Tag Archives: “no evidence”

Et tu, Ken Warner? (and some musings about “endgame”)

Posted on 16 April 2013 by | 11 Comments

by Carl V Phillips

The tobacco control industry’s house organ pseudo-journal, Tobacco Control, just released a special issue about what they call the “endgame”, which is their code word for the elimination of all of tobacco/nicotine use.

It is kind of a funny choice of words, since the word derives from the phase of a chess match where there are few pieces left on the board and a decent player can analyze every possible set of moves with greater certainty than earlier in the game.   This is rather unlike the situation with tobacco/nicotine today where there are more options, more companies, more tobacco control activists, more real public health and consumer advocates (those of us supporting harm reduction and such), and — most notably — more smokers than there have been ever before, and where there is far less certainty about what will happen next.  Most of those who use the term seem to be looking for a something more like the military concept of “mop up”, where victory is assured but some final actions are required.

On the other hand, the more I think about it, the clearer it becomes that they accidentally got something right in this case:  When a chess match between serious players has an endgame (rather than one player resigning), it means that a balance still exists and the outcome is yet to be determined.  If someone’s victory is already assured, there will be no endgame.  Moreover, the endgame is (roughly) defined as the time when the removal of other pieces makes the pawns particularly important and the kings become active fighters rather than just hiding from the action.  This seems like a pretty good metaphor for the rise of grassroots activism against the power brokers and for the emergence of active involvement of the primary stakeholders, the consumers.  The more I think about it, the more I really like that.  Bring on the endgame!

Anyway, I am not sure I have the stomach to read through most of the articles in that issue, though there is probably a month’s worth of the typical tired anti-THR lies to be found in them.  I will count on some of you to highlight any high points (which probably really means low points).  But I did read the short introduction by Kenneth E Warner, the Michigan professor who organized the conference that led to this collection of papers, and his anti-THR lies probably pretty much sum up what else is to be found there.

Ken is a smart and generally honest researcher, and was one of my mentors during my postdoc about 17 years ago.  For quite a while in the 2000s, some of us working on THR thought that he was the most likely candidate among the card-carrying respected insiders of tobacco control to seriously embrace harm reduction and say “be damned” to the ANTZ special interests.  I also remember that for a few years, he repeated something I told him during my postdoc:  I had thought about doing more work on smoking-related policy and science, but with people like him already in the space, there seemed like there was not much more to contribute that would be useful.  When I said that, I was half right:  Brad Rodu had already released his groundbreaking work on THR, though most of us in public health did not have the slightest idea about it, which made clear that there was a lot of new, interesting, innovative, and helpful work to be done.  However, I was right in my assessment that every other avenue of legitimate science about smoking was pretty much done by then; there has been approximately zero legitimate analysis any consequence since that time.

Alas, Warner never came out in favor of harm reduction, which brings us back to his recent paper, which asserts:

The continuing scourge of tobacco-produced disease is unlikely to yield to today’s evidence-based interventions. Several public health visionaries have introduced tobacco endgame proposals with the goal of substantially reducing, and perhaps entirely eliminating, the toll of tobacco.

He uses the anti-THR lie that “tobacco”, rather than smoking, is a major cause of disease.  More importantly, he implicitly claims (several times) that THR is not evidenced-based, one of the two or three biggest anti-THR lies.  The reality, of course, is that the evidence does not support the claim that current tobacco control tactics — more aggressive use of drugs, manipulation of packaging, and various other restrictions — do much more than torture smokers.  The evidence is pretty sketchy about whether further education (in already educated populations) makes any difference or what the effects of even higher taxes and similar quasi-bans will do (there cannot be much evidence about something that has never been tried, after all).  But, but contrast, the evidence that THR can reduce smoking and thus disease is overwhelming, at both the individual and population levels.

As for that last quoted sentence, the terms “visionary” and “public health” give far too much credit for the authors of the other papers in the issue and what appear — based on a quick review — to be the same tired old useless welfare-lowering and/or prohibitionist policies.  Even the paper by Lynn Kozlowski, long the tobacco control industry’s pet harm reduction advocate (i.e., the guy they brought in for their staged “debates” about harm reduction rather than dare hear from those of us who were the real advocates for THR), barely mentions harm reduction and does not acknowledge its potential.

