Tag Archives: self policing

Please don’t cite the new Nutt et al. paper as evidence for tobacco harm reduction

by Carl V Phillips

Some of you may have seen this new paper by Nutt et al. that purports to show the comparative costs imposed by various tobacco products.  There might be some temptation to cite it as evidence of the benefits of switching from smoking to smoke-free alternatives.  But I urge you not to do that for the reasons explained below. Continue reading

Basic case for THR, A-; analysis/facts/science, D

by Carl V Phillips

I will have time to write some new analysis in a couple of days.  In the meantime, to keep things from getting too quiet, I will just copy and paste some observations I made in a Facebook conversation (at the Tobacco Harm Reduction page, a still somewhat active artifact from my old University of Alberta research group).

I really hate to have to rubbish (I am in England right now, so I have to talk like that) pro-THR missives, but it is important that our side try to do accurate work.  The anti-THR liars have wealth and power, while our main strengths are the truth and a mobilized population of product consumers and other supporters that know the truth.  We do not help ourselves by embracing bad analysis.  If we are sloppy, or just try to do what they do — created a politicized set of claims that is demonstrably wrong — then they have all the advantages.

The missive if in question, unfortunately, kind of reminded me of a thought I often have when I read instructions that accompany some Asian-manufactured product that are in completely garbled English:  “This company designed and produced a good product, and have an impressive production process, but then made their whole enterprise seem shoddy by not taking the time to get the instructions right.  There are like a billion people in the world who are fluent in English.  Could they not hire one of them to spend ten minutes rewriting this so that it was not such a mess?”

For the case in point, there are obviously not a billion, or even a thousand, people who thoroughly understand the science and other technical points about THR, but there are certainly enough that it is easy to find someone to provide an expert review.  There is no shame in someone who is skilled in product engineering and another language to draft an instruction document, with the inevitable grammar problems, and then ask for help to fix up the English so as to not detract from the value he has created.  It is the refusal to take that last step before going ahead and publishing that does the harm.

So, anyway…

facebook rstreet 1

facebook rstreet 2

As I said, I really hate this, but it needs to be done.  There are some powerful good messages about THR in this document.  There is some useful information.  But….

My first response was an indication of the fact that I was aware of the paper by really just wanted to ignore it and bury my head in the sand.  But that is just irresponsible, and I got called on it.  If we are going to police ourselves — and not just behave like the ANTZ, embracing any statement from “our team” without caring whether it is sound — it has to be done.

Just to save some of you the trouble of the obvious follow-up:  please do not ask me to itemize the errors and explain why they are wrong.  Regular readers should be able to figure out a lot of them anyway.  I will just offer the advice to not rely on this paper for information, and leave it at that.  Well one other thing:  I will also beg to any of you who are writing such things to circulate them for comments before publishing them.  There are experts who can help you get them right (or suggest that you just pare them down to your basic ideas and not try to delve into needless technical analysis).  I can assure you that I do that for anything I write on a similar scope.

Real public health research on e-cigarettes?

by Carl V Phillips

A funny thing appeared in the abstracts for the upcoming meeting of the Society for Research on Nicotine and Tobacco (SRNT).  Buried amidst the few dozen abstracts about e-cigarettes from the “public health” people is some actual public health research (i.e., research that could inform messages and regulation that would help people be healthier).

Most of the abstracts on e-cigarettes are just dumb make-work projects, presumably by people trying to justify their employment.  There are numerous surveys of attitudes, which mostly just reflect how the questions were asked and are changing by the month, and other variations on how to provide no useful information other than perhaps a historical record about the social dynamics of THR adoption (I will probably try to mine them for that).

Not surprisingly, many of the supposed social science projects violate the ethical norms of social science by using the concocted term “ENDS” rather than using the population’s preferred terminology for e-cigarettes.  This offers absolutely no scientific benefit (e.g., it does not more precisely define the behavior) and was clearly designed to be somewhat derogatory, but most of all it is designed to assert researcher primacy over a population’s own self-identity.  Some types of scientists can make up words when they are helpful, and political actors can have some fun with it when describing the powerful (e.g., “ANTZ”); people doing sociological research are ethically obliged to respect the populations they are studying.  Imagine researchers making up a patronizing name to refer to a self-identifying ethnic/cultural group; their writing would generate serious deserved backlash and be refused by any respectable journal or research organization.  This alone says a lot about these “researchers” and SRNT.

Most of the abstracts contain disinformation and, indeed, the one that I am highlighting has disinformation built into it (see below) despite its possible value.  It is by Alan L. Shihadeh and Thomas Eissenberg, who unlike their SRNT colleagues seem to be trying to do useful work and have some inkling of what useful science looks like.

