that electronic cigarettes are not effective for smoking cessation.

The authors write: "Consistent with the only other longitudinal population-level study with 1-year follow-up that we are aware of, we found that e-cigarette use by smokers was not followed by greater rates of quitting or by reduction in cigarette consumption 1 year later."

They conclude that "our data add to the current evidence that e-cigarettes may not increase rates of smoking cessation."

The Rest of the Story

I'm sad to say that this is complete garbage.

It is truly an example of bogus, or junk science.

Why? Because the study does not examine the rate of successful smoking cessation among electronic cigarette users who want to quit smoking or cut down substantially on the amount that they smoke and who are using e-cigarettes in an attempt to accomplish this.

Instead, the study examines the percentage of quitting among all smokers who have ever tried electronic cigarettes - for any reason - in the past month.

A large proportion of the 88 smokers who had tried an e-cigarette may have simply been trying these products to see what they are like. It is plausible, in fact probable, that many of these 88 smokers were not actually interested in quitting or trying to quit with electronic cigarettes. These products have become very popular and have gained widespread media attention and it is entirely possible that many of these smokers simply wanted to see what the big fuss is all about.

It is easy to see how this fatal flaw in the research destroys the validity of the authors' conclusion.

But that isn't the end of the story. If this were simply a bogus conclusion, then we could simply evaluate the article as being junk science, dismiss it as bogus, and leave it there. But unfortunately, it doesn't end there.

Why? Because it is quite apparent from the study itself that the authors knew that the overwhelming majority of the 88 electronic cigarettes "users" in their study had little or no interest in quitting and were not using these products as part of a quit attempt.

How do we know this? Because the authors tell us!

In the Table, the authors report that of the 88 e-cigarette "users," only 8.0% reported that they were trying to quit at that time (that is, within the next 30 days). And only 39.8% of the e-cigarette users had any intention of quitting in the next six months. This means that we actually know for a fact that the majority of e-cigarette users in this study were not using these products as part of a quit attempt.

What this indicates is that this is not simply junk science. Rather, it is a deliberate attempt on the part of the investigators to misuse data. They are using these data to draw a conclusion about whether electronic cigarettes are effective in helping smokers quit, yet they are knowingly drawing upon data from smokers who are using e-cigarettes for other reasons, who may have simply tried an electronic cigarette once, and who most definitely were not using these products as part of a current quit attempt.

In other words, 92% of the e-cigarette users in the study were not trying to quit. We know for a fact that 92% of the e-cigarette users were not making a quit attempt. And yet the study authors interpret the data as if these smokers were trying to quit using e-cigarettes, but failed!

This is dishonesty in research.

Unfortunately, it does not appear that these investigators are truly interested in whether e-cigarettes help many smokers quit or not. Instead, I believe that these researchers have a pre-determined conclusion that e-cigarettes are ineffective and that they are trying to manufacture results that support their pre-determined conclusion.

It would be a tragedy if policy makers use the conclusions of this "study" to draw conclusions about the effectiveness of electronic cigarettes for smoking cessation purposes.

Another Tobacco Control Practitioner Tells Public that Smoking May Be No More Harmful than Vaping

Adding to the long list of tobacco control practitioners who have publicly declared that smoking may be no more harmful than vaping - which involves no tobacco and no combustion - a South Carolina respiratory therapist is telling patients that they should not quit smoking using electronic cigarettes because these devices may be more dangerous than tobacco cigarettes, which kills more than 400,000 Americans each year.

On the Greenville Health System blog, a respiratory therapist writes: "I strongly oppose the use of e-cigarettes. It is unregulated and could potentially be more dangerous than a regular cigarette."

This respiratory therapist misleadingly reports that: "emergency rooms across the United States have been reporting visits from patients that use e-cigarettes, with a variety of complaints, including blood clots, difficulty breathing, coughing, headaches and chest pain." But he fails to also mention that emergency rooms across the nation have also been reporting visits from patients who use NRT, with a variety of complaints that include blood clots, difficulty breathing, coughing, headaches and chest pain.

Moreover, he fails to report that emergency rooms across the nation have also been reporting suicides and attempted suicides from the use of Chantix.

The Rest of the Story

This irresponsible advice, supported by a fraudulent lie - that smoking may be safer than vaping - represents public health malpractice, in my opinion. In fact, as it may convince some smokers to continue smoking rather than switch to a non-tobacco product that has helped thousands quit smoking, it could actually constitute medical malpractice, as this negligent information and advice could actually lead to medical harm.

Why is it negligent? Because it deviates from a well-accepted standard of care in medical and respiratory therapy practice, which is telling the truth. By disseminating false information - that smoking may be no more hazardous than vaping - to patients, this could lead to medical harm by convincing smokers not to quit via electronic cigarettes, but based on false information.

It is certainly not medical malpractice to advise patients not to use electronic cigarettes, because these products are not yet the standard of care in medical treatment for smoking dependence. However, to tell patients not to use electronic cigarettes because they may be more dangerous than cigarettes is clearly negligent, and in my opinion it rises to the level of malpractice if it ends up causing medical harm (i.e., a smoker who is misled by this advice and decides not to quit smoking because of the advice).

