Tag Archives: Legacy

Stanton Glantz is such a liar that even the ACS balks: his latest ecig gateway “study”

by Carl V Phillips

Stanton Glantz recently published a paper, Electronic Cigarettes and Conventional Cigarette Use Among US Adolescents; A Cross-sectional Study,  whose conclusions do not even remotely follow from the analysis.  That is hardly news, of course.  In fact, it is probably sufficient to end the sentence with “published a paper”, since the rest is pretty much a given.  But it is interesting to see that this time even some of the semi-respectable anti-THR liars are pushing back against how blatant it is.  I wish I could say that this reflects a new era of tobacco control people consistently calling for honest science, but I seriously doubt that is the case.  Still, it is something.

This is a long post (by the standards of this blog – it is what is needed to do a serious scientific analysis), so I outline it so that you can know what you want to skip if you are in a hurry:  1. The real reason why Glantz’s statistics do not support his conclusion.  2. Addressing a common red herring claim about the ordering of events.  3. Delving deeper into exactly what Glantz is claiming and why it is even worse than the simple headline claim.  4. Coming back to the ACS reference in the title and related press coverage.  5. Some further random technical observations. Continue reading

A paragraph-by-paragraph dissection of an unusually good article about e-cigarettes (part 3 of 3))

by Carl V Phillips

Finishing up the series that starts here, I pick up the discussion of how providing clean needles for injection drug users is a poor analogy for tobacco harm reduction.  I used it myself for a long time, but now I tend to avoid it.

First, the reduction in harm is not nearly as impressive.  Switching to smoke-free alternatives lowers the risk from smoking — which THR’s most vocal opponents insist is the absolute worst health scourge in the world — to very close to zero.  Clean needles do a lot to reduce risks that dwarf those of that “worst” scourge, but that alone leaves IDU quite dangerous.  The fact that Philip Seymour Hoffman was (presumably) using clean needles obviously was not enough.  There are more serious harm reduction strategies for IDU, that include safe injection sites, or distribution of rescue drugs combined with avoiding using heroin without someone else there to administer them.  But even in the best case, the residual risk dwarfs that of using smoking-free tobacco products (and indeed, by any reasonable measure, still exceeds that from smoking).  Thus, the analogy sells THR short.

But more important, it implicitly buys into the “everyone should quit, but [shake head, let out a sigh] if they will not, we should make it less harmful” mentality.  That is sometimes described as the philosophy of harm reduction, but this characterization is incorrect.  As I noted previously, the public debate – as exemplified by articles like the one under discussion – covers the range of opinions from A-through-P, with P being merely accepting that statement in quotation marks.  Injection drug use is, in the opinion of almost everyone (almost – keep reading) something everyone should be pushed to quit.

But if we continue a few letters beyond P, we find a recognition that THR is more like harm reduction for sexual behavior, particularly encouraging condom use.  No one in their right mind claims that “everyone should quit having sex, but if they will not….”  (I have to specify “in their right mind” because some public health advocates actively suggest abstinence is the best choice in anti-HIV education campaigns.)  Like tobacco use, sex has great benefits (for many people) and potentially great health costs that can be largely eliminated.  Yes, there are people who believe that sex is usually immoral and so pushing for abstinence, the lowest risk option, is reasonable.  But not nearly as many who have the same deranged notions about tobacco.  For both behaviors it is clear that if you get the risks low enough, abstinence not only harms happiness, but harms health also.

It is worth continuing the digression one step further, to consider the views of those who are the most genuine supporters of harm reduction for illicit drug use and sex work, rather than just using it as a rhetorical point and a way to claim broadmindedness.  They are far past P on the spectrum, and generally do not condemn the high-risk version of the behaviors even as they promote harm reduction.  They also support decriminalization of the behaviors, in sharp contrast with the P-level advocates for e-cigarettes who actively advocate further creeping criminalization of smoking.  Harm reduction is not just about health risk, but about defending people’s rights to not be punished or demeaned for their choices (whether they be high- or low-risk).  The traditional harm reduction community also includes, within the core leadership of the movement, many people who engage in those behaviors, or once did and still strongly identify with them.  By contrast, the influential people and ostensible experts who appear in the public THR debate, as exemplified by the article being discussed, include almost no one who uses tobacco products.  The exceptions tend to be when someone from CASAA (whose policies embrace the true harm reduction philosophy) or from the e-cigarette industry is allowed to have a voice.  This would not happen if the discussion were really about harm reduction.

Solid evidence about e-cigarettes is limited. A clinical trial in New Zealand, which many researchers regard as the most reliable study to date, found that after six months about 7 percent of people given e-cigarettes had quit smoking, a slightly better rate than those with patches.  “The findings were intriguing but nothing to write home about yet,” said Thomas J. Glynn, a researcher at the American Cancer Society.

The first sentence of that is so vague that it is meaningless.  The rest clarifies what it – naively – means:  We do not have useful tightly regimented experiments about smoking cessation using e-cigarettes.  That is true.  And it will always be true.  The conditions “tightly regimented experiments” and “useful” are mutually exclusive in this context.  The success of an “in the wild” harm reduction method, something that requires no formal intervention, and indeed is probably hindered by a regimented intervention, cannot be measured that way. Anyone who thinks that trial (rather than the real world) is the most reliable study to date clearly knows so little about scientific inquiry that they do not deserve to be called “researcher” (let alone “expert”).

We measure the effectiveness of seat belts in reducing harm not by putting people in seat belt clinical trials, but by observing what portion of the population use them (and crossing that with data about how much lower their risks are).  That “nothing to write home about” quip is a gross understatement.  If it were true that e-cigarettes have barely more impact on smoking than NRT, they would be a dismal failure.  But obviously they perform far better than NRT, and thus that study primarily serves to demonstrate the irrelevance of studies like that for understanding what really matters.

In Britain, where the regulatory process is more developed than in the United States, researchers say that smoking trends are heading in the right direction.

More developed?  Yes, the UK has an “indication” for THR in their medicines regulation system, which could allow for an e-cigarette to be approved as a medicine.  But none have been, and it is not clear when one will be (and it will likely be no more than one or two for a very long time).  At the same time, the national regulators arbitrarily issued a threat to ban all non-medicalized e-cigarettes in the near future, which will probably not be implemented but will be fought over.  Of course, that will become moot if Brussels overrides them and issues rules that cripple or effectively ban e-cigarettes, which is a distinct possibility despite the proponents of that action offering no cogent arguments in its favor.  If that is what “more developed” regulation looks like, we are better off taking our chances with anarchy.

“Motivation to quit is up, success of quit attempts are up, and prevalence is coming down faster than it has for the last six or seven years,” said Robert West, director of tobacco studies at University College London. It is impossible to know whether e-cigarettes drove the changes, he said, but “we can certainly say they are not undermining quitting.”