(However, in spite of his increasingly valuable contributions, I believe the latter still owes the world an apology and/or retraction for his widely-cited publication that claimed that e-cigarettes do not deliver nicotine.  Politicians and activists make errors like that all the time and then pretend it never happened; scientists who make the mistake of epistemic immodesty need to rise to a higher ethical standard.  In science, the phrase “our one-off limited empirical study found something contrary to what all the previous evidence suggests” should always be followed by “so we probably did something wrong, so please ignore this result until we do additional research” rather than by “and therefore what everyone knew before was wrong” (or, better still, they should do the additional research to explain the discrepancy before publishing).  He does however get credit for trapping the ANTZ into starkly illustrating that science is just window-dressing to them and they do not really care what it shows:  When they were foolish enough to believe his claim, they condemned e-cigarettes as failures because they do not provide nicotine.  After it became clear that his claim was wrong, they condemned e-cigarettes because they effectively deliver evil evil nicotine.)

The abstract (or just skip down to my observations about it if you are in a hurry – there is really just one important point in it):

Background: “Electronic cigarettes” (ECIGs) heat a nicotine-containing solution to produce a vapor for inhalation. There is considerable variability in device characteristics and puff topography and each of these factors may be related to vapor toxicant content.

Method: We investigated the role of device voltage and puff duration on vapor toxicant content. We examined total particulate matter, nicotine, and volatile aldehyde emissions from 15 consecutive puffs of V4L™ ECIG cartridges (18 mg/ml nicotine) while varying device voltage (3.7 vs 5.2 volts) and machine-produced puff duration (1.8 vs 3.6 s). We used a puff velocity of 38.8 ml/s and 10 s interpuff interval (Goniewicz et al., 2012). In another study, we investigated a non-cartridge ECIG use method that involves dripping nicotine containing liquid directly onto a heating element and inhaling the resulting vapors. We measured aldehyde emissions from dripping 3 drops of e-liquid (16 microL, similar to the amount of e-liquid consumed in 15 e-cig puffs) onto a 300 C heater surface.

Results: The higher voltage tripled vapor nicotine content, and doubling puff duration doubled nicotine content. We also found that longer puffs resulted in greater cartridge temperatures, and that, for a given puff duration, higher puff velocities resulted in lower temperatures. Dripping liquid onto a heater surface produced more than 200 micrograms of formaldehyde, compared to 0.03 micrograms for 15 puffs of an ECIG cartridge (V4L™cartridge, topography of Goniewicz et al., 2012). We also measured 2-20 fold greater emissions of other aldehydes (9 species in total).

Conclusions: Overall, these results demonstrate that device characteristics (e.g., voltage), puff topography, and use behavior (i.e.,“dripping”) can influence vapor toxicant content. Indeed, these findings suggest that ECIG aficionados who take longer duration, slower puffs (Hua et al., 2011) are working to obtain higher nicotine doses and that those who drip liquid directlyon the heater (McQueen et al., 2011) risk significant exposure to formaldehyde that is a human carcinogen and is associated with COPD in conventional tobacco product users.

Most of the results fall into the “incredibly obvious” category:  Faster puffs result in lower temperatures (because more cool liquid moves across the atomizer, cooling it faster than it can heat).  Longer puffs extracted more nicotine, approximately proportional to the length of the puff (anyone surprised by that?).

It was interesting to see how much delivery (reported as nicotine quantities, but that is obviously just a measure of how much total liquid was aerosolized) increased with the increase in voltage.  This, of course, is not some universal finding for the ages, like something that might be discovered about the behavior of a molecule (though undoubtedly countless naive readers will interpret it as such).  Every result in this research depends heavily on the exact variables of the equipment and other methods they were using, and every device and every user is different.  But the authors get credit for actually varying a few of the variables a bit.  Reading most of the research on e-cigarettes would give the impression that there are no such variables, so actually the authors get a lot of credit for starting to correct that error.

The result that is potentially real health-affecting knowledge (unlike, as far as I can tell, every other bit of research on e-cigarettes in the SRNT abstracts) is the result of dripping e-cigarette liquid onto a heater at 300C.  This result is, unfortunately, also the germ of more disinformation because this is far hotter than what actually occurs (except, perhaps, with a seriously ill-advised novelty mod).  This presumably explains why the concentration of formaldehyde they found is enormously higher than that observed in analyses of real e-cigarette vapor.  Even if you preheat an atomizer to that temperature before dripping on it, it will rapidly cool toward an equilibrium temperature.  I am guessing that the “heater surface” they used was a piece of lab equipment that has a much larger mass than an atomizer filament, and thus maintained close to the original temperature rather than rapidly cooling when the first bit of liquid touched it.

We can safely assume that some people will spin this result as showing that e-cigarettes generate this quantity of formaldehyde, and thus the way the information was presented is a gift to the liars.  (Perhaps such an offering to the liars is the price of admission to SRNT.)  Still, this might offer a genuine contribution to health.  It does suggest that using very-high-temperature mods or a high preheating of the atomizer (by holding the switch on for too long before starting to draw) might increases vapors’ health risks.  Even if most of the liquid would not be heated to 300C, a bit of it might.  That is intuitive if you think about it:  higher peak temperature = more pyrolysis = more nasty chemicals.  But it is not clear there has been much thinking about it.