But beyond the issue of medical or public health malpractice, I am most concerned about the simple principle of honesty. As medical and health professionals, our very first obligation is to be truthful with our patients and with the public. The information being provided by this respiratory therapist is untruthful. It is simply not the case that smoking may be less hazardous than vaping. There is no credible scientific debate about that issue in the year 2014.

Thursday, March 20, 2014

Exactly 44% of Kids Who Start Smoking Do So Because of Smoking in Movies

Not that our science allows us to be precise to the percentage point, but the American Legacy Foundation has publicly claimed that exactly 44% of kids who start smoking do so because of having seen smoking in the movies.

The claim is made in a press release entitled "44 Percent of Adolescents Who Start Smoking Do So Because Of Smoking Images They Have Seen In The Movies."

According to the press release: "As viewers around the world prepare to tune in for Sunday's 86th annual Academy Awards honoring achievements in the film industry, the public health community is drawing attention to new data concluding that by eliminating tobacco imagery in youth-rated movies, youth smoking rates could decline by an estimated 18 percent. Incidents of smoking in youth-rated films have doubled between 2010 and 2012, returning to levels of a decade ago. In fact, according to Thumbs Up! Thumbs Down! two of the three PG-13 movies (Captain Phillips, Philomena) that are nominated for Best Picture this year include smoking. Large-scale studies have demonstrated that movies with smoking cause youth to start smoking, and this rebound represents a set-back for national youth tobacco prevention goals. According to research funded by Legacy, in 2013 youth-rated movies delivered an estimated 14.8 billion tobacco impressions to theater audiences, a 169 percent increase from 2010."

The Rest of the Story

The major problem with this claim is that exposure to smoking in movies is likely to represent a proxy measure for a wider constellation of media-related exposures to smoking that likely all contribute to the smoking initiation process. These include magazine advertising, outdoor advertising (especially on the exterior of stores and point-of-sale advertising within stores), exposure to smoking on television, in music videos, video games, the internet, etc.

The studies upon which the 44% figure is derived did not produce a comprehensive picture of each youth's exposure to smoking in all media and then isolate the impact of smoking in movies. In fact, these studies simply compared smoking initiation between youth with differing levels of exposure to smoking in movies.

Therefore, I don't think it is valid to isolate the specific impact of exposure to smoking in movies and claim that this exposure alone is the cause of youth smoking in these 44% of youth smoking cases. It is likely that a much wider array of exposures is contributing to the initiation process. Exposure to smoking in movies may certainly be one of them, but it is not the only one, and I do not believe that from the underlying studies, which didn't measure any of these other exposures, one can tease out the smoking in movies and claim that it is the precise (and sufficient) cause of the observed smoking behavior.

Why is this important? After all, couldn't one argue that since the ultimate effect of this research and any resulting policy action will be to reduce exposure to smoking and decrease smoking (albeit by a lower amount than 44%), it is ultimately not a problem?

I think it is a problem, however, for two reasons.

First, I think that despite all this scientific work being for a great cause, it ultimately hurts the science base for tobacco control in general to have specific claims being made from studies that do not support those claims. It is only an observation, but it certainly seems to me that the rigor required before we start making these kinds of precise quantitative claims has decreased over the years in which I have been doing research in this field. Ultimately, I guess that I am concerned somewhat about the credibility of tobacco control research findings among the public if they are continually exposed to these types of quantitative claims being made from research designs that are simply not "designed" to produce such claims.

Second, if, for the reasons I have outlined above, the claim is an overestimate, then we will fail to see the expected decline in youth smoking if we do address the problem definitively. So even if we were to ban all smoking in movies tomorrow, I very much doubt that we would subsequently see a 44% reduction in youth smoking initiation.

In fact, there is evidence to support this contention. After all, the Legacy press release claims that there was a doubling of youth exposure to smoking in youth-rated movies between 2010 and 2012. Further, there was a 169% increase in tobacco impressions in youth-rated movies between 2010 and 2013.

If it were true that smoking in movies is responsible for 44% of youth smoking initiation, then certainly we would have expected to see an increase in smoking initiation over the past three years, concurrent with this drastic increase in smoking in movies. However, the opposite is the case. Smoking among youth is now at an all-time low. It has declined significantly, rather than increased drastically, during the past three years.

These data hardly seem consistent with the claim that smoking in movies - alone - is responsible for 44% of youth smoking initiation.

An even more significant problem is that of confounding. Youths do not randomly choose to watch or not watch films that are likely to show lots of smoking. Some of the factors that predict what movies a youth is likely to view are also likely to predict their risk of smoking initiation. It is difficult to identify, much less quantify and measure these variables, and the existing studies have controlled for a few potential confounders, but not for many of them.

For these reasons, I think it is scientifically unsupportable for the American Legacy Foundation to claim that 44% of all smoking initiation is caused by exposure to smoking in movies.

Does smoking in movies contribute towards media exposure that influences youth smoking?


Should we take efforts to reduce youth exposure to smoking in movies and other media?