Interestingly, Warner fails entirely to even mention THR, let alone point out that it is the most important phenomenon in the area today, something that he surely realizes.  Perhaps he did not want to risk offending his friends and patrons by even acknowledging it (very much like the last time I ran into him, at a Society for Research on Nicotine and Tobacco conference nine or ten years ago — after I had become a visible proponent of THR but before the U.S. SRNT stopped allowing us proponents to present — where he literally distanced himself from me, practically running away to avoid being seen talking to me).  Yet at the same time, he acknowledges that “something new, bold and fundamentally different from the tried-and-true” is needed.  Funny that.

Fortunately, as with actual endgames, one player does not get to just decide how it will play out.  And unlike with the opening in chess, where following memorized long-established sequences is the norm, or the middle game where most players make use of general heuristics about what positions are better, in the endgame the exact ramifications of each move are thought out precisely.  It is pretty clear that the ANTZ have little idea how to play in that world.

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Kelvin Choi is a liar

Posted on 30 January 2013 by | 6 Comments

by Carl V Phillips

A new ANTZ on the scene seems to be aspiring to be the new Ellen Hahn.  I supposed it is possible, given that he is at University of Minnesota that he aspires to the be the new Stephen Hecht, but that might be a stretch since Hecht seems to do somewhat useful bench science, and then just lies about the health and political implications.  Choi, by contrast, seems to be fully ensconced in the “public health” junk science paradigm.  Consider this recent abstract:

Objectives. We assessed the characteristics associated with the awareness, perceptions, and use of electronic nicotine delivery systems (e-cigarettes) among young adults. Methods. We collected data in 2010-2011 from a cohort of 2624 US Midwestern adults aged 20 to 28 years. We assessed awareness and use of e-cigarettes, perceptions of them as a smoking cessation aid, and beliefs about their harmfulness and addictiveness relative to cigarettes and estimated their associations with demographic characteristics, smoking status, and peer smoking. Results. Overall, 69.9% of respondents were aware of e-cigarettes, 7.0% had ever used e-cigarettes, and 1.2% had used e-cigarettes in the past 30 days. Men, current and former smokers, and participants who had at least 1 close friend who smoked were more likely to be aware of and to have used e-cigarettes. Among those who were aware of e-cigarettes, 44.5% agreed e-cigarettes can help people quit smoking, 52.8% agreed e-cigarettes are less harmful than cigarettes, and 26.3% agreed e-cigarettes are less addictive than cigarettes. Conclusions. Health communication interventions to provide correct information about e-cigarettes and regulation of e-cigarette marketing may be effective in reducing young adults’ experimentation with e-cigarettes. (Am J Public Health. Published online ahead of print January 17, 2013: e1-e6. doi:10.2105/AJPH.2012.300947).

Let’s set aside obvious problems, like the limited value for anything other than historical tracking of an awareness survey about e-cigarettes from 2010, or describing 20-something-year-olds as “experimenting”, as if they are children.  (Many of those crazy kids are also experimenting with buying houses, military service, and parenthood.)  Consider the core conclusion.  How can a simple cross-sectional survey of awareness and belief tell us anything about the effects of communication and regulatory interventions?  If you said, “I have no idea”, you nailed it.  It is a complete lie that the conclusion follows from the research.

And, of course, there is the little matter of which bits of information he wants to correct.  Does he want to help the 55.5% who do not realize that e-cigarettes help smokers quit?  Or is it the 47.2% who do not realize they are lower risk than smoking?  As you might guess, it is the ones who actually know the truth that he wants to “correct”.

(Note:  I trust my regular readers will recognize as subtle ridicule my use of three significant figures in reporting those numbers.  As anyone who understands sampling — and anyone familiar with my writing — knows that reporting that level of unwarranted precision is a bit of junk science in itself.)