There should be more.  Good scientists who have more knowledge than I about the chemistry should really think this through — a little bit of theory and existing general knowledge would be worth for more than a series of one-off experiments on particular equipment.  If there is going to be any actual health-improving research about e-cigarettes, it obviously will not be the attempts to demonize them out of existence, but it also cannot be the attempts to claim everything about them is always just fine.  Real public health researchers do not behave like “public health” people who just look for an excuse to say “never do this, no matter how much you want to”; they figure out how to advise “if you are going to do this, you are better off doing it this way….”  This is, of course, the reasoning behind THR in the first place, and also describes what real health research about nicotine inhaler technologies should look like.  I suspect that most of this public health learning will have to wait until the tobacco companies report what they are doing, but it is good that at least one independent research team is headed in that direction.

Can we agree not to make obviously incredible claims?

by Carl V Phillips

Related to the claim in my recent post that THR advocates stick to solid science, and are properly skeptical and critical, while anti-THR is grounded entirely in unabashed lies, I really hope THR advocates do not start citing making strong claims based on this report that:

One third of smokers say, in a University of Canterbury (UC) survey, they would use a nicotine electronic cigarette to quit now, if it was available.

I will grant that it is delightful to see anti-smoking sponsored research that might actually give some insight into how to reduce smoking (though note that this was funded by Murray Laugesen’s shop, not the ANTZ).  And there are probably some useful insights to be gleaned from the actual study results.  But not from that press release.  1/3??!  E-cigarettes are legal and widely available in a lot of places that are not terribly unlike New Zealand, and the successful smoking cessation they have facilitated is impressive.  But nowhere close to 1/3 of smokers are using them to try to quit.

A realistic estimate for e-cigarette uptake can be found by simply looking at the USA or the UK.   Indeed, I suspect that most NZers who really want to use e-cigarettes, like Canadians who wish to avoid the ban there, can get them if they really want.  So asking about actual usage would probably provide a better realistic estimate than this cheap-talk hypothetical.

There are ways to honestly interpret the results, and these are still undoubtedly pro-THR.  And that survey result was what it was, of course.  But reporting it without the realistic context as if it were a simple picture of reality is not a good choice.  The ANTZ frequently make claims that are this discordant with observed reality based on a survey result.  We must not.

My Alberta shop did a survey years ago that asked smokers about “hypothetical” low-risk alternatives (that were really understated descriptions of existing low-risk alternatives) and a huge number of subjects (most of whom had never actually considered trying the alternatives) indicated that they would try them.  Needless to say, we did not assert the conclusions that widespread adoption would happen if there were a change in the availability of products.  Rather, we examined the implications of the difference between the responses and the observed reality.

Similarly, if you want to estimate how people will actually respond to prices, you need to do what economists and marketers do (look at how people actually respond to prices), not merely ask them a hypothetical question and conclude:

if cigarette prices doubled, two thirds of smokers would quit

Real prices have doubled several times historically.  They more than double as you move from some places to others.  None of those show a 2/3 reduction in smoking.

Finally, I hate to laugh at pro-THR messages, but I could not help it when I read:

Smokers sampled nicotine electronic cigarettes and liked them 83 percent as much as their own brand on average.

Granted this is not nearly as funny as Snowdon’s ROTFL-level extended discourse on a particularly stupid ANTZ’s claim about something being “100% easy”.  But it was still LOL-level for me.  What the hell is liking something 83% as much?  (And notice it is not merely 80% as much, but a full 83%!)  Presumably there was some arbitrary scale in the survey, and the e-cigarettes scored .83 the level that own-brand cigarettes did.  But there is no cardinal scale of liking (other than the economic approach of trying to measure willingness to pay, which seems to have been absent), so while an ordinal list of the ratings of multiple products could mean something, it is silly to make the claim that they did.

Please, people, do not go telling the FDA or your local politicians that 1/3 of smokers plan to switch to e-cigarettes and that they are 83% as good as smoking.  Our goal is to make it clear that we are the reality-based side of this debate.

More on a research agenda for e-cigarettes

posted by Carl V Phillips

I am going to keep brainstorming this (clearly related though somewhat tangential) subtopic that I started here, which has produced some useful feedback.

Based on numerous conversations I have had two different meetings since making that post, as well as the comments on that post, I think there is a need to dramatically increase the emphasis on the hardware specs and conditions, as compared to my original portrayal.  That is, I mentioned that we need to study the mapping from e-cigarette liquid chemistry to vapor chemistry as a function of the hardware used.  But I did not put enough emphasis on the latter bit.

While we are not going to be able to test every possible configuration, we should at least carefully examine the effects (on the liquid->vapor relationship) of different heat and power levels, as well as such things as what happens when the atomizer is heated dry.  We should also want to know what changes as components get old.  As noted in the previous comments, there are too many variables but if we can see what happens to a high-quality, pure, relatively typical liquid under varying circumstances, that would be useful.

The next step after that — dramatically more expensive and harder to do, but useful — is to look for human biomarker changes.  A bit of this had been done, but it is very limited.  It should also be tied back to the chemistry — given how much more expensive human subjects research is, it should always be combined with a chemical analysis of what is being vaped.  Perhaps we will have to wait until very large companies want to test their specific highly standardized products this way, perhaps to please regulators, but the results will also offer useful general knowledge.