But I don't think we do ourselves any favors when we go beyond the science and make sweeping, yet quantitatively precise claims like this one from Legacy. Ultimately, it hurts our scientific credibility and undermines the integrity of our work.

Wednesday, March 19, 2014

New Hampshire Public Radio - The Exchange Segment on Electronic Cigarettes and Smoking

Yesterday, The Exchange segment on New Hampshire Public Radio featured a detailed discussion of electronic cigarettes and smoking. If you listen, you'll hear a great example of the typical public health perspective on this issue, along with my arguments against that perspective.

Tuesday, March 18, 2014

Tobacco Control Science Deteriorating to an All-Time Low

Just days after Stan Glantz told the public that his cross-sectional study, which was unable to determine whether youths who use e-cigarettes go on to start smoking or whether smokers are more likely to try e-cigarettes, proves that e-cigarettes are a gateway to a lifetime of smoking addiction, researchers from elsewhere at the University of California are telling the public, based solely on mouse studies, that thirdhand smoke is as harmful as active smoking.

According to an article at Liberty Voice, thirdhand smoke is as deadly as smoking. In other words, if you sit in a room where people have smoked, you might as well be a smoker yourself.

This conclusion comes, by the way, purely from mouse studies in which mice treated with thirdhand smoke in controlled experiments experienced impaired wound healing and other forms of cell damage. Not a single human, clinical study was performed by these researchers to support their conclusion that thirdhand smoke exposure is every bit as bad as active smoking.

According to the article: "Studies are now showing the dangers of smoking, not just that of first and second-hand smoke, but the dangers presented by third-hand smoke. It is that sticky substance that is left behind on the walls, furniture, toys and surfaces after someone smokes indoors. ... The latest research, funded by the Tobacco-Related Disease Research Program, was published by the American Chemical Society on March 16. It states that young children are at high risk when they put toys in their mouth that have been exposed to third-hand smoke. It actually causes DNA damage and poses a risk for developing cancer." ...

"In another recent study, conducted by the University of California and published in PLOS ONE, researchers found that third-hand smoke is dangerous to the lungs and liver, possibly due to inflammation. They also found that it leads to type II diabetes, even when patients are not overweight or obese. Furthermore, they discovered that, while studying mice in a controlled environment, wounds on the skin did not heal as quickly. They determined that the collagen had been damaged. The study claims that third-hand smoke is as big a danger and just as deadly as smoking itself."

The Rest of the Story

The rest of the story is that this is complete garbage.

It is truly depressing to me to watch this - day in and day out.

When the tobacco industry decided - sometime back around 2000 or so - to stop monitoring tobacco control science and to just let us say anything we wanted to - I thought they had made a poor decision. But in retrospect, I think it may have been brilliant. They apparently knew that before long, without the restraints of having to answer to Big Tobacco's public questioning, our science would deteriorate and we would just start saying anything we wanted to. Unrestrained, the tobacco control movement's scientific rigor would fall to such a low level that we would end up discrediting ourselves and undermining our own credibility.

Well, we're there. We're officially there.

I'm sure I'll have more to say about this later. But for now, I'm just too damn depressed.

Monday, March 17, 2014

Daly City Mayor Wants to Shut Down Shops that Sell E-Cigarettes, Keep those that Sell Real Cigarettes

In a move that could not be more favorable to the cigarette industry in Daly City, California, the city's mayor wants to ban vape shops that sell electronic cigarettes which are being used by many Daly City smokers to quit smoking or cut down substantially on the amount they smoke, while allowing the city's 85 cigarette stores to continue selling those deadly products.

Ironically, Mayor Canepa wants to close up shop for stores which are arguably selling a product that deters consumers from using toxic tobacco cigarettes, while at the same time, protecting existing stores from this competition and allowing them to continue selling their deadly cigarettes to Daly City smokers, which according to recent data, include children, who were able to buy cigarettes at one out of every four Daly City cigarette stores.

In fact, 96% of residents of Daly City believe that it is far too easy for kids in Daly City to purchase cigarettes. Thus, the logical action taken by the Mayor was which of the following:

A. Crack down on the sale of cigarettes to minors in Daly City
B. Eliminate the sale of cigarettes in Daly City
C. Decrease the number of stores allowed to sell cigarettes in Daly City
D. Ban vape shops which sell cigarettes to zero youths in Daly City.

The answer, sadly, is D - ban vape shops which sell cigarettes to zero youth in Daly City. Moreover, youths are not even allowed in these vape shops and it would be quite easy to adopt rules to ensure that youths do not have access to these stores.

Congratulations to Mayor Canepa, for making an early bid for the 2014 Colonel Benjamin Church Anti-Smoking Hypocrisy Award.

Friday, March 14, 2014

Cease and Desist: Clive Bates Tells Glantz to Stop Misrepresenting His Research on E-Cigarettes

On his wonderful science and advocacy blog, tobacco control practitioner and former director of Action on Smoking and Health (ASH-UK) Clive Bates issues a cease and desist order: an open letter to Stan Glantz urging him to discontinue the misrepresentation of his research to spread false and unsupported information about electronic cigarettes being a gateway to cigarette smoking.