I have nothing to add to that, other than it is so nice to see real scientific reasoning in a discussion about e-cigarettes.  One wonders whether West went so far as to suggest that, though there cannot be certainty, there is decent support for the hypothesis that e-cigarettes did indeed contribute to the trend.  Such knowledge would have ruined the suspenseful movie script narrative of the article, so he might have said it and it was intentionally omitted.

The scientific uncertainties have intensified the public health fight, with each side seizing on scraps of new data to bolster its position. One recent study in Germany on secondhand vapor from e-cigarettes prompted Dr. Glantz to write on his blog, “More evidence that e-cigs cause substantial air pollution.” Dr. Siegel highlighted the same study, concluding that it showed “no evidence of a significant public health hazard.”

The first sentence of this is the leading reason why I credit Tavernise with writing a genuinely good article.  Though buried, this is really the most important thesis of the entire piece, and it takes an insightful neutral party to say it because partisans are too busy seizing scraps.

The insight is further buried by being tacked onto a paragraph about dueling interpretations of a study, neither of which actually looked at the real science.  The scientific reality is that the study was fatally flawed, and should be mainly interpreted as worthless.  This further bolsters Tavernise’s observation about “scraps of new data”, though the reader would never know just how how  paltry those scraps are because the he-said-she-said approach omits any scientific analysis.

That Big Tobacco is now selling e-cigarettes has contributed to skepticism among experts and advocates.  …blah blah blah…
“Part of the furniture for us is that the tobacco industry is evil and everything they do has to be opposed,” said John Britton, a professor of epidemiology at the University of Nottingham in England, and the director for the U.K. Center for Tobacco and Alcohol Studies. “But one doesn’t want that to get in the way of public health.”

Usually the seemingly-mandatory references to evil big tobacco in a story about THR is a tangential throwaway.  In this case, something very insightful comes out of it:  “Part of the furniture.”  It is just there.  It is there because someone put it there a very, very long time ago (we are talking about English university furniture, after all) for purposes that have nothing to do with present reality.  No one thinks about whether it ought to be there.  No one considers moving it.  It just has to be – tradition and all that, mate.

Carefully devised federal regulations might channel the marketing might of major tobacco companies into e-cigarettes, cannibalizing sales of traditional cigarettes, Dr. Abrams of the Schroeder Institute said. “We need a jujitsu move to take their own weight and use it against them,” he said.

Back to the furniture themes about how “public health” has to exert control over the dumb animals (us), and how everything good comes results from commands from the top, not from free choice.  Still, I have to think that Abrams is clever enough to know that large successful corporations are not large and successful because they are stupid enough to let their strength be used against them.

Perhaps what he really meant is leveraging their inclination to promote their low-risk products at the expense of cigarettes (not at the expense of themselves).  That makes a lot of sense.  One could go further and speak of assisting their organic efforts to promote the alternatives.  This is certainly part of the most effective road toward greater THR.  But many anti-industry activists (not so much “advocates” and definitely not “experts”) have hardened their violently anti-THR positions (“skepticism” grossly understates it) because of this.  The A-through-P debate has thus become even more impoverished because the only acceptable opinions about the role of “Big Tobacco” are the ones embedded in the furniture.

And finally:

“If we make it too hard for this experiment to continue, we’ve wasted an opportunity that could eventually save millions of lives,” Dr. Siegel said.

Dr. Glantz disagreed.

“I frankly think the fault line will be gone in another year,” he said. “The evidence will show their true colors.”

Siegel is obviously correct.  Glantz scores about 1/4 correct:  The evidence will show more-and-more over time, of course, as he says.  But he is wrong in believing that very much new will be learned this year.  His innuendo that the new evidence that will somehow be contrary to all the evidence so far is about as anti-scientific as you can get (call it faith-based Bayesianism: having such a strong prior belief that, no matter what the evidence says, your posterior believe is still that all future evidence will show you are right).  Perhaps “genuinely delusional” needs to be added to the list of hypotheses, alongside “sociopath” and “senile”.  But most wrong of all, as he would know if he could correctly analyze even himself, is the notion that the fault line will not be gone.  He and his tiny cabal of extremists will say the same thing in February 2015 (and 2016, and 2017…) as they are saying now, no matter what happens in between.

And, unfortunately, the press will still be reporting their rants as if they represent an expert view.  Even in the surprisingly good articles.

A paragraph-by-paragraph dissection of an unusually good article about e-cigarettes (part 1)

by Carl V Phillips

Most of what gets published in newspapers about tobacco products is complete garbage, written by someone whose research and critical thinking abilities seem to be at about the level of a middle-school report.  Thus, this article about e-cigarettes in the New York Times by Sabrina Tavernise was extremely refreshing.  By virtue of that, it is a great opportunity to explore some of the common misconceptions, oversimplifications, and narrow thinking that appear in the intelligent discussion of the topic.  Dissecting the usual drivel gets pretty useless after a while, but this is different.

After introducing Stanton Glantz and his protegé and reluctant antagonist, Michael Siegel, the Tavernise continues:

These experts represent the two camps now at war over the public health implications of e-cigarettes. The devices, intended to feed nicotine addiction without the toxic tar of conventional cigarettes, have divided a normally sedate public health community that had long been united in the fight against smoking and Big Tobacco.

Reporters like to turn slow-moving, complicated, and broad political fights into movie scripts.  Perhaps this paragraph is just an example of that.  But there does seem to be a genuine misconception that the fight about THR is new, and that there is something unique here.  In reality, that fight has been going on a long time, and the “public health” political movement has jumped the shark on this and numerous other issues (“Big Food”, 20 ounce sodas, smoking in cars, helmet laws, you name it) and has lost the support of many who are genuine public health advocates and researchers.  This is important context for understanding this fight.  There is, in fact, nothing unique going on here.

Also, it is not entirely fair to the anti-THR faction to claim they are represented by their court jester, Glantz.  Many of them are just as dishonest and evil as he is, but are not cartoon villains who spout easily verifiable lies.  It probably is reasonable to use Siegel as a representative voice in the narrow fights about e-cigarettes, but he is not a supporter of harm reduction more generally, or of individual freedom.  This may make him the “public health” faction’s pro-ecig guy, but missing from this entire movie script are the many voices from outside that faction.

The essence of their disagreement comes down to a simple question: Will e-cigarettes cause more or fewer people to smoke? The answer matters. Cigarette smoking is still the single largest cause of preventable death in the United States, killing about 480,000 people a year. Dr. Siegel, whose graduate school manuscripts Dr. Glantz used to read, says e-cigarette pessimists are stuck on the idea that anything that looks like smoking is bad. “They are so blinded by this ideology that they are not able to see e-cigarettes objectively,” he said. Dr. Glantz disagrees. “E-cigarettes seem like a good idea,” he said, “but they aren’t.”

