Monthly Archives: January 2013

Kelvin Choi is remarkably clueless (and a liar) – part 2/2

Yesterday I started dissecting the simplistic and false anti-e-cigarette claims being made by University of Minnesota researcher, and Ellen Hahn wannabe, Kelvin Choi.  This post picks up where that one left off.  To recount, Choi recently released a paper that contains some possibly useful historical data from a survey of knowledge and attitude about e-cigarettes.  But not content to do real science, he proceeded to tack on anti-e-cigarette lies and a conclusion that does not in any way follow from the research.  He then published an interview in which he bungles even the description of e-cigarettes and presents his reasons for worrying about the health effects, none of which actually involve any claim about any health effects.

I will note that the interview I am dissecting did not appear in some free weekly local paper or a radio news report.  It was published by the American Public Health Association (which runs the “journal” where Choi’s paper appeared), and was clearly crafted as a written document by that organization and Choi.  So we cannot attribute the gaffes to trying to dumb things down for a grade-school audience or misspeaking.

Continuing with examples of the lies that Choi and APHA chose to publish:

To date, e-cigarette marketing is not regulated.

Presumably he means in the United States (his apparent failure to recognize that regulations vary across jurisdictions is so minor among his errors that I only mention it because I need to clarify before continuing), in which case he is badly wrong.  Not only is e-cigarette marketing regulated by all basic federal and state rules about truth-in-advertising and such, but it is also severely restricted in terms of health claims.  Merchants cannot offer their customers any comparative risk or smoking cessation information, such as the obvious truths that switching to e-cigarettes is a good way to quit smoking for many people, or the health risk from e-cigarettes is trivial compared to that from smoking.  If this is Choi’s view of anarchy, I would hate to see what he considers to be regulation.

Advertisements for e-cigarettes appear on TV, magazines, the Internet and even in social media. Cigarette advertising has been known to have a strong influence on the perceptions and the use of cigarettes.

Ah, that explains it.  I believe he is mixing up the words “regulated” and “banned”, a common mistake when a native ANTZ speaker tries to communicate in English.

Therefore, it is similarly possible that e-cigarette advertising is one of the sources of influence on young adults’ views about e-cigarettes.

It is worth recalling that this interview was to tout a paper that reports results from a 2010-11 survey.  There was not exactly a lot of advertising of e-cigarettes back then.  This is the standard “public health” bait-and-switch:  do one simple and minor bit of research on a topic, with no policy analysis and no apparent understanding of the big picture, and then claim to be an authority on what policies should be implemented.

It appears that his complaint is that advertising — you know, that “unregulated” advertising which is prohibited from truthfully informing people about the smoking-cessation benefits or comparatively low risk of e-cigarettes — is contributing to people’s knowledge that e-cigarettes have low risk and are good for quitting smoking.  (Note that “knowledge” is the English word; to trANTZlate that into Choi’s ANTZ-speak, I believe their word for “knowledge” is “misinformation” when used in a context that means “knowledge that the ANTZ want to prevent people from learning”.)

I am sure the marketers will be glad to know that they are successfully communicating information that they are not allowed to communicate.  I suspect that during his continuing research on this topic, Choi will eventually learn about the restrictions on the advertising and then realize, like Stanton Glantz, that he needs to crusade for broader censorship of accurate information.

He concludes this thought with:

The challenge is whether we should swiftly regulate e-cigarette advertising before the issue gets out of hand.

Even trANTZlating “regulate” into “ban”, it is difficult to make any sense of this.  What issue?  What constitutes “out of hand”?  I am not even sure this qualifies as lying hype because although it tries to be hype, it is not at all clear what is being claimed.  So, moving on…

The second challenge lies in developing a better understanding of the effective communication channels to reach specific populations and how to best use these channels. For example, we know that a lot of young adults use Facebook, but we do not know how to effectively use Facebook to communicate the correct information about e-cigarettes to young adults. I think we still have a lot to learn in that regard.

Nice discovery about that Facebook thing.  Maybe he will write a paper about it before Facebook ceases being used by a lot of young adults — though I would not recommend holding your breath for that given that his claim to fame is his new paper about survey data from two years ago (ancient history in this fast-moving area, something he apparently does not understand).  But, of course, we again need the trANTZlator here to point out that when he suggests exploring ways to “communicate the correct information”, he really means to “get people to believe his lies”.

Because, after all, if he really wanted to use Facebook to communicate correct information, all he would need to do is point people to pages like CASAA, the We Are CASAA members page, ECCA UK, Vapers Network, the Tobacco Harm Reduction page created by my research group (which I believe is about as old as Facebook, though most of the traffic has shifted to those others over the last few years), or any of several other very active pages with a plethora of truth and where incorrect information is seldom posted without being corrected by someone.  His “we” may well be as clueless as he claims, but fortunately we are way ahead of them.