The letter picks up on many of the precise points that I have been arguing during the past few weeks: post 1; post 2; post 3.

Clive's letter begins as follows:

"Dear Professor Glantz, Dr. Dutra:

Misleading use of survey data has no place in professional public health practice
I had intended to blog about your recent paper, but decided instead to write an open letter and to put these concerns to you directly. So, I write to express dismay at the false, misleading and damaging conclusions you have drawn from your recent paper in JAMA Pediatrics and related media communications. The errors of reasoning are elementary, but have been used to draw conclusions that are relentlessly hostile to e-cigarettes and the important public health concept of ‘tobacco harm reduction’.  

It should be stressed that misleading information in this arena can cause actual harm to real people if they react to misplaced concerns in ways that cause them to continue to smoke. Further dangers arise as physicians and other trusted professionals give bad advice based on false information. Finally, there is the danger that policy-makers and legislators will be misled into making excessively restrictive regulations that protect cigarette sales from competition from much safer and better alternatives.  I believe your study and the subsequent media work owe more to misguided activism than to responsible academic investigation, and as such they have no place in professional public health practice or a reputable university."

Clive goes on to cite two specific examples of conclusions that Glantz disseminated to the public which were not supported by his own research.

First, he cites the JAMA Pediatrics article in which Glantz and Dutra conclude that electronic cigarettes are exaggerating, rather than ameliorating smoking among youth. Clive writes: "somehow you have managed to position this study as showing there is a gateway from e-cigarette use to smoking. NOTHING in the study or the underlying data suggests this.  You would need information on how smoking, e-cigarette use and abstinence evolved over time to test these hypotheses, but your study does not have that."

Second, he cites the press release from that study, which opened with the admonition that electronic cigarettes are a gateway to smoking. Clive writes: "There is no basis for drawing this unequivocal ‘gateway’ conclusion from the data presented in the study.  None whatsoever – and the published study even makes this clear. In fact the data are consistent with the opposite hypothesis – that e-cigarettes are primarily used by smokers interested in quitting or cutting down. Indeed the observation  that users have a higher intention to quit smoking lends support to that hypothesis more than to your preferred explanation."

Clive further shows how the misguided headlines created by Glantz have already led to public policy makers being misled by this misrepresentation of the science.

The letter concludes: "I really hope you will reconsider your approach – it does not serve public health or the public interest. It is wrong simply to assume that e-cigarettes will play no part in reducing the expected one billion 21st Century deaths from smoking. The evidence that there is, taken as a whole, is actually very encouraging, and certainly not a reason to mount a ‘dirty tricks campaign’ against these products. In any event, there is never a case to mislead the public, policy-makers and legislators even if you are convinced the end justifies the means, which in this case it does not."

Like Clive, I do not criticize Stan for having a different opinion on the issue of electronic cigarettes. Having a diversity of opinions is a healthy thing and in the long run, it will help ensure that the best possible public policies result. However, misrepresenting scientific evidence, deceiving the public about the science and what it shows, and lying to the media and the public about the science are simply not acceptable. They serve no positive purpose and in the long run, they end up undermining the credibility of the entire tobacco control movement.

Thursday, March 13, 2014

UC Researcher: Vaping May Be More Hazardous than Smoking

According to an article in the UC Riverside campus newspaper, a UC Riverside researcher has discovered that electronic cigarettes are more hazardous than tobacco cigarettes.

According to the article: "UCR professor of cell biology Dr. Prue Talbot and her team discovered the chemicals used to refill electronic vapor cigarettes (e-cigarettes) may be more harmful than tobacco cigarettes. Her team discovered that electronic vapor requires a consumer to take deeper breaths which may potentially draw in harmful chemicals to fragile parts of the lungs, as opposed to a tobacco cigarette that burns on the other end, allowing the consumer less inhalation. “Our earlier studies with electronic cigarette refill fluids showed that some of these products were toxic to both mouse neural stem cells, (and) human embryonic stem cells as well as to adult lung cells,” she said in a UC press release."

The Rest of the Story

You've got to be kidding me! Based on some non-human studies of the toxicity of electronic cigarette chemicals in cell culture and based on the fact that her researchers believe vapers may have to take deeper breaths when vaping than smoking, Professor Talbot has concluded that vaping may be more harmful than smoking?

This is what we call science in tobacco control today?

Even if e-cigarette vapor shows some toxicity in cell culture studies, how does that demonstrate that vaping is more harmful than smoking?

And even if vaping involved deeper inhalation than smoking, how would that demonstrate that vaping is more dangerous than smoking, especially since the vaper is inhaling far fewer carcinogenic chemicals - and at far lower levels - than the smoker?

Furthermore, it is well known that electronic cigarette users do not inhale more deeply than smokers. While smoke does enter the distal airways - which is why adenocarcinoma rates have increased so dramatically - vaping involves aerosol inhalation and the aerosol is mostly absorbed in the upper, not the lower airways. As with a nicotine inhaler, most of the nicotine absorption occurs in the upper airways.