Moving on from chemistry, I will branch the conversation into other areas of research.  We really need to collect the many personal testimonials about quitting smoking using e-cigarettes and analyze them.  In this case, by “we” I mean not a vague “the scientific community” or “humanity”, but CASAA in particular.  We have been planning to do that, and will start on that soon.

It would likewise be nice to have more of the data about how much product is actually being sold and how many people are consuming it.  This is not all that difficult to know, in theory, but there is remarkably little public information.

Finally, going beyond the relatively easy observations in the social science situation to actively create information, it would be valuable to understand more about users who fall in between trialers/beginners and the category I call “aficionados” (basically anyone who uses mods).  They are most of the users, almost certainly, and growing.  But are they really happy with the products they are using?  Are they at risk of relapse to cigarettes?  What would improve their vaping experience?  We have some good guesses about those, but learning more could improve THR efforts.

That is what I have for now.  I open the floor to comments, which are most welcome.

An agenda for (useful) e-cigarette chemistry research

posted by Carl V Phillips

This is a bit off topic, but it follows from recent posts and this blog is where I have the most readership that will be interested.  Following up in particular on this post and the extensive comments therein (especially those from Mike Siegel, Konstantinos Farsalinos, and Spike Babaian) and in consultation with my colleague Igor Burstyn, the following is my assessment of what would be most useful for further research on the chemistry of e-cigarettes.

Right now, the research agenda seems to be driven by attempts by anti-harm-reduction activists to show that e-cigarette vapor contains measurable level of “toxins”, along with responses by others that in all the samples that have been studied, the levels of these toxins are below anything that we should worry about.  These have been done.  They are both established.  It is time to move on and do something that is useful for making sure that e-cigarettes are consistently as low-risk as is practical.

Researchers who have been studying cigarettes for decades have fallen into a laziness trap of believing they are in a static world where all exposures are exactly the same.  This is not true even in that world.  (Despite a favorite lie of the researchers in this area, it is obviously inevitable that some cigarettes pose less risk than others.  Indeed, the difference in risk among cigarettes probably dwarfs any differences among all the smoke-free alternatives, but that is a topic for later.)  The homogeneity assumption is even less true (when thinking in relative terms) in the world of e-cigarettes; variations from product-to-product and year-to-year are huge compared to the results of interest.

So the urge to do the simplest possible research, to just study a few e-cigarettes under one particular circumstance and imply that the results represent e-cigarettes in general, is misguided.  A study of a few particular products can only produce lasting knowledge by assuming all products are and will continue to be similar, which is not useful in general and is particularly not useful for understanding what might lead to a substantial increase in risk for a particular product.  At the low levels of contamination of interest, there will be too much variation for that extrapolation.

That said, there is no use in throwing out the data we already have, though to a remarkable extent that is what has been done because it is almost impossible to make sense of the existing studies.  With that in mind, the first item in the agenda for useful research would be to consolidate existing information from the several vapor studies that have already been done, from the original Ruyan study up to the present.  The results of these studies have been reported in such incommensurate ways, and so incompletely (with the exception of that first one, which provided the detailed reporting that is a defining characteristic for anything to deserve to be called “published”), that there may be a lot to learn from them by simply consolidating the information — particularly where the analyses discussed below are actually possible but simply were not reported.

This should include an effort to collect unreported information from the original researchers, which they should be willing to provide so long as they are interested in legitimate science and not cheap propaganda.  (Subtext:  It will be interesting to see if the US FDA provides their information, or if they are just going to admit that they fall into the latter category.)  It would be relatively inexpensive, and I am confident I could find someone who has not been involved in any of the studies or the debates to do it if the community and the industry could come up with funding — a small fraction of the funding that went into the recently published vapor study.

The main need for the research agenda, though, is creating results that offer generalizable information.  Future studies should focus on the mapping from e-cigarette liquid to the vapor, as a function of the technical specifics of the atomizer and e-cigarette hardware.  That is, instead of just learning what a few sample liquids and devices happen to create, in terms of vapor chemistry, what we really want to know is how to measure the liquid, consider the device, and then predict the vapor chemistry.

It will always be the case that measuring the liquid chemistry is relatively cheap and easy, while measuring the vapor is expensive and finicky.  Analyzing the liquid’s chemistry is cheap enough that it could become a standard part of the manufacturing process, or at least a frequently-used form of quality control.  But, of course, what we would really like to know is what is in the vapor that is produced from the liquid and inhaled, and so the mapping is far more useful than knowledge about one particular vapor sample.

Along the same lines, would be the mapping from vapor chemistry to the chemistry of what is exhaled by the vaper into the environment.  This is of rather less real practical interest, given how very little is actually exhaled and how minimal the apparent risk from vapor is even before this reduction.  But so long as there is political warring over “second hand vapor” there will be a demand for this also.  To the extent that anyone wants to study exhaled vapor, they should do it in ways that produce the most useful information, particularly comparing the vapor chemistry (sans human), but also looking at effects of behavior and comparisons to exhaled pure air (is that formaldehyde coming from the people or the vapor?)  Indeed, human subjects ethics demands that we get as much useful information as possible when we are using people in experiments.