There is some potential usefulness in the actual survey in terms of helping us learn about the rate of at which accurate knowledge of e-cigarettes and THR has spread.  However, what has no apparent usefulness are Choi’s thoughts and opinions, as evidenced by this interview.

I will skip past his first answer, a remarkably amateurish description of what e-cigarettes are, something that could be corrected by basically anyone who is familiar with the topic.  (But go ahead and read the whole interview if you are inclined to find unintentional comedy in ANTZ rantings — it is a good one for that.)  I skip that because it gets far worse:

There are a variety of reasons why e-cigarettes are unhealthy. First, they contain nicotine, which is a known addictive chemical. A recent study conducted by Vansickel and Eissenberg found that experienced e-cigarette users can obtain a significant amount of nicotine through e-cigarettes, which may be comparable to smoking cigarettes.

E-cigarettes deliver nicotine?  Who knew?  Glad we had that study (by the guy who originally claimed just the opposite and never admitted his error — but that is another story).  And the reason that they are unhealthy is that this chemical is addictive (whatever the heck that means), not because it is harmful.  Choi might want to ask for a tuition refund from whoever claims to have taught him about health.

Second, previous chemical analyses of the e-cigarette nicotine liquid found that some samples contain tobacco-specific cancer-causing agents and anti-freeze.

Yawn.  Yes, this PhD “researcher” cannot do any better than some random county public health nurse, citing the propaganda (rather than the actual scientific results) from the FDA.  Another tuition refund, please.  Oh, but wait.  Maybe that nurse could do better.  She probably would not claim that e-cigarettes actually “contain…anti-freeze” [sic], but merely “an ingredient found in antifreeze”.  The latter form of this is an example of lying with literal truths, of course, as previously discussed in this blog (did you know that breast milk contains an ingredient found in antifreeze?!! we should stop nursing babies immediately!).  Apparently Hahn Junior does not even realize that he is reciting propaganda meant to confuse people — he is among the genuinely confused.

Third, with the product being promoted as a cigarette alternative at places where smoking is not allowed, smokers may use these products to sustain their nicotine addiction, and may therefore be less likely to quit smoking

And another “problem” that is not an actual health risk from e-cigarettes.  That “where smoking is not allowed” pseudo-argument deserves a post or two of its own, which I will do that soon.  So today I will politely refrain from pointing out how utterly moronic it is.

And that is all he offers.  Not even a single claim of health risk.  Apparently he wants to keep people from “experimenting” with e-cigarettes because they… …um… cause no health risk at all.

Oh, but it gets dumber.  So much dumber.

I think the perception of e-cigarettes as cessation aids is of the greatest concern. First, this perception may drive young adults to use e-cigarettes when trying to quit smoking instead of proven-effective cessation treatments. To date, no studies have shown that e-cigarettes are more effective than proven-effective cessation treatments such as nicotine replacement therapy and counseling. Therefore, e-cigarettes may hinder young adult smokers from quitting smoking.

E-cigarettes are (correctly) perceived as being useful for quitting smoking?  Well, that is a dire concern indeed.  As for the claim they are not shown to be more effective than other methods that are “proven” to help a mid-single-digit percentage of smokers quit (to charitably take a best-case figure from the biased research on the topic), so what?  Even setting aside the fact that he is baldly lying about that — the evidence strongly supports the claim that e-cigarettes are more effective — how exactly do they prevent someone who wants to quit smoking from trying those other methods if the e-cigarettes do not work?

Anyone with a basic understanding about smokers and quitting — even at the casual layperson level of knowing actual humans who smoke or smoked — understands that most people who are interested in quitting try multiple methods.  How exactly can one method, even if he genuinely believes it is of no value at all, interfere with the others?  Does he really think that smokers are so dumb as to say “well, I wanted to quit and tried an e-cigarette, but it did not work for me, so I will just keep smoking because I have never heard of any other method I might try.”  Gee, if only there were some way to inform smokers that the powers-that-be think they should try NRT and counseling.  Someone should really get on that.

