CDC refines their lies about kids and e-cigarettes

by Carl V Phillips

I will interrupt my series on the failures of peer review to look at a great example of the failures of peer review, a new broadside (I hesitate to call it a study) from the CDC that appears in Nicotine and Tobacco Research, an alarmist piece about kids’ reported use of e-cigarettes.  Here is the official abstract at the paywalled journal page.  And here is a bootleg copy of the full manuscript (the US government does not let you hide your work behind paywalls if it comes from taxpayer-funded grants, and so I am not going to let them do it when we are paying for it directly). Continue reading

What is peer review really? (part 2)

by Carl V Phillips

In the previous post, I pointed out how the system of journal peer review that dominates in health sciences is a relatively new invention that is already obsolete and has been abandoned by more serious sciences.  In spite of that, there is an idolatry of that system results in a lot of harm, caused by those who mistakenly believe that “in a peer-reviewed journal” means “correct”.  While it genuinely baffles me that anyone needs to have the falsity of that equivalence explained, the reality on the ground shows it is apparently needed.  In this post I will start to make more concrete the observations about the limitations of the system in the form of a series of myths. Continue reading

What is peer review really? (part 1)

by Carl V Phillips

In this series I am going to jot down some observations I am building into more formal presentations about the nature of peer review in the health sciences, and in to tobacco subfield in particular.  This is, in part, motivated by my observations about the FDA’s apparent relationship with the corpus of scientific evidence in CASAA’s comment on the e-cigarette deeming regulation, in which they acted as if anything stated in a peer-reviewed journal article must be true, whereas the rest of human knowledge does not even exist.  This is not just a problem of false negatives (failing to recognize the vast majority of the useful scientific information that does not appear in journals), though that is the worst problem.  It is also a matter of false positives — they apparently believe that publication in a “peer-reviewed journal” confers some claim of accuracy — on not only the research results but every last offhand opinion in the introduction — that excuses them from acquiring real expertise.. Continue reading

ISO the worst anti-tobacco junk science

by Carl V Phillips

I will resume my regular responding and debunking shortly.  In the meantime, I thought I would crowdsource the following question:  What do you think are among the worst examples of research papers or other writings making scientific claims about e-cigarettes, smokeless tobacco, cigarettes, and other tobacco products, or about consumption of those products, their effects, etc.

By “worst” I am thinking of some vague combination of especially junk science or overreaching scientific claims, along with the specific claims having some importance for future policy or current thinking (because of the content or the influence of the authors).  I am not actually restricting this to the anti side (i.e., I am also interested in junk science that is in the pro direction), though I suspect there is little of that to be found that I have not already commented on.  It can be a particular paper, a body of papers, or just a repeated claim.

Please post your nominations in the comments here, or email them to me if you prefer to avoid blog comments (my email is cphillips).  Links are highly welcome, but anything is fine — I can track down the original.  Feel free to suggest as many as you might want, to duplicate suggestions, or whatever else you want.  You can explain why you think a suggestion is particularly bad, or just suggest it without comment.

Thanks in advance for your contributions.

UPDATE: In response to a question I received, suggestions about particular repeated “expert” claims are welcome, even if there is no particular key paper they refer to, so long as they seem to be systematically claimed and not just some one-off gaffe.  For such topics, multiple examples of the claim being repeated are highly welcome.

CASAA comments on FDA deeming of ecigs

by Carl V Phillips

Hello.  Sorry for the blog silence.  I was busy.

Half of it was writing our comment to the FDA about the e-cigarette deeming regulation.  You can download a copy of it here.   For the other half, see the next post I put up on EP-ology.

The CASAA comment is a few(!) blog posts worth of material for you to read, so I will end at that.  Oh, and this represents the end of this series, which was the basis for some of the comment.  I was going to do two more posts in it, but I ran out of time to do the intermediate step and that material just went straight into the comment.


Economic illiteracy about tobacco, from the antepode

by Carl V Phillips

The most fundamental lie of the tobacco control industry (TCI) is what I have dubbed the “demonic possession” theory of tobacco use. It is the myth that no one likes to use tobacco products.