Focusing future studies on the mapping will merely require doing the easier measurements alongside the difficult ones, and doing a decent job of reporting the full methodology and results (i.e., adhering to the standards of science, not of public health journals).  If someone is setting out to measure vapor chemistry, they just need to do the comparatively cheap and easy measurement of the same liquid’s chemistry at the same time, and also report exactly what was used to create the vapor.  Ideally this should include some useful technical measurements of the vaporization process, like what temperature was attained, but at least a report of the e-cigarette’s technical specifications would be of some use.

One of the biggest open questions about e-cigarette chemistry is whether some particular contaminants found in vapor are in the liquid already or are caused by the vaporization process, and if the latter, is this is an inevitable result of the entire technology or are there ways to reduce it (should there be any health concern at all).  It is really quite amazing that in 2012 we still only have what might be called “decent guesses” about this.  This relates to the more general question of whether it is enough to know the liquid chemistry to be confident that the unintended unhealthful exposures are trivial, or do we need to know something else.

There is no excuse for wasting resources doing e-cigarette chemistry studies that do not seek to determine the mapping.  There is almost no downside, other than a modest increase in the cost of the study.  The effect on information produced will be entirely positive; the usual throw-away result — what happened to be in this particular sample from this particular product, on particular day — will still be there if someone really thinks there is value in it.  Indeed, that will be doubled because there will be information about the chemistry at two stages.  But the real value will be the relationship between them.

[UPDATE: This conversation continues here.]

Another study confirms lack of concern about vapor toxicity – too bad about that press release and some of the details

posted by Carl V Phillips

I have to leave my series on what constitutes useful evidence as a cliffhanger for another day or two, because people are clamoring for my comments on the latest in the series of studies about e-cigarette vapor chemistry that was recently published.  (Article summary here; full version is paywalled.)  The study tends to confirm what we already knew about vapor, and the fact that it does not contain important quantities of unexpected toxins.  This is certainly good news for e-cigarette users (vapers) and THR advocates.

Before continuing with the study, though, it is worth tying this in to the current series I interrupted and asking, “How did we know that?”  The bulk of the evidence comes not from the half-dozen or so lab studies that have been done, but from the basic chemistry and physics of the situation.

That is, how do we know that e-cigarette vapor is not similar to cigarette smoke?  The same way that we know that it is not similar to monkey urine — with our scientific reasoning process that says, “Why would we ever even expect it to be similar?”  Cigarette smoke is produced by burning complex plant matter which produces a lot of the many known products of combustion and a little bit of more chemicals than we could ever count.  E-cigarette vapor is produced by heating a liquid of (mostly) known chemistry, very much not like plant matter, into a vapor phase with little change in the chemistry other than its physical state.  The best evidence that we have that they are different is right there in that reasoning.

One of the biggest mistakes that THR advocates can make is to implicitly endorse the anti-scientific tactics of anti-THR activists, who would pretend that most of the evidence does not exist.  In other words, it is a potentially fatal error to send the message, “Because of this study and the handful that came before, we know…” rather than the more accurate and useful observation, “Before the first study was ever done, we were 99% sure that…, and these studies show that, indeed, we did not overlook anything in our previous reasoning.”

If you live by the one-off little study, you will die by the one-off little study.  There is an obvious response, by those who seek to prevent harm reduction, to all of the chemistry studies that have been done (including those spun by the anti-THR liars, which have actually shown the same good news as the others).  They can say, “these only looked at a few samples of the product, and we do not know what might be in other or current products.”  This is a reasonable response, though ultimately not true.

It would be completely true if I had phrased it differently, substituting “they do not provide observations about what might be in…” rather than “we do not know what might be in…”.  “We do not know” is a lie is because of all the rest of our knowledge, apart from the handful of studies.  But if we seem to be claiming the handful of studies are what really matters, we are arguing the liars’ case — after all, eventually one of these little studies will get a bad result due to lab error or real contamination.

Circling back, what is contained in the “…” a few paragraphs back?  The main observation there is that e-cigarette vapor contains the same stuff as e-cigarette liquid (disbursed into air), in obvious contrast to cigarette smoke, which is obviously not just the contents of an unlit cigarette plus air.

Should we be worried about unwanted chemicals in e-cigarette vapor, then?  Well, basically: garbage in, garbage out.  That is, whatever is in the liquid will end up in the vapor.  If the liquid is contaminated with something that should not be there, it will also be the vapor (though this creates approximately a zillion times as much concern for the vaper herself as for any bystanders for reasons elaborated upon below).

Is there some chemical activity that might depart from this observation?  Not much, but perhaps some.  And therein lies the very unfortunate limitation of the new study.  Its value would have been dramatically increased had they analyzed the chemistry of the same liquid that was used to produce the vapor, a step that would have been quite easy and inexpensive.  Any important differences would give us new (because it would be unexpected) information that might help in creating better products.  If there result were the expected correspondence, however, it would help reassure us that studying only the liquid chemistry (much easier and quite practical to do for samples from every large-scale production run, and for some portion of small batches) would be roughly as useful as more complicated aerosol studies.