I wonder if this self-appointed e-cigarette “expert” has ever even seen those Facebook pages and our websites.  Probably not, or he would not have bungled so many simple points.  Still, maybe he is one of the rare ANTZ who actually reads outside of their echo chamber, and he will read this post and follow those links.  I look forward to seeing his comments there trying to provide us with “correct information”.  If you are reading this, Dr. Choi, please consider yourself encouraged to jump into the conversation — unlike your fellow ANTZ, we do not censor contributions from people who disagree with us.  Oh, but be warned, also unlike life inside your ANTZ echo chamber, when someone is lying, we call them on it.

Kelvin Choi is a liar

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.

People who report health risks as percentage changes are (often) liars

by Carl V Phillips

I have been having an ongoing conversation with Kristin Noll-Marsh about how statistics like relative risks can be communicated in a way that allows most people to really understand their meaning.  There is more there than I can cover in a dozen posts, but I thought I would at least start it.  I have created the tag “methodology” for these background discussions about how to properly analyze and report statistics (“methodology” is epidemiologist-speak for “how to analyze and report data”).

Most statistics about health risks are reported in the research literature as ratio measures.  That is, they are reported in terms of changes from the baseline, as in a risk ratio of 1.5, which means take the baseline level (the level if the exposures that are being discussed are absent) and multiply by 1.5 to get the new level.  This is the same as saying a 50% increase in risk.  It turns out that these ratios are convenient for researchers to work with, but are inherently a terrible way to report information to the public or decision makers.  There is really no way for the average person to make sense of them.  What does “increased risk, with an odds ratio of 1.8” mean to most people?  It means “increased risk”, full stop.

Every health reporter who puts risk ratios in the newspaper with no further context should be fired (some of you will recall my Unhealthful News series at EP-ology).  But the average person should not feel bad because it is likely that the health reporter — and most supposed experts in health — cannot make any more sense of it either.

The biggest problem is that a ratio measure obviously depends on the size of the baseline.  When the baseline is highly stable and relatively well understood, then the ratio measure makes sense.  This is especially true when that deviation from the baseline is actually better understood than actual quantities.  So, for example, we might learn that GDP increased by 2% during a year.  Few people have any intuition for how big the GDP even is, so if that were reported as “increased by $X billion” rather than the ratio change, it would be useless.  Of course, that 2% is not terribly informative without context, but the context is one that many people basically know or that can easily be communicated (“2% is low by historical standards, but better than the recent depression years”).

By contrast, to stay on the financial page, you might hear that a company’s profits increased by 10,000% last year.  Wow!  Except that might mean that they profited $1 the year before and got up to $100 last year.  Or it might be $1 billion and $100 billion.  The problem is that the baseline is extremely unstable and not very meaningful.  This contrasts yet again with a report of revenue (total sales) increasing by 50%, which is much more useful information because a company’s sales, as opposed to profits, are relatively stable and when they change a lot (compared to baseline), that really means something concrete.

So returning to health risk, for a few statistics we might want to report, the baseline is a stable anchor point, but not for most reported statistics.  It is meaningful to report that overall heart attack rates are falling by about 5% per year.  The baseline is stable and meaningful in itself (the average across the whole population), and so the percentage change is useful information in itself.  This is even more true because we are talking about a trend so that any little anomalies get averaged out.  By contrast, telling you that some exposure increases your own risk of heart attack by about 5% per year is close to utterly uninformative, and indeed probably qualifies as disinformative.

As I mentioned, the ratio measure (in forms like 1.2 or 3.5) are convenient for researchers to use.  You probably also noticed me playing with percentage reporting, using numbers you seldom see like 10,000%.  This brings us to the reporting of risk ratios in the form of percentages as a method of lying — or if it is not lying (an attempt to intentionally try to make people believe something one knows is not true), it is a grossly negligent disregard for accurate communication.

Reporting a risk ratio of 1.7 for some disease may not mean much to most people, but at least that means it is not misleading them.  There is a good way to explain it in simple terms, something like, “there is an increase in risk, though less than double”.  If the baseline is low (if the outcome is relatively uncommon) then most people will recognize this to be a bad thing, but not too terribly bad.  So the liars will not report it that way, but rather report it as “a 70% increase”.  This is technically accurate, but we know that it is very likely to confuse most people, and thus qualifies as lying with the literal truth.  Most people see the “70%” and think (consciously or subconsciously), “I know that 70% is most of 100%, and 100% is a sure thing, so this is a very big risk.”

(As a slightly more complicated observation:  When these liars want to scare people about a risk, they prefer that a risk ratio come in at 1.7 rather than a much larger 2.4.  This is because “70% increase” triggers this misperception, but”140% increase”, while still sounding big and scary, sends a clear reminder that the “almost a sure thing” misinterpretation cannot be correct.)

The problem here is that people — even fairly numerate people when working outside areas they think about a lot — tend to confuse a percent change and a percentage point change.  When the units being talked about are percentages (which is to say, probabilities, as opposed to the quantities of money like the above examples) that are changing by some percentage of that original percentage, this is an easy source of confusion that liars can take advantage of.  An increase in probability by 70 percentage points (e.g., from a 2% chance to a 72% chance) is huge.  An increase of 70 percent (e.g., from 2% to 3.4%) is not, so long as the baseline probability is low, which it is for almost all diseases for almost everyone.