So not only are these researchers lying by making false extrapolations, they are lying even in the assumptions they are making prior to making those extrapolations. Worst of all, they are trying to make determinations of risk based on only one small slice of the total information that is necessary to judge the relative safety of electronic cigarettes compared to tobacco cigarettes.

I don't understand why electronic cigarette researchers who oppose electronic cigarettes have to go to such extremes to deceive, mislead, and lie to the public. Why are we acting like the tobacco industry used to? Where is the error in simply being honest and truthful to American consumers?

Wednesday, March 12, 2014

President Obama Wants to Make Early Childhood Education Dependent Upon High Rates of Cigarette Sales; Campaign for Tobacco-Free Kids Applauds

Hopefully, we can all agree that funding early childhood education should be a national priority. The question is: where do we get those funds?

Last week, President Obama announced his answer: from smokers. The President proposed a 94 cent per pack increase in the federal cigarette tax, with revenue going to support a much needed expansion of early childhood education.

And predictably, the Campaign for Tobacco-Free Kids (CTFK) applauded.

The Rest of the Story

But here is why that knee-jerk reflex that CTFK exhibits any time a tax increase is discussed is short-sighted and premature.

In funding early childhood education from cigarette sales revenues, the President is forever tying the financial solvency of early childhood education on continuing high sales of cigarettes. If cigarette consumption were to drastically fall (as we should all hope it will), then the revenues for early childhood education would drastically fall as well, and the program would lose its fiscal solvency.

This creates a huge incentive for Congress, and the President, not to take any action that would substantially reduce cigarette consumption. For example, it would create an incentive to bury electronic cigarettes somewhere under the Beltway so they cannot compete with the traditional cigarette products.

Moreover, the scheme is regressive and unfair because it balances the budget on the most needy, rather than most well-off, members of society. If we have a budget shortfall and need to find revenues to fund a much-needed early childhood education program, shouldn't that money come from the wealthiest 1% and from corporations, rather than from individuals who tend to be at the lower end of the income spectrum?

Sure, I understand that it is a lot more politically advantageous to go after smokers than it is to go after corporations and the wealthiest citizens. But it is also uncourageous. And it is certainly not leadership. Nor does it show vision.

What it does, sadly, is continue to exaggerate the income disparity between the richest and the poorest in our society. And saddest of all, it forces the poorest in our society to pay for their own benefit programs - programs that should be provided by the government to all citizens.

Unfortunately, the Campaign for Tobacco-Free Kids is just all too ready to buy into this political propaganda and to jump on the train being conducted by communities of privilege that runs ramshod through poorer communities.

Should early childhood education be funded?


Should it be funded by smokers?


Who should fund it?

The wealthiest 1% of Americans, along with corporations that are enjoying inappropriate tax breaks.

Should the cigarette tax be raised?

Sure, but only if the revenue is used to directly benefit those who are bearing its burden. Raise the cigarette tax and use the money to fund anti-smoking programs and services, research, and treatment for smokers, especially in poorer communities and communities of color, and the policy is no longer regressive but progressive. It could reduce, rather than exacerbate existing income and health inequities.

Why is it that the Campaign for Tobacco-Free Kids always acts as if everyone is white, everyone is middle- or higher-income, and everyone is living in communities of privilege?

Tuesday, March 11, 2014

E-Cigarettes are a Gateway to Cigarette Use and Inhibit Quitting? Then Why is the Decline in Cigarette Consumption Accelerating?

According to Stan Glantz and a number of anti-smoking groups and agencies, including the CDC, electronic cigarettes have been shown to be a gateway to youth smoking. In addition, Glantz maintains that electronic cigarettes inhibit quitting among current smokers. Thus, in the opinions of these groups, the use of electronic cigarettes is exacerbating, rather than ameliorating the cigarette smoking epidemic.

Well, the 2013 numbers are in and they simply do not support the Glantz/CDC conclusions.

The Rest of the Story

According to figures from Reynolds American, domestic cigarette volume declined by 4.6% in 2013, compared to just 2.3% in 2012. In other words, the rate of decline in total cigarette consumption doubled in 2013. Because of the growing population, this means that per capita cigarette consumption declined even more strikingly in 2013.

According to the Reynolds American summary: "Cigarette industry volume was down 6.2 percent in the fourth quarter, and down 4.6 percent for the year. This was a challenging comparison as industry volume declines were below trend in the prior-year periods -- industry volumes were down 0.8 percent in the quarter and down 2.3 percent in 2012. ... When looking at industry volume declines over the past several years, they are about 3.5 percent."

Thus, even accounting for market volatility, it appears that there was a substantial decline in expected cigarette consumption in 2013. This hardly seems consistent with the drastic proliferation of electronic cigarettes that are supposedly driving youth to start smoking and smokers to continue smoking rather than quit.

Philip Morris also reported that its own figures show a decline in domestic cigarette units sold in 2013 compared to 2012:

"PM USA’s 2013 fourth-quarter and full-year reported domestic cigarettes shipment volume decreased 5.8% and 4.1%, respectively, primarily due to the industry’s rate of decline, changes in trade inventories and other factors, partially offset by retail share gains. When adjusted for trade inventories and other factors, PM USA estimates that its domestic cigarettes shipment volume was down approximately 4% for both the fourth quarter and the full year, which is consistent with the estimated category decline."