And if Choi really believes that introducing a new method of quitting will actually prevent the use of other options, does he rail against the introduction of new NRT products or counseling methods because they will keep people from trying the existing methods he thinks are actually “proven”?  I didn’t think so.

In short, either he has not even given enough thought to this topic to be considered even a generally aware layperson, and so is grossly lying about his expertise, or he is just making up lies because he wants a ride on the ANTZ gravy train.

Is there more?  Oh, yes, there is more.  It will have to wait until the next post.

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Don’t Be Fooled by the Canadian Lung Association

Posted on 25 January 2013 by | 5 Comments

By Elaine Keller, with input from CASAA Board

[Note: Carl will resume his series about useful truths next week.  We have a few lies we want to cover first.]

Good health advice is any instruction or set of instructions that, when followed, results in health improvement or the avoidance of illness or injury. Bad health advice, when followed, results in illness or injury that would have been avoided by not following the advice. The public expects organizations that position themselves as leaders in fighting disease to provide good health advice that is based on accurate information.

“Don’t be fooled by e-cigarettes,” states a press release from the Canadian Lung Association (CLA). “These electronic devices could be potentially harmful to lung health” and that smokers should “avoid” them. Is it good health advice to discourage smokers from using an effective method for quitting? Clearly not, since there is overwhelming scientific evidence that smoking is harmful, not just to lung health, but in many ways. They are trying to discourage quitting by any smoker who is not willing and able to do it their way.

If they truly were concerned about lung health, they would have pointed out that there is no doubt that vaping is better for lung health than smoking. Then they would have discussed any actual concrete concerns about vaping and lung health. Instead, they just presented several irrelevant details intended to distract the reader from the truth. It might have been defensible advocacy for the lung association to say something like, “If you have quit smoking using e-cigarettes, that is some progress, but now you need to quit the e-cigarettes.”

But that is not what they did. For example, two paragraphs of the CLA press release are devoted to conjecture that the products might appeal to children. There is no evidence of this, but more important, how does this support what they are supposedly claiming, that there is a health risk? They clearly did not believe they could support their claim about health risk. And for good reason, when you consider the available evidence about e-cigarette effects on lung health.

First, consider what consumers who switched from smoking to an e-cigarette say about their lung health. For example, a University of Geneva researcher wrote, “Respondents reported more positive than negative effects with e-cigarettes: many reported positive effects on the respiratory system (breathing better, coughing less), which were probably associated with stopping smoking.”

Second, what do other sources say? In 2009, the U.S. Food and Drug Administration (FDA) invited consumers to use the agency’s Adverse Event Reporting System (AERS) to report problems experienced with using e-cigarettes. Results were reported in a letter to the editor of Nicotine and Tobacco Research. There had been 1 AE reported in 2008. There were 10 AE reports in 2009, 16 in 2010, 11 in 2011, and 9 in the first quarter of 2012. The types of problems reported are very similar to those reported with pharmaceutical products such as nicotine gum or lozenges, for example, headache, sore throat, abdominal pain, coughing, etc. The author commented, “Of note, there is not necessarily a causal relationship between AEs reported and e-cigarette use, as some AEs could be related to pre-existing conditions or due to other causes not reported.”

The author also mentioned that the number of people reporting ever an using e-cigarette more than quadrupled between 2009 and 2010. If there were any serious health risks posed by e-cigarettes, we would expect the number of AE reports to quadruple as well, but the number of reports dropped in 2011.

Third, the clinical trials that have been completed and that are in progress would be stopped if serious adverse events, such as lung health impairment, occurred. To date, no clinical trial of e-cigarettes has been stopped due to adverse events.

Under the heading, “E-cigarettes are not proven safe,” pediatrician Dr. Theo Moraes, a medical spokesperson for the CLA is quoted, “People who use e-cigarettes inhale unknown, unregulated and potentially harmful substances into their lungs.” Is this statement accurate? No, it’s a lie. It is a lie simply  because we have a quite a good accounting of what is in e-cigarette vapor. Additionally, its implication is a lie. As Dr. Phillips pointed out in an earlier post, before the first study of e-cigarette chemistry was ever done, we were 99% sure that cigarette smoke was many times more hazardous than vapor. People who smoke inhale thousands of chemicals from combustion, many of which are quite hard on the lungs (to say nothing of other parts of the body). Those chemicals are basically absent from vapor.