There seems to be more research on this regarding breast cancer than other topics (breast cancer is characterized by an even larger industry than anti-tobacco that depends on misleading people about the risks, and there is also more interest in the statistics among the public).  It is pretty clear that when you tell someone an exposure increases her risk of breast cancer by 30%, she is quite likely to freak out about it, believing that this means there will be a 1-in-3 chance she will get the disease as a result of the exposure.

Reporting the risk ratio of 1.3 will at least avoid this problem.  But there are easy ways to make the statistic meaningful to someone — assuming someone genuinely wants to communicate honest information and not to lie with statistics to further a political goal or self-enrichment.  The most obvious is to report the relative risk based on the absolute risk (the actual risk probability, without reference to a baseline), or similarly report the risk difference (the change in the absolute risk), rather than ratio/percentage.  This is something that anyone with a bit of expertise on a topic can do (though it is a bit tricky — it is not quite as simple as a non-expert might think).

Reporting absolute changes is what I did when I reported with the example of 2% changing to 3.4% (or, for the case of 1.3, that would be changing to 2.6%).  The risk difference when going from 2.0% to 3.4% would be 1.4 percentage points, or put another way, you would have a 1.4% chance of getting the outcome as a result of the exposure. Most people are still not great at intuiting what probabilities mean, but they are not terrible.  At least they have a fighting chance.  (Their chances are much better when the probabilities are in the 1% range or higher, rather than the 0.1% range — once we get below about 1% intuition starts to fail badly.)

To finish with an on-topic example of the risk difference, what does it mean to say that smoke-free alternatives cause 1% of the risk of serious cardiovascular even (e.g., heart attack, stroke) of smoking?  [Note: that this comparison is yet another meaning of “percent” than those talked about above — even more room for confusion!  Also, this is in the plausible range of estimates, but I am not claiming it is necessarily the best estimate.]  It means that if we consider a man of late middle age whose nicotine-free baseline risk is 5% over the next decade, then his risk as a smoker is 10%.  Meanwhile, his risk as a THR product user would be 5.05%.  Moreover, this should still be reported as simply 5% (no measurable change) since the uncertainty around the original 5% is far greater than that 0.05% difference.

Opinion surveys provide information about personal beliefs and behavior – only!

by Carl V Phillips

Why am I writing a post under a heading that is so incredibly obvious?  Because in the world of the tobacco control industry, even incredibly obvious truths are often ignored.

Survey research that asks people what they have done or experienced is often the only source of scientific data that addresses those questions.  Also, when we are interested in people’s personal preferences or guesses about something, some sort of survey is often the only way to find out.  The problem comes in when someone who does not understand science — or whose job description includes pretending to pretend to not understand — says, “hey, we use survey data as scientific fact when studying behavior and exposures, and opinion polls look similar to behavior and exposure surveys, so it must be that the results of opinion polls can be used as scientific data.”  Um, yeah.

Surveys about opinions are, of course, evidence of what people think, which is interesting for answering some questions.  But those are questions about belief/knowledge/understanding/confusion, not about the physical world.  Some of you might recall that the whole “third hand smoke” scam traces back to a survey where random people with no expertise were actively tricked into saying they believe that it is a hazard.

There are methods of aggregating the opinions of people with some expertise to crowdsource a legitimate prediction about some event.  It only works with predictions, though, because it requires placing a bet on the outcome which are paid out when the outcome is determined.  This is how we determine the probability of a sports team winning a game and also has been used in some clever tools for predicting elections.  Those who respond to these surveys (other than with small self-entertainment bets that are not going to be big enough to affect what the crowd predicts) are self-selected people who think that they know enough to come out ahead on their bets, not just the average person on the street.  And, importantly, there is a punishment (losing the money you bet) for expressing an opinion that is uneducated, or that you know to be wrong — this is not cheap talk.

Contrast this with a recent “study” that used an opinion poll to “predict” the effects of plain packaging of cigarettes.  The “researchers” asked a handful of people in the tobacco control industry, presumably many of whom are directly invested in the plain packaging boondoggle, what will happen and reported the result as if it was a useful prediction.  Needless to say, the prediction of the effect of taking away brand logos by the people who have run out of useful things to suggest, was an absurdly large impact.

I would write more, but there is no way to usefully add to what Snowdon (who reported this story) already wrote about this, so give his very funny post a quick read.

The limitation of this survey is just the obvious point that the respondents are not only ridiculously biased, but they have absolutely no incentive to give an accurate prediction or to refrain from predicting if they lack confidence in their opinion.  The “researchers”, had they been interested in actually learning something, could have asked the respondents to place a bet, but did not.  Without a bet, there is no incentive to tell the truth because there are absolutely no penalties in the tobacco control industry for making incorrect predictions or scientific declarations that are clearly shown to be false.  It would be delightful to see ANTZ “researchers” and “experts” being held to account for lying and forced to do a Lance Armstrong, begging for forgiveness, promising (without credibility) to never do it again, and begging to not have to give up the hundreds of millions of dollars they swindled by lying.