Of course, that tells us what the vaper is exposed to, rather than those sharing space with the vaper (who we expect will breathe some of whatever was exhaled by the vaper, just as we always breathe whatever people around us are exhaling).  This is important because much of the rhetoric coming from the anti-THR liars claims that the exposure of bystanders justifies enacting bans on the use of e-cigarettes in public, and even private, places.  But the exposures of bystanders are going to be attenuated compared to vapers by both dilution (a little bit of vapor in a lot of air) and absorption (most of the content stays in the user unless he is intentionally quick-puffing in order to make a cloud rather than to more effectively deliver nicotine by holding the vapor longer).

The recent German study — which was spun by the authors’  and others’ anti-THR lies (links above) as showing a serious risk to bystanders when it actually showed quite the opposite — looked at exhaled vapor, providing a better measure of the actual environmental exposure.  The new study, unfortunately, just diluted the vapor that the vaper would inhale, a rather odd arbitrary methodology.  This was apparently supposed to offer some measure of what a bystander would be exposed to, but it fails to do that.  Mostly what it does is make all of the quantitative results meaningless, except in relation to each other.  The arbitrariness is clearly illustrated by considering what would happen if, instead of diluting the vapor into roughly half a cubic meter of air [the rest of the paragraph is UPDATED based on first comment] and then apparently multiplying the concentrations as if this were diluted to a 40 m^3 room, they had diluted it into a different volume.  In an alternative scenario, the concentrations would have all been changed by some multiplicative factor, assuming we ignore any actual effects of the room (gravity, adherence to solid surfaces).  Moreover, even if they chose the “right” dilution factor (whatever that might be), this would still not mimic the exposure of a bystander (read on).

This means that only the relative results matter.  The relative comparison is made is to cigarettes smoke, but we already knew that there was a big difference.  The comparison does not answer the question about whether the real-world concentration of chemicals from e-cigarettes is “too much” (whatever that might be judged to be by a hypothetical rational and honest policy process).  A similar observation about the sensitivity to the dilution mattering is true for any study of vapor (or smoke) also, but in this case the dilution factor was utterly arbitrary.  It was far smaller than a room['s dilution given that that large number of puffs represents a lot of vaping time], but far larger than someone’s lungs.

I bring up lungs again because, despite how this study was spun, this was a study of “first hand vapor” not “second hand vapor”.  The methodology description is a bit incomplete, but it is pretty clear that there was no attempt to simulate the process of the vaper absorbing most of the content of the vapor or a smoker absorbing the smoke to which it was being compared.  Yet the press release had the very unfortunate headline, “New e-cigarette study show no risk from environmental vapor exposure”.  The second-biggest flaw in this headline is the reference to environmental exposure, which was not studied.  Unfortunately, two of the people quoted in the press release make the same mistake as the headline, with one of them even making the error of referring to “second hand vapor”.

Of course, if what the user is exposed to does not contain anything we should be worried about, then the much lower exposure of the bystander is even less worrisome.  But, again, we know that because it is obvious for numerous reasons, not because of this study.

Finally, there is that “no risk” claim.  This is another example of the overblown claims that — as I argued previously — will ultimately harm the cause, not help it.  First, a chemistry study is not a health study, and does not include any measures of health outcomes.  This study looked at more results than the example of overblown claims I cited in the previous post, but that other study had the advantage of measuring health outcomes.  A claim like “found levels of environmental exposure that are not considered worrisome for health” would be fine, but no actual health claim can be made based on chemistry results like these.

Second, the claim “no” (as in “no effect”) is never a legitimate scientific claim.  “Too small to measure” — great.  “Showed no evidence of an effect” — fine.  But we can never be sure there is no effect.  It is generally suspected that nicotine is a little bit harmful, though the effects are too small to measure.  Some people are definitely sensitive to polypropylene glycol exposure.  Further similar observations can be made about the contaminants.  So if someone breathes enough of the vapor (and, again, the absolute concentrations that were measured were totally arbitrary), there could well be some harm.  Nothing is gained by pretending otherwise.

Finally, as a policy analyst, I have to strongly object to treating natural science results as if they provide policy analysis as was done in the press release (though not in the actual article).  Do these results show that we should not ban vaping in any indoor spaces?  Definitely not.  Nor would have less-reassuring results shown that we should ban indoor vaping in some indoor spaces.  Such claims require both a statement of the ethical basis for imposing restrictions on people’s choices and the accompanying economics (assessment of costs and benefits) which would be informed by the natural science results.  That requires several more steps than are ever included in a research report.

Why we absolutely positively must avoid pro-THR lies (and honest errors that look like lies)

posted by Carl V Phillips

This blog is only two weeks old but it is not too soon for an aside that addresses a critical tangential point, the accuracy and credibility of pro-THR claims.

Almost all anti-THR discourse is dominated by lies.  It has to be, because the truth has such an obvious pro-THR bias.  Most pro-THR claims are solidly based on evidence and honest communication of it, as well as established ethical norms and the very popular political view that people should have freedom to make their most intimate choices without interference by those in power.  Thus it is not surprising that, with the exception of a few unscrupulous merchants and Chinese spammers writing about e-cigarettes (scourges which it is impossible to avoid or eliminate when there is free communication), pro-THR discussions are almost never anchored in misinterpretations of the evidence.