The exaggerated toll from smoking and the “preventable” trope, in this context, matter little, so I will not dwell on them.  The notion that anti-ecig activism is motivated by vaping looking like smoking is far too narrow, and falls into the movie script simplification:  That seems to be what Glantz is motivated by, but it does not generalize.  The main motivation seems to be that THR stands in the way of “tobacco-free world” goals, as I have discussed at length, and is bad for business (it hurts the revenues of institutions and individuals who depend on concerns about smoking, and to a lesser extent those who sell anti-smoking products).

Science that might resolve questions about e-cigarettes is still developing, and many experts agree that the evidence so far is too skimpy to draw definitive conclusions about the long-term effects of the devices on the broader population.

“The popularity is outpacing the knowledge,” said Dr. Michael B. Steinberg, associate professor of medicine at the Robert Wood Johnson Medical School at Rutgers University. “We’ll have a better idea in another year or two of how safe these products are, but the question is, will the horse be out of the barn by then?”

The first bit of that seems like a simple statement of fact, but it is not. Following on the issue of whether e-cigarettes reduce smoking, the incorrect implication is that research on current behavior could tell us much about that.  But then notice the unacknowledged switching from the question of smoking cessation to the question of exactly how hazardous e-cigarettes are in themselves (which, incidentally, we also will know very little more about “in another year or two”). This conflation and changing of topic is a common tactic by anti-THR activists and a common error by non-activist commentators.  These are very different questions.

Equally interesting is the “horse out of the barn” metaphor, which seems to represent a common view.  First, it illustrates the ruling class attitude of “public health”, suggesting that their job is to control dumb animals, rather than to advise free and rational people.  Second, is patently wrong.  THR products can and will be improved upon over time.  And have been: worry about nitrosamines in smokeless tobacco (probably overblown, but leave that aside) has resulted in a huge reduction in their concentration over the last few decades.  E-cigarettes will be improved and the current technology will probably be mostly displaced by others.  In the extremely unlikely event that something very hazardous is found, many people will rationally choose to switch products, as happens all the time with other goods.  There is nothing irreversible here other than the embrace of THR and the rejection of the abstinence-only orthodoxy.  That, of course, is the main motivation of anti-THR.

After a couple of paragraphs about FDA regulation:

And many scientists say e-cigarettes will be truly effective in reducing the death toll from smoking only with the right kind of federal regulation — for example, rules that make ordinary cigarettes more expensive than e-cigarettes, or that reduce the amount of nicotine in ordinary cigarettes so smokers turn to e-cigarettes for their nicotine.

Activists who trust only themselves and believe they should control people do say that (though I would not suggest they should be described as either many or scientists).  But is it even a little bit plausible?  THR will replace smoking because it lowers the risk and keeps a lot of the benefits.  It is certainly true that high taxes on cigarettes (having nothing to do with “the right kind of federal regulation”) make e-cigarettes more appealing (just as high taxes on smokeless tobacco make that approach to THR less appealing).  But in most jurisdictions, the starter e-cigarette products are not cheaper than smoking, but people are still making a rational choice to switch.

What is more interesting to people who look beyond rich countries, is the issue of offering affordable THR products to the rest of the world.  Even if there were not cigarette taxes that made them price competitive, e-cigarettes would be affordable to Westerners.  But their real resource cost is so much higher than cigarettes that they are prohibitively expensive for most of the world’s population.  Since the article is exclusively focused on the USA, it is understandable that this is not mentioned, but it is still bothersome to make such general statements about tactics when they are only relevant to a small fraction of the world’s tobacco product users.

As for reducing the nicotine in cigarettes, this madness has been a pet fantasy of a few dozen people who now have a lot of influence.  But unless the goal is to actualize Glantz’s fantasy world where e-cigarettes are used primarily as a supplement to smoking rather than a substitute, it is insane.  Smokers who just want nicotine will switch products anyway.  With less nicotine in cigarettes, some people who want to smoke will smoke more, while others will supplement (and that does not require e-cigarettes, by the way: enroll in a stop-smoking program and get free nicotine patches, slap one on, keep smoking).  And, of course, the black market will benefit nicely from being able to offer not just a cheaper product than is available legally, but one that is higher quality — that is, assuming there is not an easy DIY recipe (“I have a bottle of inexpensive e-cigarette liquid in this hand and a cigarette without enough nicotine in my other hand.  Hmm….”; possible added bonus: flavored cigarettes!).

“E-cigarettes are not a miracle cure,” said David B. Abrams, executive director of the Schroeder National Institute for Tobacco Research and Policy Studies at the Legacy Foundation, an antismoking research group. “They need a little help to eclipse cigarettes, which are still the most satisfying and deadly product ever made.”

Despite being a card-carrying tobacco controller, Abrams has emerged as one of the most cogent voices on the topic.  It is not entirely clear whether he is responsible for the unfortunate preceding paragraph, about trying to lower the quality of cigarettes.  The quote seems to endorse it, so perhaps.  But maybe he is just pointing out that these particular products are not for everyone. Somehow lost in the fanaticism on both sides is the simple fact that like the THR products that predated them, e-cigarettes appeal to some people but not everyone.  As noted above, we are missing a lot of useful data, but we do know that most smokers who have tried e-cigarettes are still smokers.  People who find them appealing — and those who breathlessly call them a miracle or the greatest health technology breakthrough since penicillin — seem to overlook this.

I will skip over the standard background paragraph on e-cigarettes and uncritical reporting of the breathless predictions about the market from the usual stock flogger (who seems to exemplify the unawareness cited in the previous paragraph).  In the interests of length, I will also break here and resume this in my next post, picking up with:

Pessimists like Dr. Glantz say that while e-cigarettes might be good in theory, they are bad in practice. The vast majority of people who smoke them now also smoke conventional cigarettes, he said, and there is little evidence that much switching is happening. E-cigarettes may even prolong the habit, he said, by offering a dose of nicotine at times when getting one from a traditional cigarette is inconvenient or illegal.

Anti-THR liar of the year #7: Cheryl Healton and the Paleo Tobacco Control Industry

Continuing our countdown of the top anti-THR liars of 2013, we have a last-minute entrant, Cheryl Healton, who seems to be the perfect representative of the stone age (i.e., c.2003) faction of the tobacco control industry.  Even as the post-Healton leadership of the American Legacy Foundation seems to be moving toward realizing the value of THR (though they continue Healton’s tradition of just hoarding the Foundation’s money, not actually doing much other than paying extravagant salaries), she writes anti-THR lies with the simple-mindedness of a past era.