Another recent example of dumb polling is more troublesome in its implications.  A media blast by the Schroeder Institute for Tobacco Research and Policy Studies (Steve Schroeder must just be so proud of the “research” that is coming out attached to his name) claimed that it is a good idea to mandate a lowering of the nicotine content of cigarettes because a majority of random Americans were tricked into saying they thought it was a good idea by a survey.  (For more details, see this article, which unlike the usual churnalism includes good analysis by Michael Siegel and others.)  It turns out that this “majority” consists of forty-something percent, but we do not expect basic numeracy from tobacco control, so I will just move on.

What does this survey really tell us?  It tells us that the tobacco control industry’s efforts to confuse people about the source of harms and benefits from smoking have been rather successful, though surprisingly not quite as successful as one might have guessed.  Obviously it tells us nothing about whether such a policy would actually be a good idea by any measure.  It does not even tell us whether people really have this belief in any meaningful sense, or if they merely decided to agree with the statement while blasting through a survey.  Polling people about something they have never given any serious thought is unlikely to provide useful information, even if they have no incentive to be dishonest and even if they might know something about it. Even a poll of people asking them how far they could drive given the gas currently in their car is well within their expertise to answer, but their answers would not be very accurate.   They would just give a snap answer without bothering to go check how much gas they have, let alone calculate their mileage.

It is obviously worse when the question is well beyond people’s expertise.  We know, after all, that a majority (a term I am using like the Schroeder Institute people do, to mean “at least a substantial minority”) also believe, without any scientifically defensible basis whatsoever, that: we should not worry about the future because the gods are going to end life on Earth within our lifetimes; that it is healthier to eat “organic” foods; that screening mammography provides a major health benefit; that Iraq posed a threat to the US in 2003; that current-tech wind turbines are an environmentally friendly way to generate electricity; and that cutting government spending in an economic depression characterized by zero-lower bound interest rates.

The problem is that for all but the first two of those, policies have conformed to the opinion of that majority (or “majority”) that is unmoored by the facts and the science.  What distinguishes the first two from the others?  For all of the others, the rich and powerful people profited by keeping people ignorant and getting them to believe, and thus support, something that is false.  While the tobacco control industry is not nearly as rich and powerful as those who have profited from the mammography, wind turbine, and Iraq War boondoggles, they differ only in degree, not in their willingness to foster ignorance to support their cause.  So there is little doubt that they will use the cultivated ignorance to further their agenda.

Reducing nicotine content reduces the benefit of smoking a cigarette while not reducing the harm.  The same would be true for adding some harmless but foul-tasting chemical to the cigarettes.  The main difference is that the latter option would almost certainly cause people to smoke less, while everything we know suggests that lowering nicotine content will cause people to smoke more.  If people had been polled about a proposal to add the foul chemical to cigarettes, it is likely that a smaller “majority”, maybe 25%, would support that too — because they basically favor prohibition, and that would be roughly equivalent.  But no one would mistake that for scientific evidence that the policy would have a positive impact on the world.  Whatever someone might think of the ethics of intentionally lowering the quality of cigarettes to discourage smoking, it seems that the dumbest possible way to do it is in a way that makes people want to smoke more.  Make no mistake, reducing nicotine is benefit reduction, not harm reduction.

[Aside: It is worth noting that while all the evidence suggests that substantially lowering the nicotine content would increase harm, this does not mean that substantially raising the nicotine content would reduce harm.  So much of smoking behavior is habitual (and many people seem to smoke enough that at the margin their nicotine receptors should already be saturated) that it is not entirely clear that higher nicotine would reduce total smoking, unless accompanied by some other change like making the cigarettes shorter (“same great nicotine with only half the stick”).  But at that point, why not just advocate replacing some of someones daily cigarettes with smoke-free nicotine?  That would have the advantage of encouraging a complete switch, as well as avoiding several obvious downsides.]

To sum up, there is a lot to be learned about perception, propaganda, and ethics from looking at results of surveys like this.  But there is nothing useful to be learned about science or science-related policy.  That finally circles my thinking back to a survey from 2003 that is a large part of why I was inclined to address these points.  It is still cited as if it actually represents an estimate of the risk of smoke-free alternatives, a practice I have repeatedly criticized but apparently never posted about.  But this is already enough for the day, so I will try to come back to that.

Miss Manners is a liar

by Carl V Phillips

Yes, I have a backlog of several important scientific analyses to do here.  But sometimes, you just find something is just too funny to pass up…

H/T to Treece for finding this column about vaping by advice columnist Judith Martin who write under the pretentious “Miss Manners”.  Can an advice column even be considered a lie?  Or is she merely a bitch, to quote Treece’s tweet?  After all, newspaper columnists on any topic are rarely (though not never, of course) scholar-level analysts of their topic.  Still, when someone claims to offer expert advice, but then makes claims that are beyond that expertise or are personal pique disguised as expert analysis, that is a kind of lie.