Almost never.

And there is the problem.  The example to hand is the recent widely repeated claim that a study in Greece showed that “e-cigarettes do not damage the heart“.  The study showed nothing remotely that general.  It showed that under in particular circumstances, the brief use of an e-cigarette does not produce measurable acute (immediate) changes in a few particular biomarkers of cardiac functioning.  Is this good news for e-cigarette users and THR?  Of course.  It is the best news that could come from that study, which was only looking at the immediate effect of one vaping session on the particular short-term biomarkers that were measured.  But I trust that it is obvious why this is not sufficient to justify the headline that was repeated by many e-cigarette advocates.  The study obviously could not address what matters for health outcomes, the long-term effects of long-term use (the natural interpretation of the headline of that press release).  Moreover, it measured only a few of the many possible short-term effects.  It is a result that should be added in to the body of technical knowledge that is useful for experts who are compiling all existing information into conclusions; it should not be interpreted as having clear practical implications and should not have been touted to the general public as saying there is no risk of damage.

Imagine that an anti-harm-reduction “researcher” did a lab study in which they asked a few smokers questions that reflect their desire to have a smoke later that day, asking before and after they used an e-cigarette, and found that the measured desire increased afterward.  Headline: “E-cigarette use increases smoking”.  Of course, the measure was very limited and artificial, and tells us very little about long-term effects.  In that, it is very much like the e-cigarette cardiac study.  In fairness to the latter, the cardiac study could have been legitimately reported in useful and accurate terms like, “certain cardiac functions that show acute negative effects with smoking do not show the same effects with e-cigarettes”, whereas the imaginary anti study has no apparent legitimate interpretation.  But the accuracy of the more general declaration is similar in the two cases.

Of course, you do not have to imagine.  Readers of this blog will undoubtedly have noticed that this heart study sounds remarkably like the lung effects study that we wrote about for the last three days, which was press released at about the same time.  Both studies looked at short-term biomarkers of acute effect that could not possibly tell us anything about real health effects (unless the results were catastrophically bad, which we knew in advance that they would not be).  Both studies could add a bit of useful technical information to what we know about e-cigarettes.  Both were from Greece, though I think that is probably not relevant to anything.  And, unfortunately, both were reported via press releases that absurdly overstated their implications.

There were important contrasts:  The actual methods and useful results of the cardiac study were contained in the press release (to the extent possible in a few score of words), as opposed to the obviously misleading non-presentation of the science in the Christina Gratziou lung study.  The cardiac study author’s stated conclusions in the text of the press release were quite modest (one might say even more timid than the facts support) about whether THR was a good idea, and did not lean too much toward claiming that his results were particularly important, whereas Gratziou was basically shouting “my results prove that you might as well smoke!”   But still, the false claims in the headlines were remarkably similar, as was the willingness of news sources with the particular bias to uncritically repeat the claim in the headline.

Anti-THR activists cannot afford to not lie, because the truth is not on their side.

THR supporters cannot afford to make the mistake of blindly repeating overzealous pro-THR claims.

But, wait, a common response goes, you just pointed out that anti-THR people do exactly that, pretty much all the time.  They do a lot worse too: full-on campaigns of lies and research misconduct.  They lie constantly.

But that does not justify us doing it.  In addition, and probably more important in the minds of most THR supporters, it does not make it tactically sensible.  We have to police our own claims much more carefully, for the following reasons:

1.  We do not want to be like them.  Right?  Nuff said.

1.5  And if we are like them then ,well, live by the favorable tiny little biomarker study of limited scientific value, die by the much larger number of unfavorable little biomarker studies of limited scientific value.  If that cardiac study is evidence that e-cigarettes do not harm the heart, then the lung study is evidence that they do harm the lungs.

2.  One false claim from our side — even if it is basically consistent with all the evidence (as is the claim that we do not think there is any major cardiac risk), and even if it is presented with the best of intentions, as an honest mistake rather than a crafted lie — will be used to excuse every single lie from the other side.  We do not need to make false claims, but they do, so why give them the gift of being able to respond “well perhaps our claim of …, based on one finding from one study, overstates the case a bit; but the THR people claim that one little study of a few biomarkers showed that e-cigarettes pose absolutely no threat of cardiovascular disease, so they are really worse.”  (Note, by the way, that this is true: claiming “no damage” based on any single study is more inaccurate than claiming “damage” based on a single study, because no little study can provide much evidence for the universal absence of a something, but it can show its existence.)

It does not matter if their claim in the “…” is more egregious.  It does not matter that they have a legion of paid operatives who are intentionally trying to mislead, while we are running volunteer operations and trying to make the best sense we can of the science with limited resources, and so occasionally err by accident.  And most of all, it does not matter that they tell a thousand lies that can fill in the “…”; every last one of those thousand will be declared to be justified by just a single example that can be presented on the other side.