The substances in e-cigarette liquid are well known, and all ingredients are government-approved for human use (though not specifically in the form of e-cigarettes, of course). They include USP grade propylene glycol and/or vegetable glycerin, water, approved food flavorings, and (optionally) pharmaceutical-grade nicotine. Numerous toxicology studies have been conducted on the liquids and on the vapor, and none have found quantities of any chemical that are believed to be substantially hazardous.

The infamous FDA initial lab test is mentioned in the CLA press release, without pointing out that the “detectable levels of carcinogens” match the levels in FDA-approved nicotine patches. The “carcinogens”, tobacco-specific nitrosamines (TSNAs), are present at similar trace levels in any product that contains nicotine because nicotine is extracted from tobacco. The “toxic chemicals” turned out to be a non-harmful quantity of one chemical in one sample. Also not mentioned is the fact that the only two brands tested were the two companies that were in the process of suing the FDA, which is a red flag for bias.

Bottom line: Dr. Moraes is either deliberately misleading the public or is woefully uninformed about the contents and nature of e-cigarettes. He certainly does not understand the purpose of the products. “There are many nicotine replacement therapies approved by Health Canada to help someone quit smoking; the e-cigarette is not one of them,” he stated.

The nicotine replacement therapies (NRTs) approved by Health Canada are not aimed at helping people to quit smoking. They are aimed at treating “nicotine addiction”. They provide a reduced quantity of nicotine on a temporary basis, which is then further reduced and ultimately discontinued. E-cigarettes are not intended to treat nicotine addiction. They are used as a replacement for smoking that doesn’t require nicotine cessation.

Which works better? The vast majority of smokers who try to quit by cold turkey or using recommended medical interventions resume smoking. The published research probably overstates how often these “approved” therapies work, and even it agrees that they are nearly useless. As one example:  “Approximately 75% to 80% of smokers who attempt to quit relapse before achieving 6 months of abstinence. Of the remainder, relapses may occur years after a smoker initially quits.”  Consider what passes for “success” for NRT, such as a study comparing 6-month abstinence rates of those using NRTs versus those not using NRTs. In the first phase of the study, rates were 9.4% in the NRT group versus 3.5%. In the second phase, the rates were 6.9% in the NRT group compared with 4.3% in the non-NRT group. The authors stated, “NRT use was associated with improved chances of long‐term abstinence when controlling for nicotine dependence.” Both of these studies, as well as numerous others and simple common knowledge, also tell us that there are some smokers who are much less inclined to become abstinent from nicotine.

The critical difference between the “approved” approaches and typical e-cigarette use is that e-cigarettes do not involve becoming abstinent from nicotine. Once e-cigarette users have replaced all of their smoked cigarettes with e-cigarette use, they have stopped smoking. Because they are not required to become abstinent from nicotine, those who are more dependent or who simply are less inclined to give up the beneficial effects of nicotine, can continue to experience those benefits without destroying their health by smoking.  We do not know what portion of all smokers who seriously try to switch to e-cigarettes succeed at it, but we do have good evidence that the rate is pretty good — certainly better than quit rates using “approved” methods — and that lots of people who would not have quit smoking using those other methods have quit by using e-cigarettes.

To summarize the evidence, e-cigarettes: (i) have not been shown to harm users, based on either actual outcomes or what we can predict from the chemistry; (ii) appear to be much more effective at smoking cessation than “approved” methods, even for those who would consider quitting nicotine entirely, and (iii) are clearly more effective for those who want to quit smoking but do not want to quit nicotine.