Of course, she is not alone in this, and thus is symbolic in the #7 spot for thousands of people in local health departments, schools of public health, and the media who also traffic in the simple-minded lies (another recent example).  For years the tobacco control industry did not need to say anything other than “we think this is bad” to win over a gullible public.  But the public has become much more sophisticated about this topic and about mass communication in general, and of course have betters sources of information than whatever some county health official told the clueless local newspaper.  The better liars have learned how to deploy sciencey lies rather than just assertions and innuendo, which is more effective at tricking people, and also at not making the speaker look like an idiot.  But there is still a large paleo contingent — a far larger headcount than those who have gotten more sophisticated — who are not really part of the debate and thus have never been schooled that they cannot just lie like it is 1999, a time when there was little organized opposition to their lies.

My favorite example in this case is Healton, in urging New York City to ban the use of e-cigarettes anywhere that smoking is banned (see above link), deployed the paleo-tobacco-control tactic of calling for extreme restrictions on freedom — and the resulting damage to public health — in order to solve a simple problem.  Perhaps she is right that not allowing vaping on packed subway trains is reasonable, but what, exactly, does this have to do with not allowing bars to choose for themselves whether to allow vaping and how does it justify banning it throughout Central Park.  The one other specific place she cited, in terms of suggesting that upstanding citizens like herself should oppose e-cigarette use there, was walking down the street.  Of course, this is about the only place left where people can vape (or smoke) given the restrictions.  That is just classic tobacco control:  imposing restrictions that do not even address their own stated goals.

An important distinction needs to be drawn between Healton (and others like her who are getting rich off of anti-THR) and the workaday health department bureaucrats and clinicians who act as the footsoldiers for paleo tobacco control.  The latter are merely useful idiots who Healton and company manipulate.  They tend to be non-specialists and do not even pretend to be scientists, and are victims of the lies that are crafted by the actively dishonest puppet masters.  The knowing liars are clearly the most guilty.  Still, this does not let the ignorant liars off the hook — they may not pretend to be scientists but they do pretend to be experts on the topic when talking to the press, the public, politicians, or clinical patients.  They repeat the lies that they have been told as if they have assessed them to be true, when really they have no clue about the truth — and know it — and are merely transcribing what they have been told.  People living in the information age have no excuse for allowing themselves to be brainwashed by widely-debunked lies.

Cheryl Healton lies (a lot!) to try to get NYC to restrict ecigs

by Carl V Phillips

This analysis, of this blog post, might seem a little more brutal than usual.  That is because the author, Cheryl Healton (the former head of the leading anti-tobacco organization, American Legacy Foundation — a fact that is omitted in the introduction of her in the blog in question — and now head of the public health program at NYC), knows the truth.  This is not a case of someone who is too innumerate to not know she is lying, or a useful idiot that is being used by the anti-tobacco extremists.  Healton is one of the puppet masters who manipulates her useful idiots (like New York Assemblywoman Linda Rosenthal), which she is doing in this post.  Notice in particular the many times that she lies by using literally true but highly misleading statements, the mark of someone who knows she is lying but wants to be able to pretend otherwise.

The post appears in the blog of the “NYC Coalition for a Smoke-Free City”, an obviously misnamed group since they are campaigning not against smoke, but against e-cigarette use.  The thesis is that NYC should go ahead with its proposal to prohibit e-cigarette use anywhere that smoking is prohibited.  It is remarkable how close Healton comes to lying in every single sentence.  The first few about the fact that NYC is about to act on this are true, but most everything that follows is a lie:

Who is the e-cigarette industry?  Increasingly the e-cigarette industry is owned by the tobacco industry, an industry that would not be permitted to exist were it invented tomorrow because it would violate the consumer protection laws of all states and virtually every country in the world.

As I have pointed out, this “would not be allowed to exist” claim is at best pure speculation, and probably wrong.  But apart from that, it refers to a product (cigarettes), not an industry.  If the industry came into being right now selling low-risk products like smokeless tobacco, e-cigarettes, and NRT (all of which are sold by “the tobacco industry”), it would be allowed to exist.  But, of course, this soup of words is not meant to analyze the actual claim, but to lie about e-cigarettes, suggesting they are some industry plot.  In case the innuendo is lost on the reader, she goes on to lie,

For this reason, a healthy degree of skepticism about the industry’s ultimate goal in buying up e-cigarette manufacturers and creating more “efficient” e-cigarettes should prevail as policy makers establish regulations governing them. It is quite possible that the net effect of e-cigarettes will be to induce greater youth initiation of smoking and reduce the adult cessation rate, but the jury is still out.

I cannot imagine that Healton is stupid enough to actually believe that.  It is impossible to come up with a story to explain why the existence of e-cigarettes (let alone the acquisition of a few companies that she led into that with) could cause smoking at all, let alone to cause a net increase in smoking initiation.  E-cigarettes, like any popular low-risk alternative, will replace smoking initiation, not cause it.

Both youth and adult smoking rates are at their lowest levels in decades, so much is a stake for the health of the public.

Setting aside the fact that the “so” is a non sequitur, is what she is saying is that having almost 20% of the population smoking is such a success that harm reduction should be avoided?  It appears so.

There is also much at stake for the tobacco industry as it seeks to apply its considerable marketing acumen and seemingly endless resources to maximize profit by increasing the number who start smoking by enticing youth worldwide to smoke and by trying to retain current smokers.

Complaining about “endless resources” is pretty funny coming from someone who is at the apex of the billions-per-year tobacco control industry.  But the real question is what this passage has to do with e-cigarettes at all, let alone restricting where you can use them.  It is typical tobacco control misdirection:  “Cigarette manufacturers profit from more people smoking and remaining smokers, and therefore we should restrict where people can use e-cigarettes.”  Huh??!

Who might be hurt by e-cigarettes?  The tobacco products the industry has historically manufactured and promoted as “reduced harm” are not benign products created to meet the broad range of consumer preferences in the United States, rather they are deadly products that when used as directed kill over 400,000 Americans each year and are predicted by the World Health Organization to kill a billion people worldwide this century, 10 fold more than they killed in the 20th century. To put the scope of the current tobacco-related epidemic in perspective, in a few years, global lung cancer deaths will surpass AIDS deaths as the steady march of tobacco industry marketing continues to engulf the world’s poorest nations.

Again, huh??!  Does anyone see any connection between that question and what follows?  (Yes, I realize that the reader might now be questioning my assertion that Healton is too smart to not know she is lying.)  Her allusion to historical products is the usual tobacco control canard about the introduction of “light” cigarettes four decades ago, products where there was no evidence to suggest they would be lower risk.  And yet they were actively endorsed by the public health community, not just the manufacturers.

However, a mistake by everyone a couple of generations ago about what might be lower risk tells us nothing about the present world of products that are known to be lower risk.  It is an utterly absurd and blatant lie to suggest otherwise.