The column in question was in response to the following very reasonable query about the not-yet-established etiquette rules about vaping in public.  (Note: given the eloquence of the question, I assume the questioner used the word “vape” and some bad editor changed it to the bizarre “e-smoke”.  Almost the entire profession of copy editors are a great example of people who often claim expertise that they do not have.)

Where is it impolite to e-smoke? Does modern etiquette differ from historical smoking etiquette, when it was common and socially acceptable to smoke? In particular, is it improper to e-smoke when giving a large speech?  I am quite fond of my electronic cigarette. It has a white light and cannot be mistaken for a real cigarette. It is odorless, but I exhale a visible gray vapor, which can be confusing to people who haven’t discussed it with me yet.

… I already use it during informal business functions (essentially any business function where it is acceptable to wear jeans). Does it hurt one’s public image if I e-smoke when I do speaking engagements? … Would it hurt my image if I were to e-smoke while giving an engaging and riveting talk? I’m already seen as a bit of a provocateur, but I don’t want to cross the line into gauche….

The reply begins with (and, for any reader who is too busy to bother to finish reading something that is obviously written by a moron, also ends with):

While sharing your interest in history, Miss Manners apparently reads more of it than you do. The smoky society you describe existed only in the middle decades of the 20th century; before that, it was not tolerated. In the preceding decades and centuries, smokers, also known then as gentlemen, did not smoke in the presence of nonsmokers, then known as ladies, without their express permission, which could be politely withheld. For the most part, the smokers did not even venture to inquire, but withdrew to smoking rooms and put on smoking jackets, so as to isolate the effects. When ladies began to smoke openly, the rules were regrettably abandoned. Even so, an occasional professor might have clutched his pipe, but it was not the rule.

Ok, let me see if I got this. Smoking did not occur in university classrooms before the 20th century because of the plethora of “ladies” in the room? Everyone who smoked before the middle 20th century had a smoking room and owned a smoking jacket?  Yes, apparently Miss Manners’s oh-so-extensive reading of history seems to consist mainly of Jane Austen novels.  (And her knowledge of English seems to not include first person pronouns, as is the case with a one-year-old learning to speak and reasoning “everyone calls me Miss Manners, so I should refer to myself as Miss Manners”.)

Needless to say, smoking customs have varied substantially across space and time, and things changed in the 20th century (rather early in it, actually) because of the growing popularity of cheap cigarettes.  She goes on to make a few more equally clueless and unintentionally funny pronouncements about the history of smoking, but I will move on.

Yes, I know that the qualifications for being an advice columnist consist mainly of knowing where to place each fork when hosting a dinner for Hapsburg royalty.  But come on!  If she were truly the expert in etiquette that she claims to be, she would realize that arbitrary social conventions from the past were whatever they were.  A half century ago in the US (and in many places still today) when smoking in many public places was not considered to be bad manners, it was not bad manners.  That does not change based on what people think about it now, even if it was causing some harm.  That is the whole nature of manners, after all.  Surely anyone even a little bit expert on the topic understand this concept.

Moreover, if you are only qualified to answer questions that are relevant to 16th century European nobility and other people who own smoking jackets, do not presume to offer history lessons about the other 99.999% of humanity.  Nor should you try to offer advice about normal people’s legitimate concerns.

Oh, but she does.

You ask about your public image. To those who recognize electronic cigarettes, you would appear to be someone struggling to give up smoking and therefore relying on a crutch. We have come to the point where that is considered pathetic, at best.

While I do not receive salary to offer advice about etiquette, I will go out on a limb here and suggest that characterizing the quarter of the population who are not happy to be be bereft of smoking/tobacco/nicotine as “pathetic” qualifies as bad manners.  Perhaps her extensive readings of the history of smoking managed to miss a few minor details, like the fact that many people find quitting to be extremely unpleasant.  I am sure I do not need to explain to my readership how moronic it is to characterize someone who has quit smoking using e-cigarettes as “struggling to give up smoking”.

So far, the self-appointed manners expert has attacked her reader’s personal choice as a “crutch” but has not offered any useful advice about manners.  Does she get to that?  No, she finishes with:

But not everyone does distinguish the real from the imitation, particularly at a distance from a speaking platform. Such people would not consider you pathetic, you may be relieved to hear: They would consider you evil. The now-accepted rule against smoking near nonsmokers is perhaps the most dangerous one to break. People will excuse heinous crimes before condoning that.  But here is the crushing part: Everyone will be thinking “He’s smoking,” rather than paying attention to your riveting words.

Yes, according to Miss Manners, smoking in public puts you in the Jerry Sandusky category.  I realize that some of the ANTZ liars that we write about here probably do actually hate smokers more than they hate child molesters, but even if someone is personally biased as to think smokers are evil, how is this observation useful?  Writing things like that apparently leaves readers thinking “she’s a clueless bitch” rather than reading her riveting advice about manners.