In the final analysis, the CLA, like the American Lung Association, is a liar. The CLA says “don’t be fooled,” but the evidence says that the CLA is the one trying to fool the public. If the CLA were truly concerned about lung health, it would be doing everything possible to help smokers stop smoking as quickly as possible. If they genuinely believed that e-cigarettes left some tiny fraction of the lung risk for those who quit smoking, then they would try to address that. Instead, the CLA is actively discouraging smoking cessation by misinforming Canadian citizens about the speculative risks of using e-cigarettes and overstated claims about everyone can easily just quit nicotine entirely.

If you smoke, or care about someone who does, don’t be fooled by the CLA or ALA.  (And definitely make sure that you and people you know avoid supporting them financially.)

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Glantz’s tenuous grasp of science (cont)

Posted on 16 January 2013 by | 43 Comments

by Carl V Phillips

[This is a continuation of yesterday's post on this topic and will probably not make much sense if you have not read that one.]

I will pick up the analysis with a thoughts that came up in the comments (h/t to the comment by “mav” in particular):  On the topic of whether Glantz is a liar, it is possible that he genuinely believes his absurd claims about how mere imagery of smoking is what causes people to benefit from nicotine/tobacco, and that he might have genuinely humanistic concern about the harm such images would cause.  (I.e., on that count, he is not the calculated corporate liar that dominates the tobacco control industry leadership.)  But then, it might also be that he is so worried about e-cigarettes creating such imagery (despite most of the decent e-cigarettes not looking much like cigarettes) that he is motivated to lie about e-cigarettes specifically.

There was also the observation that a single reported example of an exploding e-cigarette battery or contamination of the e-cigarette liquid is considered by the anti-harm-reduction activists to be true and worth repeatedly reporting.  So obviously they do understand the concept that a single observation is often adequate scientific evidence of a particular claim.  This argues in favor of the explanation that they are consciously lying when they deny the usefulness of personal success stories of how e-cigarettes caused someone to quit smoking.  If a personal testimonial of an exploding battery constitutes evidence, then countless testimonials about smoking cessation certainly do.

One of the reasons that both of these are so compelling is the plausibility of the claim.  Batteries (in all devices, whether they cost $5 or $200 million) do occasionally fail catastrophically, especially if someone uses the wrong kind.  Thus, it is not at all surprising that a few batteries have burned or exploded.  The e-cigarette is purpose-built for smoking cessation.   Thus, it is not at all surprising that e-cigarettes have caused lots of people to quit smoking.  There are many other examples of how to use prior knowledge in our scientific reasoning:  Since nicotine is derived from tobacco, we would expect to find a miniscule (inconsequential) trace of other molecules that occur in plants — e.g., TSNAs — in the nicotine that is used in NRTs or e-cigarettes, and indeed it has been found.  This contrasts with, say, a study of e-cigarette vapor that finds tobacco smoke combustion products that we do not expect to find; in that case, the explanation is probably sloppy lab procedure and equipment that was contaminated by previous analyses of smoke.

So for something that is easily predicted to be true, apart from the empirical evidence, we only need a little bit of empirical evidence to convince us that it is indeed true.  That evidence is valuable, though, no matter how strong the theory is.  So, recent efforts by smokeless tobacco manufacturers to bring new products to the American market have almost certainly caused some smokers to quit, but absent a bit of evidence to confirm success, it is not unreasonable to consider that conclusion less than definitive.  This relates back to the light switch point from the previous post:  We have strong reason to believe that the switch on the wall and not, say, the fact that it is 8:00 is what causes the lights to be on, so when our switch-flipping experiment seems to confirm that, we can be confident of the claim.

This does bring up the one bit of possible doubt about personal experiments:  What if someone is quite sure about a particular cause and effect, but they are wrong?  You only need to wander through the internet for a few minutes to find examples where this is pretty clearly the case.  But how could someone possibly be wrong about their smoking cessation?  Glantz tries to make up such a story by claiming “placebo effect”.