3.  It is not just the anti-THR people who will do this.  There is a silly notion in the American press to seek what they call “balance” in anything they report, and this has spilled over into a lot of public Anglophone discourse (I cannot say for sure whether it is so common beyond that).  A slight caricature of this is Krugman’s observation that if the mainstream press was running a story on the Earth’s shape, they would find one person who says it is flat and run the headline “Shape of the Earth: views differ”.  Their silly urge to “balance” is even stronger when pointing out that someone is lying; no matter how blatant a lie is, the mainstream media’s reporting of this fact is almost always accompanied by a hunt for some error from “the other side” to “balance” the information.  It just would not be [insert affected accent and fan self dramatically like a character from Gone With The Wind] proper to seem to be biased against a liar who represents an established and powerful institution, after all.

So, when we get mainstream discourse that points out that anti-THR claims are based on lies — which is what is something we really need to generate — it will most likely juxtapose that with pro-THR “lies”.  If all they can find are a few shady merchants making absurd claims, it will not look so bad (so long as they do not lie and suggest that everyone on our side is making such statements).  But “does not damage the heart”, widely reported by non-merchant THR supporters, is just the perfect balance to show that “both sides are making exaggerated claims.”

It may not be fair, but we have to deal with the way things are.

3.5  But it gets even worse and more unfair than that:  The mainstream discourse is actually going to favor anti-THR lies over our pro-THR truth, since it almost always defers to lies from powerful institutions.  So it will take a very long list of very obvious lies to hurt their credibility as much as one clear exaggeration hurts ours.  The “public health” movement is a small-minority special interest group that has abandoned society’s norms of ethics and scientific conduct, but it is a rich and powerful special interest group and used to be respectable.  The mainstream media, as well as most of the liberal-leaning new media and — most important — the average person on the street, still treat “public health” as if they are honest and public-spirited.  The “public health” people know this, of course, which is why they do not hesitate to lie.

But more importantly for present purposes, it is also why they can get away with misleading fixation on unrepresentative individual actions of opponents that distract from the real truths of the matter (e.g., fixating on one unfortunately-phrased ad for smokeless tobacco from the 1970s as a reason for condemning all smokeless tobacco forever, or on the claims of a few fly-by-night e-cigarette merchants, or that whole “tobacco industry documents” obsession).  The public is still ready to believe any bad thing that is claimed about THR products or those who support them (who will be labeled “the evil big tobacco industry”, of course).  We cannot give them the openings.

Again, it is not “fair”, but the total dishonesty and unearned credibility of the Drug Warriors-types and other anti-harm-reduction activists in “public health” forces us to be even more scrupulously honest than might be needed otherwise.

4.  If we start making every claim that seems to be pro-e-cigarette, treating anything that is pro as right and attacking everything that is perceived as anti as wrong, we will learn a lot less.  Learning is good.  Perhaps the marketers want everyone to believe that there is only good news, but those of us who care about more than pumping sales want to find the bad news when it exists.  This is not just because of Point 1., and the potential loss of credibility if an overblown claim turns out to be wrong.  It is also because consumers are better off if they know the risks, and only if we know about problems we can try to fix them.  E-cigarette users should be the absolute last ones to want there to be claims of “no risk” when we do not actually know that.

This issue reminds me, to a very disturbing degree, of work I did in the 1990s, trying (unsuccessfully) to persuade vegetarian advocates to stick to the true and scientifically valid arguments that supported their position, rather than glomming onto every blatantly irrelevant or junk science claim that seems to point in the right direction.  The bad information basically drove out the good (both the good information and most of the good people).  The situations are quite different in many ways — e.g., there are relatively few non-experts writing books and junk science websites about THR (yet!), while such people dominated (and still dominate) the discourse about vegetarianism.  But there are also some clear similarities.

There are honest and accurate pro-vegetarian arguments that would appeal to the substantial part of the population that is concerned about animals or the environment, and to a lesser extent their health, and yet vegetarianism was widely perceived mostly as a nutty cult.  The true claims that might have persuaded people were (and still are) hopelessly lost amongst the easily-debunked false claims which were more prominent.  So, almost two decades later and even as lots of people have stopped eating much meat, vegetarianism’s negative image has hardly changed.  For example, it has been mentioned to me that my credibility in the work I do to promote animal well-being is enhanced by the fact that I am no longer vegetarian (I am pretty close, but not entirely).  I believe that had influential pro-vegetarian advocates stopped acting like a bunch of unscrupulous marketers and doe-eyed cultists back then, things would look very different now.

THR is not nearly so vulnerable to being marginalized (a lot more people practice THR than practice vegetarianism in the West), but there is a powerful opposition that wants to marginalize it.  If we do not police ourselves and discourage THR advocates from embracing any claim that seems to support the cause, we run the risk of become an insular fringe that opponents can just ridicule and thereby ignore.  Quick: name an organization that advocates vegetarianism that you would turn to for credible information about the topic?  I didn’t think many of you would have an answer, though if you have ever thought about the subject, you probably thought of several that you would not trust.  There are some good resources out there, but you pretty much have to already be an expert to sort them out from the marketing and cultish propaganda.  Do we want to risk THR and e-cigarette advocacy looking like that in a few years?