Oh, except there is no such advice offered, and that is unfortunate, because it is an area worth exploring.  Manners is not about the inherent worth of an action (and thus whether or not it is “pathetic”), nor about presentation skills (and thus not whether it might or might not affect that).  There is room for differing views about whether it is impolite to do something that offends people’s irrational or hateful prejudices, but an honest expert would point out the tension.  Instead, Miss Manners Maven offers an assessment that is solidly at the extreme of that debate and is basically analogous to, “if you are gay, it is bad manners to tell a story about your domestic situation when giving a talk, because there are many people who think your lifestyle is evil and your unwillingness to convert to being straight is pathetic, and so your story will distract from your talk.”  After all, many people consider being gay to be worse than, say, murdering a gay person, and it would be oh-so-impolite to let such people know that you think they should go f— themselves.

I will conclude with the assertion that as an observer of the human condition, and frequent speaker, I believe I can offer much better manners advice than Miss Martin does, and so will answer the question:  Vaping when giving a presentation is somewhat more obtrusive than drinking coffee during the talk, but rather less obtrusive than snacking.  When presidents and people in similar positions give televised or large-room talks, they avoid any such distraction unless they absolutely need to take a sip of water.  Most professors, however, would not hesitate to go through a large coffee during a talk, just as professors and news-readers used to smoke while presenting.  On the other hand, it is generally considered impolite to engage in the somewhat more obtrusive activities of eating, taking medicine, or tending to bodily discomforts while giving a talk, and if someone knows that he will need to do that, he will actively apologize for it.

Falling in between those, vaping is not physically much more obtrusive from sipping coffee, but does not disappear into the background because it is still unusual.  Stepping that far beyond what it typical is not generally considered gauche, except by a few people who care deeply about the placement of forks.  But it does mean that if you vape in front of an audience, you will be known as “that guy who vapes when giving a talk”, just as someone might become known as “that guy with a ponytail”, or “that guy who always wears a suit when most everyone dresses casual”.  The questioner self-identified as a provocateur and seems to want to be known for vaping, so that seems to be ok.  (I personally vape during talks sometimes, but that it because I am talking about vaping, so it is a bit different.  Still, it gets noticed — e.g., see one of the comments here.)

A rather more important question for THR advocates, however, is not arbitrary manners but manners as tactics.  If you have a lot of credibility or goodwill with those around you and you let them see you vaping, it is definitely good for the cause.  This applies when you are just hanging out at a pub, or when the floor is yours at a talk.  But if you are in a situation where the happiness of polite society depends on everyone trying to minimize their impact on those around them, then it is not a good idea.  Examples of this include most times when you are surrounded by people who are not interacting, such as when waiting in a queue, or when in the audience in the same room where that talk is taking place.  In many such situations, the rules of manners say that most anything that gets you noticed is impolite, and the reality is that it ends up reflects badly on whatever accoutrement is contributing to that notice, whether it be an electronic device, children, or an e-cigarette.  Needless to say, it is bad tactics to be impolite in a way that causes that to happen.

Don’t Be Fooled by the Canadian Lung Association

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.)

The value of individual testimonials and more on negative evidence

by Carl V Phillips

Continuing from my post earlier today (basically “class notes” for an interview I am doing later), which is part of the current series on how to best communicate the truths about THR.

Point 2:  What evidence can we cite to argue that e-cigarettes are useful for smoking cessation?

The good news is that we have great affirmative evidence about this rather than having to infer from negative evidence (as was the case with Point 1, how we can be confident of the low risk).  The bad news is that it is still necessary to discuss real scientific reasoning rather than just doing something easy like pointing to a simplified artificial study.

I already addressed this point in a recent series about an anti-THR liar who wants to censor the strong evidence we have (for obvious reasons).  Rather than report the details again, I refer you to these two posts.  But I will summarize here:  We have a huge collection of individual reports of how switching to e-cigarettes facilitated people’s smoking cessation after their failed attempts to quit in every other way imaginable (except switching to smokeless tobacco, it turns out –that was seldom attempted).  These are the best evidence possible that e-cigarettes cause smoking cessation for some people who would not have otherwise quit (at least not any time soon, which is critical).

By contrast, the typical statistical study that collects various data on a lot of people — but not their valuable individual narratives — could never provide such useful information.  We would have to infer from limited data whether someone seems like they are the type who would have quite without the aid of e-cigarettes, rather than having their own testimony on this point.  “Public health” researchers might prefer that study because it is the type of work they are paid to do, but a scientist would recognize that the quality of the information is markedly inferior.

There is a somewhat legitimate criticism of the testimonial evidence:  It is difficult to assess how often e-cigarettes cause smoking cessation.  That is mostly true, though notice that the premise of the criticism is that it e-cigarettes cause cessation sometimes — a concession already!  But we do have evidence that there is a lot of success because there are so many reports.  Moreover, almost every vaper you meet will report that they cannot imagine they would have quit smoking anytime soon without e-cigarettes.  There are only a few who report something along the lines of “I would have been happy quitting entirely, but I am happier using e-cigarettes” (note that this is not a bad thing either — it means that e-cigarettes made them happier than abstinence — but the “public health” people are likely to treat it as a bad thing, so we need to save that observation for people who genuinely care about people’s welfare).  Thus, the evidence shows that the vast majority of people who switched from smoking to vaping only quit smoking because of the e-cigarettes.