It is obvious why they need this. If they admitted that people derived benefits from consuming tobacco, then they would have to balance the (supposed) benefits of their actions against the loss of benefits caused by the actions. More important, and the reason this myth is fundamental, is that if they admitted the truth they would have to admit to themselves that most of what they do inflicts harm — serious harm — on the hundreds of millions of people who they pretend they are trying to help. While many in the TCI are truly evil, and would not be bothered by this, many are not, and so need to preserve this fiction to be able to sleep at night. (And, no, “evil” is not hyperbole. It is clear that many people in tobacco control derive pleasure from inflicting pain on people who they consider to be The Other, exactly the same evil impulse that causes racism, homophobia, etc.) Continue reading

Predicting the black market in e-cigarettes

by Carl V Phillips

The anti-tobacco movement is fundamentally dishonest and unethical, and it is also led by minimally-skilled people who isolate themselves in an echo chamber that avoids scientific review.  As a result, it is frequently difficult to determine whether one of their false scientific claims is an intentional lie or blatant ignorance.  Most of their epidemiologic claims seem to fall into the former category.  But most of their economics-related lies seem to stem from an utter failure to understand even first-semester level economics.  Snowdon and I (mostly at EP-ology including a few days ago, but also on the present blog) have documented this extensively.

One of their fundamental failures in this area is the apparent belief that — contrary to all we know from the results of the Drug War, to say nothing of all other observations of supply and demand — that bans will eliminate supply even when there is huge demand.  One critical appearance of this ignorance relates to the current U.S. FDA draft regulation of e-cigarettes.  FDA has clearly made no attempt to consider what the real — as opposed to fantasy idealized — results of their proposed e-cigarette ban would be.  It is not difficult to understand that there will be a continuing market in e-cigarettes — mostly not actually “black” despite the shorthand in the title. Continue reading

New study shows that if you have an MI, you should hope you use tobacco

by Carl V Phillips

A recent study by Arefalk et al., published in Circulation, was claimed by the authors, the AHA, and the corporate media to show that continuing snus use after an MI (heart attack) is harmful. In reality – if we are to just blindly interpret the study results, without context or thinking, as the authors imply we should – it shows that among people who have MIs, snus users and even smokers are better off than non-users.

To explain this, start with the letter to the editor Brad Rodu and I submitted to the journal (which, given the integrity typically displayed by health sector journals when it comes to admitting errors and allowing dialog, has a 4% chance of being published). It explains the basic problems and our methodology, but due to word limits does not present the full picture, which I continue below. (Note: Brad expects to post about this too, and I will update with a link when he does.  Update:  It is now live, here.)


Letter by Rodu and Phillips Regarding Article, “Discontinuation of Smokeless Tobacco and Mortality Risk after Myocardial Infarction”

Arefalk et al. report mortality incidence rates (deaths per 1,000 person-years at risk, PYAR) following a myocardial infarction among Swedish tobacco users who, following the MI, continued to use snus (18.7), quit snus (9.7), continued to smoke (28.4) or quit smoking (13.5) (1). We point out several significant problems with this study.

From a methodological perspective, the authors’ inclusion of women in the estimates is a mistake. The number of women among snus users is so small that the gender control variable is extremely unstable. Any gain in power is more than offset by the resulting potential bias. Moreover, combining men and women smokers assumes that the effects of product use are the same for both, which is not justified. In this and similar studies, stratified analysis by gender is always the more informative approach.

The authors report that the mortality rate for the entire sample was 18.9, which appears to be incorrect. It is based on 812 deaths and 40,370 PYAR, which actually yields 20.1. Alternatively, one of the count numbers may be wrong; for example, the rate is 18.9 if the death count is 765. The error requires correction because it affects the article’s major conclusion about snus and smoking; the reported mortality rate for the entire sample (18.9) is similar to that for continuing snus users (18.7).

Arefalk et al. did not report the mortality rate among nonusers of tobacco, which comprise more than half of the sample. We estimated the nonusers’ rate after subtracting the deaths and PYAR for snus, cigarette, and dual users from the sample totals (our estimate of deaths and PYAR among 934 dual users assumed that they were proportional to the mean of those statistics for snus users and smokers).

The estimated mortality rate among nonusers is 21.4, based on 494 deaths and 20,031 PYAR. This is higher than the rate for continuing snus users (18.7), and far higher than that for snus quitters (9.7). In addition, it is higher than the rate for smoke-quitters (13.5). The only group that fared worse than non-users was continuing smokers (28.4). (If the death count was actually 765, the non-users disadvantage would be reduced but not eliminated.)

Thus, those who quit using tobacco products reduced their mortality risk by half compared to those who continued, but also compared to non-users. By the logic of the article’s conclusions, MI victims are better off if they use tobacco so that they can experience the benefits of quitting. The authors have the data to calculate the exact mortality rate for nonusers and adjust for age (which probably does explain part of the disadvantage among nonusers) and other factors. These additional results might explain how the reported harms from snus use can be reconciled with the apparent advantages of quitting.