Again, these declines reinforce the finding that domestic cigarette unit sales were substantially lower in 2013 compared to 2012, despite the tremendous proliferation of electronic cigarettes and the dramatic rise in electronic cigarette use among youths. Again, this hardly seems consistent with the hypothesis that the proliferation of electronic cigarettes is driving youth to start smoking and smokers to continue smoking rather than quit.

As I've already noted, however, it is quite clear that Glantz, the CDC, and most anti-smoking groups are no longer driven by data and science. Ideology has pretty much taken over. And that ideology is an abstinence-only philosophy. If you're still inhaling nicotine and you are still using a device that looks like a cigarette, you are still a smoker in their book. Even if you have just saved your life.

(Thanks to Bill Godshall for the tip.)

Monday, March 10, 2014

Glantz Press Release is Dishonest with Public; Authors Appear to be Intentionally Lying to Mislead the Media and the Public

The headline of the UCSF press release announcing the results of Stan Glantz's recent study of e-cigarettes reads: "E-Cigarettes: Gateway to Nicotine Addiction for U.S. Teens, Says UCSF Study."

Within the press release are conclusions from each of the study co-authors.

Dr. Glantz states: "It looks to me like the wild west marketing of e-cigarettes is not only encouraging youth to smoke them, but also it is promoting regular cigarette smoking among youth."

Dr. Dutra states: "E-cigarettes are likely to be gateway devices for nicotine addiction among youth, opening up a whole new market for tobacco."

The Rest of the Story

In my view, this press release, including the headline and the quotes from Drs. Glantz and Dutra, is dishonest.

In the paper, the authors ackowledge that:

1. "This is a cross-sectional study, which only allows us to identify associations, not causal relationships."

2. "The cross-sectional nature of our study does not allow us to identify whether most youths are initiating smoking with conventional cigarettes and then moving on to (usually dual use of) e-cigarettes or vice versa...".

If we accept that authors' word - that there is no way from this study to exclude the possibility that youths are initiating smoking with conventional cigarettes and then moving on to e-cigarettes - then it follows that these authors are being dishonest in telling the public that the study shows that:

1. E-cigarettes are a "gateway to nicotine addiction."

2. "The wild west marketing of e-cigarettes is not only encouraging youth to smoke them, but also it is promoting regular cigarette smoking among youth."

3. "E-cigarettes are likely to be gateway devices for nicotine addiction among youth, opening up a whole new market for tobacco."

I hope that readers understand the specific point I am making here: using the authors' own assertions, it is apparent that they are aware of the inconsistency of their public statements. In other words, it appears that these authors are intentionally lying about the conclusions that follow from their study in order to mislead the media and the public about the role that e-cigarettes are playing with regards to youth smoking.

It is not the case that the authors are simply unaware of the inability of their study to conclude that the e-cigarette use is leading to regular cigarette smoking. They readily acknowledge this in the study. Nevertheless, both of the authors still make conclusive statements to the public, misleading us to believe that the study demonstrates that e-cigarettes are a gateway to regular cigarette use.

Furthermore, the deceptive statements of both authors appear in a press release, not simply as quotes in a newspaper article. This implies that they had plenty of time to think about these statements and were not just speaking off the cuff or being misquoted.

My point is that this appears to be a deliberate attempt to mislead the public. It is not consistent with just being a mistake, an issue of a differing interpretation of study results, or a lack of awareness of the study limitations.

In epidemiology, we have a term to describe what Glantz and Dutra are doing here. There is a term that we commonly use to describe a statement that is crafted to deliberately mislead the public about study results. That term is: a lie.

The rest of the story is that these tobacco researchers are apparently lying to the public about the legitimate conclusions of their own study in order to mislead the media and the public about the role of e-cigarettes in youth smoking. This is scientific dishonesty. And regardless of one's position on electronic cigarettes, behavior like this should play no role in the scientific debate over the appropriate role for these products.

Thursday, March 06, 2014

Conclusion of New Glantz Study on Electronic Cigarettes is Junk Science

A new study published online today in JAMA Pediatrics purports to provide data showing that electronic cigarettes are "aggravating the tobacco epidemic among youth."

The article reports the results of a cross-sectional sample of adolescents interviewed in 2011 and 2012 in the National Youth Tobacco Survey. Youths were asked to report their smoking status as well as their e-cigarette use, both any use and current use (at least once in the past month).

The study finds that e-cigarette use is associated with smoking status. In addition, e-cigarette use is associated with heavier smoking and with fewer periods of smoking abstinence.

The study concludes that "e-cigarette use is aggravating rather than ameliorating the tobacco epidemic among youths."

(See: Dutra LM, Glantz SA. Electronic cigarettes and conventional cigarette use: a cross-sectional study. Published online March 6, 2014. JAMA Pediatr. doi:10.1001/jamapediatrics.2013.5488.)

The Rest of the Story

The authors of this study make one of the most cardinal errors in all of epidemiology. They ignore the principle that "correlation does not equal causation."