None of what she says in this paragraph is true about the actual reduced harm products that have been introduced by the tobacco industry and by others.  Smokeless tobacco, e-cigarettes, and other low-risk products do not cause the harms she is citing; cigarettes do.  (Well, cigarettes cause and will cause a lot of harm, though not as much as she claims.  But that is another story).  She seems to be trying to invoke the conjunction lie, that cigarettes plus low-risk alternatives do that much harm (which implies the harm is shared, even though it is basically all caused by cigarettes), but she screws up doing even that.  She actually is claiming that the low-risk products alone cause all the harm from smoking.

Nicotine addiction is in and of itself a gateway to tobacco product use because once addicted many will broaden the products they use and included among these will be the most dangerous products like cigars, cigarettes and hookah.

It is true that people who like to use one tobacco/nicotine product often try other products.  But what she is trying to imply (carefully avoiding actually saying it) is that using e-cigarettes will cause people who would not have otherwise smoked to do so.  There is no reason to believe this would be the case, and certainly no evidence of it occurring.

And it is worth pausing to remember that the title of this post says that NYC should include e-cigarettes in its smoking place restrictions.  I have skipped a few sentences but have not left out anything that addresses that.  There has been nothing yet.  Even if the previous quote were not a lie, it would still only be an argument against letting kids use e-cigarettes, not about forbidding adults from using them at their desks or in bars.

Most tobacco-related deaths are the culmination of substantial suffering and societal cost from heart disease, emphysema or various cancers and are the direct result of nicotine addiction.  Moreover, nicotine addiction is considered by many scientists as the most intractable of all addictions as measured by the percent of ever users who become addicted and the percent who remain addicted until death. Half of lifelong smokers lose their lives to tobacco addiction and among these people nearly half die before retirement age.

A pretty good argument in favor of encouraging e-cigarette use.  The bit about “most intractable” is nonsense, of course.  The reason users have more incentive to quit, say, meth than to quit smoking is the high level of short-term damage it is doing them.  And the “half” is a made-up number that is higher than what the evidence suggests.  Most important is that claims about the “addictiveness” of smoking tells us little about e-cigarettes, given the evidence that e-cigarettes are much easier to quit.

And, once again, this has nothing to do with whether there should be a place ban on e-cigarettes.

E-cigarettes are a complex product and their availability and the regulatory framework for governing them may have different implications and considerations for youth non-smokers compared to adult smokers. E-cigarette policy could produce sharply differing results by population sub-group.  Data demonstrate that a significant swath of adolescents already are using e-cigarettes. Time will soon tell whether e-cigarettes function as one more point of entry to cigarette, cigar and hookah consumption among those using e-cigarettes initially. One thing is clear however, since cessation efforts have thus far not worked with teens, e-cigarettes will likely not do anything good for kids and may well entice many to start smoking in view of the broad array of sweet, candy flavors and slick e-cigarette marketing already blanketing the internet, mall kiosks, TV and radio, which have to date eluded regulation.

Blatant lies and clueless nonsense.  (Ok, I will admit I am starting to doubt my previous assertion that Healton really understands what she is saying.)  Skipping past the distractions that the first few sentences comprise, we have the lie that many adolescents are using e-cigarettes, a repeat of the lie that there is any reason they would cause smoking, the lie that because other cessation efforts do not work for kids that harm reduction will not work for them (it might be true, but probably is not, and it is nothing more than speculation asserted as fact), and of course the usual canard about marketing.  Once again, the biggest lie here is that this has anything to do with restricting where adults can use e-cigarettes, or anything else about adult use.

Whether e-cigarettes will offer an incremental boost to cessation rates nationally also remains to be seen.

No, it doesn’t.  Close to every e-cigarette user is either a former smoker or a current smoker who has replaced some smoking with e-cigarettes and could be persuaded to complete the transition.  Many of those who quit smoking report that they had not been able to succeed at cessation until they tried e-cigarettes, and only then did they quit.  Therefore e-cigarettes have increased cessation.  This is not really a difficult concept to understand.  (She goes on in that paragraph to lie about what the research shows, but I will stop at debunking her thesis claim.)

This is the epitome of the ANTZ tactic of declaring every negative they can concoct to be a real concern, even if there is zero evidence and even if the evidence clearly shows it is a non-issue, while denying every positive by pretending that the evidence does not exist.

We should also remain open to another highly plausible effect of e-cigarettes-that they will function in the same manner “light” cigarettes did when they were introduced in the 70′s, promoted by the tobacco industry as a step smokers could take to feel safer without actually quitting smoking. As many subsequent studies showed, in fact they were not safer and millions who would have quit had they not been introduced failed to do so costing innumerable lives.

And (setting aside the lies about “light” cigarettes themselves) there is that lie about the situations being similar again.  The obvious difference is that e-cigarette users are “actually quitting smoking”, unlike light cigarette users, and they are using a product that genuinely is low risk.  What does a public health failure of the 1970s have to do with e-cigarettes?  Absolutely nothing.  It is basically the same as saying leeches turned out to be harmful rather than helpful in treating infectious diseases, and therefore we should avoid antibiotics.

Do we really want everyone vaping where they once could smoke?  

Oh, look, she is finally addressing the question she claims to be addressing.

The proposed extension of the SFAA to e-cigarettes, which will be voted on tomorrow, also will reduce the “walking billboard” effect of thousands of New Yorkers once again lighting up in bars, subways, parks, office buildings and restaurants throughout the city. But banning e-cigarettes in some locations solely for this reason is un-American in a country that prides itself on maximizing the freedom of its adult citizens to choose to engage in a range of risky and frisky behaviors. 

Interesting.  It is not a very risky behavior, of course, but it is nice to see that New York is still part of America.

The “billboard” claim is utter nonsense, of course.  How is someone vaping in their office, rather than outside the front door, a billboard?  E-cigarettes could still be restricted on the subway and restaurants could make their own choices about what is best for their patrons and vibe.  The proposed ban would eliminate all discretion, reasonableness and common sense, going beyond a few specific restrictions that some might argue are reasonable and imposing rules that are clearly absurd and harmful.

Take a step back and see what she is doing with all of this.  She is appealing to people who are worried about kids using e-cigarettes and do not like people vaping on the subway, and trying to trick them into supporting a rule that bars cannot choose to allow their patrons to vape.  If she actually cared about kids and subways, she would propose something that affects kids (this rule would not) and would endorse a rule that just applies to the subways (which could probably be done by administrative fiat).  Notice she never once offers any reason why banning vaping in bars, private offices, and many outdoor spaces would do any good for anyone, and indeed tries to hide the fact that this regulation would impose such restrictions.  Classic tobacco control bait-and-switch.