1. Arefalk G, Hambraeus K, Lind L, Michaelsson K, Lindahl B, Sundström J. Discontinuation of smokeless tobacco and mortality risk after myocardial infarction. Circulation, published online June 23, 2014. DOI:10.1161/CIRCULATIONAHA.113.007252

Brad Rodu, DDS, Department of Medicine, School of Medicine, University of Louisville

Carl V. Phillips, PhD, Consumer Advocates for Smoke-free Alternatives Association


The bottom line is that the authors tried to spin the results as suggesting that continuing snus use is bad for you after an MI. But those who did not quit snus after the MI had a lower death rate than people who did not use either snus or cigarettes at the time of their MI, and those who used snus but quit were far better off still. A simplistic interpretation of the data, then, is: “You had an MI. But the good news is that you use snus! If you now quit snus, your mortality risk compared to people who do not use snus – and thus do not have the opportunity to quit – is magically lowered by more than half. Moreover, even if you do not quit, your risk is still lower than that of non-users.” The authors really buried the lead on this one – or more accurately, did not report the lead at all.

Of course, I am not saying I believe that MI victims are genuinely better off if they use snus. But it is what these statistics suggest (and it is certainly a possibility). The authors carefully avoided reporting an obviously useful and important statistic, the mortality rate among non-users, because they presumably realized that it would call their anti-snus conclusions into question. And it does. Whatever is happening in this population, it clearly does not support the “snus is bad” message that the authors and other naive and politically-motivated commentators have presented.

There is a glaringly obvious explanation for why people who quit snus or smoking after an MI fare better than those who do not: Those who are generally healthy (except for the recent MI, of course) and expect to recover and live a long time are much more likely to take every possible precaution to minimize their risks. After being advised to give up snus, get proper physical therapy, and eat better, many of them will do it. Meanwhile, those who are sickly, have serious cancer, are depressed, etc. will have little incentive to make lifestyle sacrifices in an attempt to regain long-term health. There was no attempt to control for this obvious confounding in the study.

Of course, this would only explain the better outcomes of the quitters compared to those who continued tobacco product use, and does nothing to explain why all of them (except those who continued to smoke) fared better than the non-users. There are possible explanations for this in the form of statistical artifacts or real effects. But the key observation is that the data clearly do not support the main interpretation that the authors touted, that it is terribly bad for you to keep using snus after an MI.

Another important conclusion that should be drawn from this article is just how bad the peer review process is for medical journals. The out-and-out error we discovered in the reported numbers was not some obscure statistic buried in the depths of the paper, but was the key number reported in the first short paragraph of the results section. Brad immediately noticed that the calculation appeared to be wrong on his first read-through, and it took me fifteen seconds to provide the correct arithmetic while creating the spreadsheet that is the basis for our letter. Yet the vaunted “peer review process” let the error through. Those of us who are familiar with journal peer review understand that – contrary what most people seem to believe – the reviewers and editors cannot check anything that readers cannot check for themselves, because they have access to only the same paper the reader has, not the data or calculations. Thus it is, at best, a fairly weak check. But the failures here are a reminder that reviewers seldom even check what is in the paper.

Even without correcting that error or calculating the mortality rate for non-users, the (incorrect) reported number for the population as a whole can still be compared to rates for people who used snus or cigarettes at the time of their MI. This alone is enough to raise red flags about the analysis and conclusions, since it is still higher than the rates for smokers (averaging together those who quit and those who kept smoking) and for those who kept using snus, and far higher than the rates for those who stopped using either product.

Moreover, the obvious confounding described above is not something that only leading scientific experts understand, but is so well known that it even has a name in medical research: “confounding by indication”. It is a constant source of bias when an action (e.g., a particular medical treatment, or in this case, obeying the advice to quit tobacco) is associated with how healthy someone is. A new experimental surgical technique might have a higher death rate, not because it is worse than the conventional practice, but because it is only tried on people whose condition is particularly dire. Or to take an everyday example, someone slamming on their car brakes is much more likely to crash than someone not doing it; this is because the action indicates that there is a risk of imminent crash, not because it is harmful. But the naive logic from blindly looking at the data the way these authors did would be “never slam on your brakes – it will cause you to crash.” Anyone involved in medical research should understand this common problem, and yet the authors do not so much as acknowledge the possibility of such confounding, and the editors and reviewers let them get away with that.

In sum, the way these results were presented and interpreted is a simple classic piece of anti-tobacco propaganda. Researchers who were both skilled and honest would have tried to address the reasons that MI victims who quit using snus or cigarettes fare far better than those who did not use them in the first place, and even those who did not quit snus still did a bit better (after reporting this was the case instead of hiding it, of course). Researchers who were honest but not so skilled would have just reported that result. But the authors, and the journal editors and reviewers who enabled them, instead endeavored to hide that rather remarkable result and to lie that their results showed that snus was harmful.

[Update:  Brad recalled that Arefalk is a serial producer of anti-THR junk.  He posted about a previous claim here.]