We can endeavor to predict what portion of smokers will quit due to e-cigarettes as a function of knowledge, social forces, etc., and I am working on exactly this in my current research.  But we will not know for sure until we can look back on the history.  But the good news is that the accuracy of this prediction does not affect the argument that keeping e-cigarettes available is a good idea:  The option of switching to e-cigarettes does not crowd out any other cessation options.  If they will not work for a particular smoker but something else will, that something else will still be there.  Quitting smoking is what matters, and everything else is a rounding error.  The risks from the alternatives to smoking (various THR products and abstinence) are approximately the same, so there is no harm in offering a method even if it works for only a few people (so long as the method itself is not harmful, like Chantix or waterboarding, and trying e-cigarettes is obviously not).

Point 3 (after 1, evidence about the low risk, and 2, effectiveness) was a collection of minor points.  The most common is the classic “gateway” propaganda about youth use that will lead to smoking.  For those who do not know, the concept of the gateway was made up, based on no real evidence, by drug-war types to concoct an excuse for treating cannabis as if it were as harmful as “hard drugs”.  When cannabis is smoked, it is probably as harmful as any other smoking, but still obviously nothing compared to other strictly prohibited drugs.  So they needed to make up a reason to treat it the same.  There are several good reasons for dismissing the gateway claim about e-cigarettes.

First, if there are any youth who would never have smoked but choose to use an e-cigarette, it must be because they know it is low risk and they avoided smoking because it was high risk.  The same is true for the few older people (mostly ex-smokers) who were not already smokers when they started using e-cigarettes.  It would obviously be absurd to think that someone who avoided smoking and started using the low-risk product only because it was low risk would somehow forget that motivation and start smoking.

Second, there is no evidence of youth uptake despite the growing popularity of e-cigarettes.  Again, we have to reason from the lack of evidence because there is not much useful affirmative evidence of a lack of uptake.  A few studies, including one out this week, looked for youth uptake and found almost none.  What use there is among young people is actually for the same reasons adults use e-cigarettes — because they smoked and liked smoking, but wanted to avoid the negative health effects.  E-cigarettes just do not have the same appeal to a new user that smoking does.  But, third, to the extent that e-cigarette use does crowd out smoking among young people, this is obviously a good thing.  Harm reduction is not just for middle-aged people, after all.

Probably next on the list of topics that get argued is the “it looks like smoking” claim.  This seems to be another point (along with “people should be allowed to choose what makes them happier even if it is slightly unhealthy”) where we need to try to pry open the gap between normal thinking people from the “public health” industry.  The response needs to be: “Why is that a bad thing?  After all, the purpose of fighting smoking is to eliminate the health effects of smoking, not the appearance of smoking, right?”  It is true that vaping has much of the look and feel of smoking — that is part of what makes it useful.  The ANTZ hate it because of that, and there is nothing that can be done about that.  But normal people might be tricked by the ANTZ into believing that the appearance could be seen as an endorsement of smoking.  But, once again, there is no evidence to support this claim.  It is rather more plausible, once everyone who gets out much is aware of e-cigarettes and recognizes them (a point we may have reached already in many populations and certainly will reach soon), that every sighting of an e-cigarette will be an overt reminder that someone has decided to not smoke.

I will continue with some other points (and comments for which ways to go with this are welcome), but that is all I have time for today.  I will conclude with the key observation on that “prying normal people away from the ANTZ” point:

When presented with the choice of (i) letting smokers, if they wish to do so, continue to enjoy the benefits of smoking in a form that does not substantially harm themselves or anyone else, versus (ii) forcing all smokers to suffer a great deal in order to get rid of the harm, normal people would obviously support allowing the former.  ANTZ would demand the latter.  If you can get someone to stop and think through their answer to that choice, setting aside all the fiddly details, you can then point out to them that the anti-THR people simply want those who like nicotine/tobacco to suffer the costs of abstinence rather than enjoy the benefits with very little cost.  Since the ANTZ know that normal people would not support that, they are trying to trick everyone into believing that this is not really what they are demanding.  Even setting aside the public health (not to be confused with the “public health” industry) point that many will not obey them, and will continue to smoke, their best case view of forcing universal abstinence even though THR is an option, is not one that normal caring people would embrace if they understood the options.

How to communicate the implications of negative evidence

by Carl V Phillips

Continuing the series I started yesterday on how to mobilize the truth for THR advocacy.  I believe the next logical point for the typical discussion with an open-minded but uninformed THR skeptic, after yesterday’s, is the inevitable discussion about “addiction”.  However, I will put that off and go over some thoughts I have been assembling for an interview this afternoon.  The planned topic is what sources vaper advocates can use when arguing the merits of THR to MPs (it is a UK show).