It should be noted, however, that while we in general embrace this ethos, when it comes to public drinking we often do not. We do not embrace wandering down the street drinking a cocktail, hopping into the elevator rum and coke [sic] in hand or whipping out a flask of whiskey on a plane.

Ok, so no vaping on elevators and planes.  I suspect that even most dedicated vapers would not find those to be terribly unreasonable restrictions.  As for walking down that street, the street would be one of the few places vaping was still allowed under the restrictions.  The anti-THR people cannot even keep their own stories straight.

Do we know enough to allow vaping in public spaces?  So what are the real risks of public vaping? Is it as its promoters would like us to believe a benign, reduced harm practice that is at worst a passing fancy?

Um, no.  Its promoters think it is here to stay.  Also, the ban is mostly about private spaces, not public spaces.

Or is it a potentially toxic practice that places those in its immediate vicinity at risk. The answer is we do not completely know yet, although already studies have shown elevated nicotine levels among those exposed to secondhand vaping, and this in and of itself is ominous. Not definitively measured as yet among second hand vapers [sic] are the myriad other toxic substances which are contained in e-cigarettes. 

Cute, huh, that use of “completely” and “definitively”.  Of course we know, from ample evidence, with a very high degree of certainty that the risk to bystanders is zero or utterly trivial.   But we never know anything completely or definitively.  Someone can always use weasel words like that to intentionally trick the reader into thinking she made a statement about what we really know, rather than merely a statement about the fact that there is never proof or complete information in the real world.

And if anyone is aware of any study that shows elevated nicotine levels from people exposed to “secondhand vapor”, I would be quite interested in hearing about it.

Under these circumstances, the prudent course is to extend the SFAA to encompass e-cigarettes until, if ever, sufficient evidence exists demonstrating their safety.

Right.  And what might that be?  Oh, you say, no evidence would ever be sufficient for that.  Thought so.

And why exactly would this be prudent?  I do not think that word means what she thinks that word means.  Is it prudent to restrict a very personal freedom when there appears to be no reason to do so, just because such a reason might be found later?  (Sounds like an argument for banning, say, the building of mosques in America — there are many who would make the same “we just don’t know if this will hurt the children” arguments about that.)  Is it prudent to ensure that cigarettes remain as attractive as possible as compared to low-risk alternatives?

The only conceivable downside of not extending the SFAA to e-cigarette use is the loss of any incremental harm reduction for smokers associated with being permitted to smoke e-cigarettes in locations where smoking is now banned.

TrANTZlation:  The harm it would inflict on those not able to vape at their desk, in bars, etc. is of absolutely no consequence.  We are tobacco control.  We don’t actually care if tobacco users suffer.  In fact, we prefer it.

And, of course, making e-cigarette use less attractive creates the public health harm of encouraging smokers to keep smoking.

It is highly unlikely that such a benefit, if it in fact exists, would outweigh the harms to youth, to non-smokers exposed to vaping nicotine laden vapors and potentially other toxins, and to recovering smokers who now stay quit in part because smoking has become less ubiquitous than it was 50 years ago when the Surgeon General released the first report on Smoking and Health.

Huh?  It is highly unlikely?  Care to quantify?  I would love to hear about the harms to youth from people vaping at their desks.  What harms are caused by (barely) “nicotine laden vapors”?  What possible impact is there on “recovering smokers”?

Sadly e-cigarettes may lead to four negative outcomes: the initiation of more youth to nicotine dependence and subsequent conventional smoking; the use of e-cigarettes by current cigarette smokers who would otherwise have quit but instead use both conventional cigarettes and e-cigarettes in combination and therefore delay quitting or never quit and; the relapse to smoking by those who have already quit, first to smoking “benign” e-cigarettes and then to conventional cigarettes; and the exposure of people to e-cigarettes’ emissions unknown risks.

And how does all of this other than the last bit (a lie that has already been addressed) relate to the question at hand?

Who loses, if anyone, by extending the SFAA to e-cigarette use? Virtually no one loses. Vapers can still smoke everywhere current smokers now do. Let’s do what NYC has become known for and enact a policy that saves lives, not costs them.

Just in case the above trANTZlated passage was not clear enough, here she comes right out and says that the hardships suffered by vapers as a result of the rule do not matter.   Smoking place restrictions are designed to make smokers less happy — tobacco control advocates generally admit that these days — so obviously imposing the same restrictions on vapers will make them less happy too.  I wonder if it is a Freudian slip when she says that “vapers can still smoke” — because that is exactly what will happen:  Some would-be vapers, upon having to go out to the smoking areas anyway, will indeed smoke.  As a result, some of them will die from smoking and their blood will be on the hands of liars like Healton.

ANTZ engineer their next anti-ecig lie: They facilitate smoking cannabis

by Carl V Phillips

I am back from the recent FDA TPSAC hearings (my live blog/commentary is not too far down the CASAA Members Facebook page for those interested).  During the public comments period (in which only special-interests, not the public, were represented this time — CASAA decided to sit this one out), the ANTZ groups (Legacy, CTFK) kept making vague references to the risks that consumers would tamper with “MRTPs”.

(For those who do not know, “MRTP”=”modified risk tobacco products”, which were the main focus of these hearings, is FDA-speak for anything that is lower risk than a standard cigarette.  It is a very misleading collection, since it includes everything from minor modifications of cigarettes that might or might not reduce risks by 10% to smokeless tobacco which is definitively demonstrated to be about 99% less risky.  It is also a dumb term since many of these products are not “modified” — they are what they have always been — they are just different.  Finally, the word “modified” could refer to either increases or decreases, so what they really mean is lower.  I am tempted to say that the government is a clear and present threat to effective communication, but they are hardly the only one so that would be a bit glib.)

My reaction to these references to tampering were WTF are they talking about?  These are consumer products, designed to be used in the quantity and with the particular behavior preferred by the consumer.  “Tamper” is a meaningless concept in that concept.

What was immediately apparent, though, is that whatever they meant, it was the next orchestrated campaign of anti-THR lies.  As I noted in the previous post, the anti-THR extremists and other ANTZ maintain semi-secret channels of communication in which they engineer talking points that can then simultaneously be stated by the various paid activists and their useful idiots at the same time, as if it were something people were really thinking.  It is the same thing political parties do (and entirely different from what honest and truth-seeking organizations and associations do).  Sometimes these talking points are so utterly inane, like the one I discuss next, that you would think that the press etc. would figure out that they are engineered lies.  (Who remembers the classic when they got their useful idiots to recite “Camel Snus packages look like cellphones (i.e., they are rectangular with rounded corners), which appeal to chiiiildren”?)

