New CDC study on how to write conclusions that do not follow from the analysis

by Carl V Phillips

If you read the title of the paper (peer-reviewed journal article!), “Nicotine and the Developing Human, A Neglected Element in the Electronic Cigarette Debate” by Lucinda J. England, Rebecca E. Bunnell, Terry F. Pechacek, Van T. Tong, MPH, and Tim A. McAfee (all employees of the U.S. CDC), you might think it was a study of the effects of nicotine. But upon reading the abstract and noticing that it merely has some vague hand-waving about that, and is mostly about “needed” policy interventions, you would probably think it is instead a policy analysis. But it is neither. It is a case study of how “public health” people do not think that conclusions and policy recommendations need to be based on any analysis whatsoever.

The body of the paper itself starts with the expected wandering, useless, and misleading discourse on e-cigarettes (wasting about a quarter of the total length).  It then has brief sections that address nicotine and pregnancy/fetuses, children, and adolescents. Given that nicotine use is increasingly separated from smoking, these are useful topics to carefully analyze to determine the real level of concern (which falls somewhere above zero for the case of pregnancy, but far below panic). But these authors are not up to that task. Those sections read like a college-level term paper on the topic, consisting of a list of conclusions from other papers (with particular reliance on assertions from a Surgeon General report on smoking, rather than original sources), without any quantification (literally none), or analysis. The sources are presumably cherrypicked too, given the biases and approach to science of these authors, but I am not inclined to delve into that.

So we still await some real analysis of those topics.

But these authors are not inclined to wait for science. Oh no. Their conclusions recommend five interventions regarding e-cigarettes. With the exception of the recommendation for child-resistant packaging — a proven-useful intervention that is straightforward to implement and poses no substantial costs, and thus the mere fact that there are any accidental exposures is sufficient to recommend it — the recommendations do not in any way follow from any analysis. It is standard ANTZ practice to do a throwaway research study as an excuse for writing an unrelated editorial about how the authors would like the world to be. But these authors did not even do the research study. Moreover, they made specific recommendations that call for analysis, rather than just opining that they personally think the world would be better off without e-cigarettes.

Consider their first recommendation, “strong prohibitions on marketing that result [sic*] in youth uptake”. Does marketing that results in youth uptake even exist? Which particular marketing is it? They do not analyze these questions, let alone establish that it exists. If it does exist, would these unspecified “strong prohibitions” actually change that fact? Obviously they have no idea, since they do not even establish what the target is or suggest what a prohibition would look like. How much would this cost in terms of real resources and political capital? What would be the consequences in terms of causing fewer smokers to switch (including smokers who are “youth”)? Do the benefits justify the costs? They address none of this. Answering the last question requires quantification, which is completely absent.

[*Petty aside: The typo is kind of amusing. If you read the sentence without mentally correcting it, it actually says they recommend taking action that (itself) will cause youth uptake.]

These are the policy analysis questions that need to be asked about any proposed policy action. The same questions need to be applied to the recommendations about health warnings, protection from “secondhand” exposure (which, of course, is ANTZ-speak for banning use in adults’ private spaces while doing nothing to change it in the domestic settings where it might actually affect children), and even youth access laws.

Such analysis is always(!) absent from ANTZ policy recommendations. The reasons for this are two-fold: “Public health” people, in general, are clueless about policy analysis and dangerously narrow-minded, and genuinely think “I have identified an exposure that might have some negative effect” is sufficient for “and therefore we should implement whatever half-assed policies I can think of, which kind of sound like they might reduce the exposure, without consideration of anything else in the world.” But this becomes even worse in the case of anti-tobacco recommendations because they consider the costs to be benefits too. Indeed they sometimes even admit this, though they usually try to hide it. “So the policy will just make tobacco users suffer and impose resource costs on them and industry without contributing anything toward the ostensible goals? Great!”

Circling back to the “analysis” in the paper, I was particularly amused by the extensive discourse on “tobacco company” efforts to convince women that e-cigarettes are safe during pregnancy (efforts that, needless to say, do not exist). They assert that these (non-existent) efforts could convince women that smoking in pregnancy must be fine. Huh? That was almost 10% of the total text of the paper! I was less amused by the fact that the effects of nicotine in pregnancy is a genuinely important topic for us to try to understand, in order to make valid health recommendations, but someone reading this paper would learn nothing.

The section on children is half about e-cigarettes “renormalizing” smoking (because it is “indistinguishable from smoking”!). The bit that is actually about nicotine exposure via environmental deposition says that “the health effects of nicotine in this age group are uncertain”, though this does not stop them from recommending aggressive policy action. The section about adolescents starts with the usual CDC lies about widespread “use” of e-cigarettes, and ends with the usual gateway myths, both of which I have extensively discussed previously. In between, for a few words, it touches on the brain porn analyses of the effects of nicotine. Again, I am not amused because if there is real reason for concern, it would be useful to know. But we are not going to learn anything from tracts like this (or people like these).

Finally, it is always worth noting how ANTZ authors consistently lie about their conflicts of interest. The authors declare that they have no financial conflicts of interest other than one pharma grant that actually seems to create absolutely no hint of COI in the present context. They seem strangely ignorant of the fact that their jobs and salaries depend on toeing the CDC party line of producing anti-ecig propaganda and actively pursuing aggressive policy interventions. Needless to say, this is about the most extreme COI that someone could have.

(h/t Clive Bates)