Here, they find a correlation between e-cigarette use and higher and more sustained levels of smoking. But because this is a cross-sectional study, they cannot determine which came first. In other words, what is the direction of the causal relationship? Does the e-cigarette use precede, and cause, the smoking? Or does the smoking precede, and cause, the e-cigarette use?

The problem is that in this cross-sectional study, there is no way to determine the direction of the observed relationship.

The authors admit this in the paper. They write: "This is a cross-sectional study, which only allows us to identify associations, not causal relationships."

Furthermore, later in the paper they reinforce this point more specifically, writing: "the cross-sectional nature of our study does not allow us to identify whether most youths are initiating smoking with conventional cigarettes and then moving on to (usually dual use of) e-cigarettes or vice versa...".

Thus, the authors readily acknowledge that it is impossible from this study to determine whether or not e-cigarettes lead to smoking or whether smoking leads to e-cigarette experimentation.

Nevertheless, this does not stop the authors from drawing a conclusion. They conclude, despite their acknowledged inability to draw such a conclusion, that: "e-cigarette use is aggravating rather than ameliorating the tobacco epidemic among youths."

In other words, despite acknowledging that they cannot tell from their study whether e-cigarette use precedes smoking or whether smoking precedes e-cigarette use, they nonetheless draw the conclusion that e-cigarette use precedes smoking.

In my view, there is only one possible explanation for this: Dr. Glantz is no longer playing by the rules of science. He is now a man on a mission: to destroy the e-cigarette industry and to remove e-cigarettes as an option for smokers trying to quit. He has apparently drawn the pre-determined conclusion that e-cigarettes are aggravating the tobacco epidemic among youth, and he will stop at nothing to draw this conclusion and disseminate it to the public.

Apparently, the science no longer matters. You can acknowledge that a study does not allow you to determine the direction of a relationship, but then go ahead and draw such a conclusion anyway. Frankly, this is junk science, and it is just as bad as what we have attacked the tobacco industry for doing in years past.

Whether e-cigarette use precedes smoking or smoking precedes e-cigarette use is a critical question, but it is one which needs to be answered through longitudinal research. We need studies that follow the trajectory of teen tobacco/e-cigarette use over time. That is the only way to determine which comes first.

The problem with what Dr. Glantz has done is that he is already disseminating the "answer" to this important research question without having actually done the research. That obviates the need to do the research because it is too late. The answer has already been disseminated, and it is going to affect important public policy as well as clinical decisions.

Another problem with what Dr. Glantz has done is that it is fundamentally dishonest. He is essentially lying to the public about the science regarding electronic cigarettes. He knows full well - as he acknowledges in the paper - that this study provides no answer regarding whether e-cigarettes precede and lead to smoking or whether youths who are heavier and more dependent smokers are more likely to experiment with e-cigarettes. Nevertheless, he is telling the public that he has answered the question and that the answer is that e-cigarette use precedes and leads to smoking. This is tantamount to lying to the public.

The rest of the story is that this is what the tobacco industry used to do. It is not how we in tobacco control should be conducting our business.

Wednesday, March 05, 2014

Why is the Governor of Rhode Island Trying to Help Protect Big Tobacco from Competition?

In a bizarre turn of events, the governor of Rhode Island - who paints himself as anti-tobacco - is asking the legislature to help protect Big Tobacco from competition. Governor Lincoln Chafee, in his budget bill (House Bill 7133), proposes a whopping 80% tax on electronic cigarettes.

The Rest of the Story

Since electronic cigarettes represent a huge threat to cigarette sales - as many smokers are switching to electronic cigarettes completely or reducing their cigarette consumption substantially and substituting vaping - this massive tax on electronic cigarettes would serve to protect cigarettes from competition, thus protecting Big Tobacco profits at the expense of the protection of the public's health.

There is strong evidence that electronic cigarettes are much safer than tobacco cigarettes. These products contain no tobacco and do not involve combustion. Multiple studies have confirmed that there are only a few chemicals present beyond the nicotine, and so far, only trace or low levels of potentially concerning constituents have been detected - levels which are much lower than in real cigarettes. Users of these products generally report an immediate and dramatic reduction in respiratory symptoms. Moreover, there is strong evidence that electronic cigarettes can be effective in smoking cessation and that they may actually be more effective than traditional nicotine replacement products such as nicotine patches, gum, or lozenges. Even when not effective in promoting complete smoking cessation, these products generally help smokers cut down substantially on the amount they smoke, thus sharply curtailing tobacco cigarette sales.

So why would Governor Chafee want to place a heavy tax on electronic cigarettes, and thus shift sales away from the fake cigarettes and toward the real ones?

This move will be destructive to the public's health. It will literally cause disease and death by increasing cigarette consumption. The proposed tax is high enough that it will deter many smokers from quitting by using electronic cigarettes. It may even result in some vapers returning to cigarette smoking because the economic advantage is no longer present.

The Senate Finance Committee will hold a hearing on the proposed electronic cigarette tax tomorrow at 4:00 pm. Hopefully, the Committee members will vote on the side of protecting the public's health rather than protecting cigarette profits.