As soon as I had a chance to think about it for a few minutes, I realized that my CASAA colleagues had already picked up on some of the chatter and identified one of the meanings of these bizarre claims:  The ANTZ plan to claim that e-cigarettes should be restricted because the devices can be used for vaporizing certain cannabis products.  The reason this is a lie is not because there is not a developing technology for vaporizing a cannabis wax in devices that are quite similar to e-cigarettes — such technology is developing.  The lie is that this has any bearing whatsoever on the regulation of e-cigarettes.

First, vaping a wax requires a different atomizer and not just any cartridge/tank.  (The batteries can be the same, of course.  Batteries are batteries.)  Thus, it is not like someone can just put the wax in an e-cigarette that is designed to vape an aqueous liquid.  They need new hardware.  This contrasts with combustible tobacco products which are easily used to smoke cannabis leaf (sprinkle or roll some in, set it on fire).

Second, the liars are going to try to imply that the supply of cannabis vaping equipment can be eliminated if e-cigarettes are banned.  But see the first point: different equipment is needed, and so they are not diverting that from e-cigarettes.  But maybe we could stop cannabis users from getting, say, eGo batteries, if the e-cigarettes supply chains are banned.  Um, people, they manage to get cannabis.  Do you think that the supply chain that provides this can perhaps expand to include the hardware too?  Do you think maybe it already has?  I am sure that the ANTZ puppet masters are smart enough to know this, and thus know this new campaign is a lie, though their useful idiots include a lot of idiots (in the basic sense of the term) who can be tricked into believing that somehow the chiiiildren would not be using weed because were it not for e-cigarettes.  As I said: idiots.

One additional point:  Vaping cannabis is almost certainly less harmful than smoking it or than the devices that are normally called vaporizers in that world.  (The latter are called “heat-not-burn” when used for tobacco, and the guess is that they are perhaps about half as harmful as smoking, maybe somewhat less, but that still makes real vaping a lot less risky.)  If the ANTZ do not abandon this talking point quickly, as they usually do with their dumb claim of the month, but stick with it, we could use it to drive a wedge between them and the real public health people who support harm reduction for illicit drugs.

Thinking about this further, I realized there was a second implication to these bizarre pronouncements about the risks of tampering, this one more of a hand-tipping about a future threat, rather than a lie per se.  The statements by the ANTZ at the hearing yesterday included references to altering delivered doses.  But, of course, using your snus or modding your e-cigarette to get the dose you want is just part of using it — as I said, the notion of tampering simply makes no sense.  So, what would make that bizarre claim make sense?  If the ANTZ managed to persuade the government to impose restrictions on the physical properties of low-risk products (most likely e-cigarettes, not smokeless tobacco, for obvious reasons) such that they could not be used the way consumers wanted to use them.

So the ANTZ are tipping us off that a core part of their plan, given that they have failed in their attempt to ban e-cigarettes, is to cripple them.  Banning flavors (such that “tampering” consists of adding flavor) is an obvious example, though it does not relate to the point that they hinted at, restricting dosage.  But there are others the come to mind:  Forcing a shut-off of the device after a certain number of puffs over a certain period.  Restricting battery options or tank sizes.  And, of course, limiting nicotine strength.

So do not be surprised when these attacks on THR start flying from every direction.  You are warned.  Now make sure that we push back against the engineered “tampering” campaign any time these attacks pop up, rather than treating these as random stupid comments that will just disappear on their own.

American Legacy Foundation – lying via hypothetical research methods

by Carl V Phillips

I have spent a lot of my career pointing out how the choice of research methods and statistical models — in particular, the choice of which to report among the many that were tried — create bias in the epidemiology literature.  It is easy to create a study that is designed to get a particular result, especially if the desired result is to fail to observe a phenomenon (in the days before e-cigarettes, I was baffled that the anti-ST people never ran an intended-to-fail intervention to “show” that THR did not work).

It seems that the American Legacy Foundation has taken this one step further.  In a comment on the ECLAT study, which found that many smokers who were forced to try e-cigarettes for a while (as study participants) decided to switch to them, they basically described the designed-to-fail methodology they would have used and criticized the honest researchers for not using it.  Mike Siegel summed it up (emphasis in original):

According to the press release: “The researchers reported that e-cigarettes decreased some smokers’ cigarette consumption and that 8.7% quit smoking 40 weeks after the intervention ended. Unfortunately, they also found that smokers quit rates were not statistically different whether given e-cigarettes with or without nicotine –thereby causing a placebo effect. … We cannot conclude from this study that e-cigarettes promote cessation. While the study showed that some smokers quit, it does not show that the product itself had any role in the behavior change. In fact, the results merely show that sucking on an empty cigarette holder (a placebo) would likely accomplish the same thing.”

This press release misses the whole point. And in doing so, it ends up misleading the public.

There is no true “placebo” effect involved with electronic cigarettes because the mimicking of smoking with the use of a cigarette-like device is the main point of the product. We do not want research to control for this effect. We want research to measure this effect.

Obviously Legacy is wrong about a cigarette holder being the same experience as an e-cigarette.  But they did figure out that if you want to design your study to show a null result — to minimize the apparent effect of e-cigarettes on smoking cessation — you should compare nicotine e-cigarettes to non-nicotine and claim that this is the contrast of interest.  Based on that insight, they went back and pretended that this existing study had such a design flaw and reinterpreted the results accordingly.

Part of the problem is the entire notion of using clinical trials to study complicated learning- and socially-influenced processes like THR.  You might be able to argue that testing medicalized nicotine products (the way NRTs are marketed) can be done reasonably in a clinic because they are used in a very clinical way.  But that is not true of most ways of quitting smoking.  In fairness to the ECLAT authors, that methodology has some advantages, and they were not actually doing a standard cessation trial.  But the RCT fetish that is common among medics who only half-understand scientific research makes it very easy to design a study to fail and claim that it must be a good study because it is an RCT.

RCTs usually have net advantages compared to observational studies when (a) the assigned protocol is a realistic version of what someone would experience in real life and (b) the mere act of having people in a clinical setting and assigning them something does not affect the outcome.  This makes them nice for examining medical procedures or treatment drugs, where these conditions are pretty much met.  But they are quite bad for studying behavioral phenomena, especially those where, in real life, people fiddle with the details of the methods and act on their own without the artificial pressure of being in a study.

A further complication is what Siegel alluded to: RCTs tend to work better only if (c) it is obvious what to compare the intervention to.  Comparing nicotine to non-nicotine e-cigarettes is not an interesting comparison.  In any case, despite the rhetoric you hear about placebos, most proper RCTs do not compare a treatment of interest to a placebo, but to the realistic alternative.  To see if a new method for performing an appendectomy produces fewer complications, you do not assign half of the subjects to the placebo of being anesthetized but their appendix left in.  That would be insane.  You compare the new method to the best available old method.