The discussion will probably also address the topic of what arguments to use also, of course.  But what about those sources?  What form does our evidence take?

I think there are three categories of scientific points to be made: 1. how do we know it is low risk? 2. how do we know it works for smoking cessation? and 3. a smattering of others.

Our knowledge about the low risk of long-term smoke-free nicotine use comes primarily from studies of Western (Swedish and American) style smokeless tobacco.  Those products deliver nicotine (and other exposures too) and have been definitively shown to be very low risk.  There is a substantial epidemiology on this and a few good summaries of parts of it.  Due to the limits of the science, we cannot say for sure whether ST is 1% as harmful as smoking, or 2% or 0.1% or even 0%, or even a little bit good for you.  All of those are plausible given the evidence.  However, a number as high as 5% is not plausible.

We can extrapolate our knowledge about ST to pharmaceutical nicotine products (“NRT”), which are quite similar to e-cigarettes.  We have to extrapolate because we do not have the same evidence about long-term pharma nicotine use (because the regulators and manufacturers have pretended there is no long-term use, they have avoided studying it).  Everyone other than anti-nicotine zealots is comfortable in concluding that pharma nicotine has the same low risk as ST — perhaps 2% as bad as smoking, perhaps 0%, but almost certainly not far out of that range.  We are reassured in this extrapolation of the data by the fact that there are no apparent serious acute effects from pharma nicotine (of reasonable doses), nor has there been a strange pattern of disease detected among the many long-term users.

We can then apply this same extrapolations to another way to deliver pharmaceutical nicotine, e-cigarettes.  They are, of course, little different from the pharmaceutical nicotine inhaler which we are confident is low-risk and which the UK’s MHRA has approved for long-term use for THR.  As with pharma products, we have enough experience with the use of current-technology e-cigarettes to be confident there is not a substantial risk of acute effects and there is nothing unexpected that seems to appear after a few years.  E-cigarettes are enough different from smokeless tobacco that we cannot be sure they are quite as low risk.  They might also be even lower risk, though not much lower obviously, since there is not room for much lower.  I think the smart bet would be that they are a bit higher risk (due to airway involvement, primarily), but you would probably never be able to collect on that bet because it is too close to call.

So, back to the issue of what to say.  Any scientist (a category that does not include most people in “public health” who pretended to be scientists) will recognize this pattern of evidence and be able to use it:  Almost every conclusion in science is based on this analysis:  What we have observed in a well-studied similar case suggests that D will not be caused by E (where D=major health risk; E=e-cigarette use).  We have observed E itself to a limited extent and have seen no reason to doubt the extrapolation.  Therefore it is reasonable to conclude that E does not cause D.  Exactly how confident to be about this depends on the similarity of what we have studied, how much evidence there is, etc.  Science, it turns out, is more art than science in situations like this.

How can we explain reasoning like this to the average interested person?  I am not even sure I succeeded in explaining it to you, my readers.  I see no choice but to appeal to the conclusions that can be drawn from the lack of evidence, but we can keep it simple:  “There is overwhelming evidence that smoke-free alternative nicotine products pose about 1/100th the risk from smoking.  There is no reason, based on either our substantial knowledge about what vapers are exposed to, or actual observed health outcomes, to doubt that this applies to e-cigarettes.”

At that point, you should add in the point I made yesterday.

So how to respond to the inevitable reply of “but there is no proof they are safe!”  First, of course, is to point out that no one is claiming they are 100% safe, just that they are about as low risk as drinking soda or eating french fries (sorry, “fizzy drinks” and “chips”), or commuting to work, and a miniscule fraction of the risk from smoking.  But do not stop there.  The next bit is tricky but crucial.  Most people involved in this debate are not scientists, but it is necessary to understand one bit of science:  All statements that something has low risk are extrapolated from other observations about something that is similar but not exactly the same.

When a product has been specifically studied for a long time (like snus has), the extrapolation can be made with a bit more confidence.  But it is still an extrapolation.  Snus has been shown to be low risk when used in the past (in particular forms, in particular ways, by particular populations), but that cannot prove that snus use in the future will not be high risk.  We can be pretty confident but there is no proof.  Similarly there is no proof that eating apples will not, in the future, turn out to be high risk.  And but the same token, we cannot be sure that smoking will not be lower risk in the future than it has been in the past (indeed, it almost certainly will, due to improved disease treatment).

So every conclusion about risk is an extrapolation from the most similar experiences that we have actually studied.  The extrapolation from other sources of smoke-free nicotine to e-cigarettes is very convincing to anyone who thinks like a scientist, but it cannot be proof.  So, how do you offer a simple citation to support this?  You cannot really.  Sorry.  It is necessary to appeal to the totality of what we know about the topic, including what has not been published (i.e., no discoveries of a reason to suspect that e-cigarettes might be higher risk than expected).

I will post this and try to address point 2 in another post before the show today.  The good news is that point 2 is one that can be demonstrated based on evidence rather than its lack.