Tuesday, March 04, 2014

Another Tobacco Control Professional Declares that We Don't Know if Smoking is any More Hazardous than Vaping

The misinformation in the tobacco control field is so widespread that hardly a day goes by that an anti-smoking advocate somewhere doesn't publicly declare that smoking may be no more dangerous than vaping. Yesterday, it was the Sedgwick County Health Department (Wichita, KS), which wrote in an op-ed article in the Kansas City Star:

"It is not known how much nicotine or other potentially harmful chemicals are inhaled by users, nor is it known whether e-cigarette use may lead to use of other tobacco products. Neither are the benefits of using e-cigarettes over traditional products known."

The Rest of the Story

If a tobacco company dared to make the precise statement that this health department is making, anti-smoking groups would be dragging it into court for committing fraud against the American public. Why, then, should we treat this fraudulent statement from a public health department any differently?

It shouldn't take a rocket toxicologist to figure out that electronic cigarettes - which contain no tobacco - have immense benefits over traditional tobacco products. It shouldn't take a rocket epidemiologist to figure out that eliminating almost all of the more than 10,000 chemicals and 60+ carcinogens in cigarettes is going to result in a safer product. And anyone who has read the numerous laboratory, toxicology, and clinical studies of electronic cigarettes and tobacco cigarettes should understand that vaping is much safer than smoking.

It is so frustrating to me to wake up every day to find another anti-smoking group spreading fraudulent statements about the health effects of cigarettes. This truly undermines decades of public education about the dangers of smoking. And it helps protect the profits of cigarette companies at the expense of the protection of the public's health.

In other words, not only is this fraud, but it is doing public health damage.

Sadly, the tobacco control movement does not appear interested in holding itself to the same standards as we hold the tobacco industry.

Monday, March 03, 2014

American Thoracic Society is Discouraging Many Smokers from Quitting and Misrepresenting Scientific Evidence on E-Cigarettes

In a letter to the editor published in the New York Times last Thursday, the president of the American Thoracic Society  actually discourages thousands of smokers from quitting. At the same time, she misrepresents the scientific evidence on electronic cigarettes. In my opinion, this combination of lying about the scientific facts and providing harmful advice amounts to inappropriate medical practice.

In the letter, Dr. Patricia Finn, who is "president of the American Thoracic Society and chairwoman of the department of medicine at the University of Illinois Chicago" writes:

"a recent study of 76,000 South Korean teenagers indicates that users of e-cigarettes were less likely to succeed in quitting smoking...".

She also writes:

"The American Thoracic Society, as a member of the Forum of International Respiratory Societies, supports an age restriction and government regulation of the sale of e-cigarettes, which in many states do not exist. Until more research is done, it is dangerous to promote their widespread use."

The Rest of the Story

There are two irresponsible aspects to this action on behalf of the nation's chest physicians: (1) lying about the scientific facts regarding electronic cigarettes; and (2) providing harmful medical advice to the public. I'll deal with each of these in turn.

1. Lying about the Scientific Facts Regarding Electronic Cigarettes

The American Thoracic Society is claiming that the Glantz study of 76,000 South Korean teenagers fround that "users of e-cigarettes were less likely to succeed in quitting smoking." However, the study was a cross-sectional one and it did not compare the quitting efficiency of electronic cigarette users and non-electronic cigarettes users over time to see whether e-cigarette users were more or less likely to succeed in quitting smoking.

The authors clearly state in their paper that "Because the [survey] used cross-sectional data, the directionality of our findings cannot be established." In other words, it cannot be determined whether users of e-cigarettes were less likely to succeed in quitting, or whether youth who had trouble quitting were more likely to try e-cigarettes.

In addition, the study notes as a major limitation the fact that: "Because the [survey] did not ask whether students had smoked 100 cigarettes in their lifetime, we could not use the common definition of a “former smoker” as someone who had smoked 100 cigarettes in their lifetime but had not smoked in the past 30 days. Rather, we had to define a “former smoker” as someone who had smoked a single puff and who had not smoked in the past 30 days, which combines former 100 cigarette smokers with former experimenters who may only have used cigarettes briefly."

But this doesn't stop the American Thoracic Society from telling the public that the study found that e-cigarettes users were less likely to succeed in quitting smoking. In my view, this lying about the scientific evidence is a serious mistake.

2. Providing Harmful Medical Advice to the Public

The American Thoracic Society, apparently on the basis of its false portrayal of the scientific evidence, advises against the widespread use of electronic cigarettes. In other words, it is publicly discouraging smokers from using these devices to quit smoking.

Now, for smokers who have tried to quit and failed using NRT or other drugs and who are thinking of quitting using electronic cigarettes, the American Thoracic Society's advice is apparently not to use electronic cigarettes, which is tantamount to advising these smokers not to quit. The reality is that a recommendation to not use e-cigarettes is essentially a recommendation not to quit smoking if that smoker is someone who is considering e-cigarettes because their cessation efforts have failed with other alternatives.

This combination of bad medical advice to smokers and lying about the scientific evidence, in my view, amounts to irresponsible medical practice. Physicians should at very least do no harm. Here, however, the American Thoracic Society is doing much harm.