This further emphasizes the importance of point (b).  Who do you compare the group assigned to use e-cigarettes to?  Should they be given a placebo treatment of just being handed a quit smoking pamphlet that is known to have no effect?  If so, you are still looking at people who agreed to participate in the trial (not representative of the population) and are comparing people who were asked to take a major step to those who just throw away a piece of paper and forget the whole thing.  To merely control for the entire Hawthorne effect (the effect of feeling like you are being studied) the alternative may need to be more aggressive than that.  To control for any placebo effect it would be necessary to give people pills that are inert but described as being a satisfying substitute for smoking (not a “cure” for it), because everyone knows that e-cigarettes are about substitution.  That fiction is unlikely to hold up very long.

Basically, the more thought you give to trying to do the science right, the more clear it becomes that there is no particularly good way to do the RCT.  Thus, the advantages of observational research over RCTs start to predominate.

—–

As an aside for those who click through and read that Siegel post:  You will notice that the thesis of the post is about Legacy failing to disclose that they receive funding from the pharmaceutical industry, which stands to lose sales as a result of e-cigarettes.  I have to say that it seems like rather a stretch to demand that a large corporation disclose their relatively modest pharma funding on everything they write.  It is kind of like asking FDA to do the same.  (Perhaps the more relevant disclosure would be that Legacy was created and funded by a sales tax on cigarettes, the MSA.)

The impact of pharma funding on the anti-THR attitudes of Legacy and other pseudo-health corporations is somewhere between zero and trivial.  Part of the reason is that there are much stronger self-interested motives for being anti-THR.  More important still, people do not adopt these semi-religious beliefs because of funding.  Many gravitate to where there is funding that supports the mission they have adopted, but that is causation in the other direction.  Finally, the amount of money at stake is trivial to the pharmaceutical industry.  They give grants to keep a hand in things and get inside information, certainly.  But it is very difficult to believe that they are so concerned about relatively modest erosion of the tiny tiny corner of their business that is smoking cessation that they would exert pressure on those they fund to attack e-cigarettes.

Recall that yesterday I pointed out that holding an unrealistic view of your enemies’ motives is a recipe for adopting bad tactics.  While this case is not quite as dramatic as the one I was discussing, it is another example.  It is a mistake to think that pharma cares so much about THR that they are throwing around bribes to try to discourage it (even if you are willing to assume they would be willing to take such actions), and also a mistake to think that those funds play a major role in the decisions of anti-THR actors.  It is probably safe to say that the impact is not exactly zero, but there are much more important forces afoot.  If we focus on the red herring of donations rather than the major social forces and other base interests, we are likely to be rather less effective.

“Craving” and other annoyances from the FDA meeting

by Carl V Phillips

The FDA hearings that I mentioned previously went fairly well.  Two of the panel members were anti-tobacco extremists from the Center for Tobacco Products (CTP), and were looking for any excuse to further their crusade.  But the majority of the panel appeared to entirely professional and interested in doing their job.  They paid attention to the testimony, and seemed to consider almost all of it to be productive and almost all of it to represent useful contributions to a shared cause.  In other words, it was really refreshing, and very unlike the CTP; notice in particular that I am not suggesting that this corner of FDA are liars.

Not that there were no liars present.  The most striking thing about the meeting was that the speakers representing the tobacco industry and the pharmaceutical industry, as well as the consumer advocates (in my obviously biased opinion) were all serious, honest, and science-oriented.  They all had their own agendas, of course, but all were on the side of public health, as was the majority of the panel as far as I could tell.  This contrasted markedly with the NGO representatives (American Cancer Society, American Legacy Foundations, and a few others) who were doing anti-scientific rhetorical backflips in their dishonest attempts to claim that allowing broader marketing of pharma products for THR was a good idea, but the exact same logic somehow did not apply to smokeless tobacco or e-cigarettes.  I have to think that any honest observer could see right through their lies.

One particular annoyance, a fundamental anti-THR lie that FDA was dealing with (though not their own fault, except perhaps historically) was the concept of “cravings”.  This shows up in claims like, “NRT products are designed to reduce smokers’ cravings for nicotine.”  What is interesting about this concept is that in a better world, it would be spot-on and potentially useful.  That is, the common language meaning of the word does have relevance and particular usefulness:  It could be that someone genuinely would prefer to be abstinent from tobacco and nicotine, but keeps coming back because of some short-term urge that is different from a genuine preference.  The word is not well-defined, but you could see how it could be wrapped up with withdrawal symptoms rather than what we would call benefits of using the products.  In that case, offering a drug that eliminates that craving would have obvious value.

The reason that this is a backdoor invocation of one of the fundamental anti-THR lies (specifically, that there are no benefits from nicotine) is because that “different from a genuine preference” caveat is ignored by the tobacco control industry.  Instead they use the word “craving” as part of their fiction that no one actually prefers to use nicotine, and that there are no benefits of smoking and other product use, and so users smoke just because of something the call a craving.

I was surprised to learn that the FDA, in this context, is statutorily required to deal with the concept of craving.  That explained why they asked a series of seemingly nonsense questions about cravings to Johnathan Foulds, who answered in the same terms before finally getting a bit frustrated and pointing out that there was no definition of the term that set it apart from “a desire to smoke”.  (Prof. Foulds, a good scientist who is a long-time supporter of THR, was there representing the Society for Research on Nicotine and Tobacco, which is very much an ANTZ group posing as a scientific organization.  Thus, he might have felt a bit trapped in terms of what he could say.)

If there was honest research on this topic, then maybe we could make use of the specific concept of craving and deal with it.  But given that most of the “researchers” (e.g., most members of SRNT) are just activists who are pretending to do science, such words just create problems, not value.  There is certainly something to the notion of craving, but it is less important than normal consumer preference.  As I had already noted in my testimony, nicotine is much more like any other high-value consumer product than it is different.  Low-risk nicotine products are a good substitute that fulfills that preference, but NRT as a method to merely reduce cravings fails miserably as a method for stopping smoking.  Why?  Because those cravings are largely unimportant compared to the preferences.

This brings up a lie that lay just beneath the surface of the whole discussion, mentioned only by the consumer advocates and vividly recounted in the personal testimony of individuals who testified as stakeholders:  NRT does not work for its currently stated purpose, even though it works pretty well (though not nearly as well as higher-quality products) as a substitute.  But this initiative is progress in terms of dealing with that.

More generally, it was frustrating to observe the FDA panel asking questions as if there is legitimate and useful science not just on “cravings” but in a variety of areas related to the topic.  The representative from Legacy, in particular, presented testimony and answered questions for longer than anyone, pushing the lie that most of what is published by the tobacco control industry is science and not junk.  The ANTZ can get away with that when being judged only by their fellow ANTZ, including the CTP unit of FDA.  But it might be that the more serious and scientific side of FDA, the drug regulators whose policy on NRT could carve out space for other THR products, will not fall for it.  We shall see.