Glantz is in good company in clearly not understanding what this concept even means.  Most people who talk about placebo effects or placebo controls clearly do not understand what they are talking about.  So to explain…

The concept of a placebo, as part of a scientific inquiry, only makes sense with specific reference to context, and needs to be separate from similar but quite distinct effects.  When a placebo is referred to without a research context, it generally refers to an actual treatment method, in which someone is cured of a disease by intentionally tricking them into believing they are receiving a treatment with known benefits.  This is a good thing when it works, obviously.  To the extent that the word is interpreted this way, then for someone to quit smoking due to the placebo effects of e-cigarettes means that they quit smoking due to e-cigarettes.  Success!  (Michael Siegel wrote more about this observation yesterday.)

But that brings up the issue of what the word means in a research context, and that, rather than the intentional medical use of a placebo, is presumably what Glantz was referring to.  What would it mean for an e-cigarette to work as a placebo, rather than because… well, rather than what?  This points out that the concept of an experimental placebo has to refer to a specific characteristic of an intervention, and not the intervention in general.  Someone might wonder if the nicotine delivery from an e-cigarette really matters much, or whether the device and action itself is causing most of the effect — i.e., whether the nicotine content was merely a placebo.  In that case, the placebo control would consist of a nicotine-free e-cigarette that the subject did not know was nicotine-free.  The placebo would still be something real, as most placebos are, but not real in one specific sense.  But this would obviously not constitute a placebo if the question were “is the act of mimicking smoking useful for cessation?”  The concept of a placebo in research only makes sense when we consider the question that is being asked.

To further complicate it:  In clinical studies where some subjects are just given a sugar pill (Glantz’s example of what a placebo is), there is perhaps some placebo effect.  However, this is actually probably dwarfed by the “Hawthorne effect”, the tendency of people to behave differently just because they know they are being studied, regardless of whether anything is being done to them.  (Ironically, the Hawthorne experiment that it is named after probably actually demonstrated as much of a placebo effect as anything, but that is another story.  The concept is clearly right even though the name is wrong.)  When smoking cessation studies are performed, and it is found (as is pretty much always the case) that the NRT or other intervention had the same effect as a placebo, most of the effect is probably Hawthorne and not placebo.  That is, the cessation success rate is elevated for both groups not so much because of a placebo effect, but because people who are being studied are more likely to behave in different ways.

Indeed, I have long believed that the following intervention would have approximately the same success rate as NRT in clinical trials (or the placebos that have the same effect):  Have a reasonably attractive member of the opposite sex approach a smoker and say “I am from <organization> and we are very interested in finding out how many people are quitting smoking this year and how they are doing it.  Would you mind if I get contact information for you and check back in six months to see if you have quit?”  In both that scenario and in the real clinical studies, extra cessation (in excess of the population average rate) would mostly result from people who had been seriously thinking about quitting one of these days, and who — because they know that someone is watching them to see if it happens right now — go ahead and do it.  (We were actually considering doing that experiment when I was in Alberta, but did not manage to get it started.)

It should be obvious that both placebo and Hawthorne effects are much more likely when the outcome of interest is decision-based rather than biological.  That is, occasionally someone actually overcomes biological disease due to the power of belief, but it is much more likely for someone to choose an action because of their belief.  Indeed, people only take volitional action because of belief.  So talking generically of a placebo (rather than specifically, as with the nicotine-free e-cigarettes) when the outcome is behavioral actually makes no sense.  It seems likely that Glantz was confusing the Hawthorne effect, which occurs in study settings, with the placebo effect.  He was probably trying to suggest that since the placebo group in clinical trials quit at the same rate of those who received “FDA approved”-type interventions, that maybe that was also occurring with e-cigarettes.  But since he was talking about people making personal decisions in their normal lives and not in a study, there was probably almost no Hawthorne effect (there might have been a bit, if a friend who turned someone on to e-cigarettes was monitoring their success, but not much).

As I said, Glantz is in good company in not understanding this.  Well, I should say he is in a lot of company — the widespread failure to understand this among people who claim to be experts is not really forgivable.  When someone refers to a placebo effect, without actually identifying what specific aspect of an intervention is being replaced with a placebo, it is yet another example of someone understanding just enough about how to do science to create confusion rather than knowledge.

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