by Carl V Phillips
Apologies for my ongoing fascination with Stanton Glantz. As regular readers know, I have made a minor hobby of trying to figure out what really makes him tick, and that I sometimes hesitate to call him a liar because he seems to believe some or all of the crazy things that he claims. I have called him out as a liar because at the very least he lies when he claims to understand what constitutes good and honest science. Indeed, it seems impossible that he does not know he is lying with statistics in his claims about ETS. But he might not be the calculated and knowing liar that many others are. For example, he seems to really believe his claims that smoking in movies causes most smoking initiation; and why would someone flog such an embarrassingly nutty claim and go to war against free artistic expression except out of genuine belief? In general, he may not even know enough to know that he does not understand science. But he is aggressive and somewhat influential, and that makes him fair game, so….
My latest fascination is with this little post by him, which was basically just housekeeping. The purpose of it was apparently just to explain why he deletes comments on his blog about e-cigarette success stories. I suspect he has been deluged with those since he started becoming aggressively anti-e-cigarette. (This is relatively new. Previously he focused on anti-smoking. It is not entirely clear why he has adopted this issue.) The mere fact he posted that is interesting, and he gets props for it in my mind. He did not do what most corporate tobacco control industry actors routinely do, which is to just censor comments without admitting they are doing so, with no attempt to justify their actions. Instead, Glantz basically acknowledged that he was receiving such testimonials and felt that he owed people an explanation for why he would not post them. This also contrasts starkly with the behavior of someone Glantz is often inappropriately lumped in with, the self-important pre-adolescent bully boy Simon Chapman, who has a history of aggressively ridiculing people’s personal testimonials and taking joy making fun of difficulties people have suffered. Glantz seems to be genuinely interested in being a decent person, however misguided we might think his goals.
Frankly, I have to sympathize with Glantz on this — I would not want the comments section of one of my blogs flooded with 1000 word essays that I did not consider to be informative. Ah, but there is the problem. Glantz’s claim that these posts are not informative brings us to his profound lack of understanding of the science he claims expertise in. The post in question was just over 200 words, most of which were just his unsupported personal opinions about e-cigarette regulation. The entire content that is fascinating me is:
There is a long and well-developed literature about the placebo effect where people think a treatment worked when, in fact, it was no better than a sugar pill. Personal testimonials about the benefits of e-cigarettes do not constitute scientific evidence that they are effective ways to quit smoking. If and when there are high quality longitudinal studies showing that e-cigarettes as actually used actually help people quit smoking conventional cigarettes, I will modify my opinions on e-cigarettes as cessation aids. As of now, the reality is that such studies simply do not exist.
Let’s think about the “do not constitute scientific evidence” and “longitudinal studies” bits. What exactly does he think a longitudinal study would show better than the testimonials? Such a study would consist of gathering a group of current smokers and following them over time to see what they did. Assuming these were Americans or others with similar economic and social circumstances and access to THR products, it is safe to predict that the result would be many still smoking, many becoming tobacco/nicotine abstinent, probably many switching to e-cigarettes, a fair number switching to smokeless tobacco, and a fair number switching to other nicotine products. So assuming many switched to e-cigarettes, would that constitute particularly good evidence that e-cigarettes are an effective way to quit smoking? Not really.
It would be possible that those who switched to e-cigarettes would have become abstinent (or would have switched to another low-risk alternative) had e-cigarettes not been available, and so e-cigarettes caused no smoking cessation. That would be an absurd story, knowing what we know, of course. But if we pretend, as Glantz apparently would like us to, that the study alone provides the useful evidence and nothing else does, then we would not be able to rule that out.
Why do we know that is absurd? Because of the countless testimonials by people who tried to become abstinent before they tried e-cigarettes and did not, but that quit smoking using e-cigarettes, and moreover are delighted to be using them instead of smoking. Those testimonials are the real scientific evidence, not the vague statistics that Glantz proposes collecting. Any real scientist would recognize this. It turns out that the statistics he wants to collect offer us little or no information about what we want to know — what switchers would have done without e-cigarettes. It is that kind of information that is not scientifically useful. The testimonials, on the other hand, are a rich source of scientific information about smokers who did not quit (they would probably say “could not quit”) until they found e-cigarettes. These testimonials represent useful scientific experiments.
This leads to that light switch remark in the title: I wonder what Glantz does when he walks into a new classroom [does he even teach? not sure. a scary thought for another day] and notices it is dark and not getting any lighter? Most of us would flip the switch on the wall, and if the lights came on at that moment we would conclude that that switch causes the lights to come on and be comfortable with that knowledge and take advantage of it. Glantz apparently would stand in the dark until someone conducted a longitudinal study, observing a group of rooms and what happened to the lights. But after doing that study, he would still have a problem, since the data collection would inevitably not be sufficient to discriminate between whether the switches made the lights go on, or the presence of people, or certain hours of the day. If forced to rely on that results of that study, he would still not know if that switch caused light.
Non-scientists who are being trained to appreciate the simplest forms of scientific reasoning without really learning how to think scientifically (a characterization which applies most public health and medical students) are taught that particular formal study types give us more information than do collections of less organized observations. But real scientists learn to recognize when the simplistic rules of thumb are misleading. We figure out that sometimes a collection of one-off experiments is worth far more than a formal study. Flipping a switch, or collecting a few hundred personal testimonials, is sometimes better evidence about what we want to know than any other practical study could be.
[This post is already running long, and I will probably come back to this theme later. But for those who are interested right now, I wrote a paper whose major theme is further exposition of this point for a different but remarkably related topic, which you can find here.]
I will give Glantz some more credit here, though. It is true that it is difficult to assess exactly how often something happens based on personal testimonials alone. Unfortunately, his longitudinal study would not provide very useful information about that either, since it would be for a particular population at a particular time, and would be almost impossible to extrapolate to anyone else given how rapidly circumstances are changing with respect to e-cigarettes. He also gets credit for not calling for clinical trials. Again, people who half understand science think that clinical trials are always useful, or even always best. But while they are great for studying people’s biology under fairly simple circumstances (e.g., for assessing most disease treatment options), they are generally quite poor for studying anything else, like behavior. Something like smoking cessation involves the effects of countless complicated real-world factors that are absent from an artificial clinical setting. (Of course, it is possible that Glantz’s real motive is that a longitudinal study would take much longer than clinical trials, and he just wants to stall. If that turns out to be the case, I will take back several of the things I have given him credit for.)
Having spent >1000 words dissecting his 100 words, I have still not gotten to his equally fascinating lack of understanding about the placebo effect. But discussing that will take another 1000 words, so I will leave it for tomorrow.
I’m not a scientist and I’ve deduced the following as true according to my experience: I could not stop smoking using the patch, the nic gum and lozenges, and finally Chantix. I desperately wanted to stop smoking as another lung cancer death in my family had me grief stricken and very badly wanting to quit. After a year of unsuccessful attempts to stop smoking I became resigned that I’d be a smoker till I died. Then the ecigarette came into my life. I haven’t smoked since 11/04/2010. My elderly mother has COPD and asthma and cannot be around a smoker even from a distance outside, yet I can vape in an enclosed car and it doesn’t bother her at all. So after finding a solution to my overwhelming smoking dilemna I am now coming face to face with what a sham the agencies are that pretend to want to protect our health are, such as the FDA ( the AMA, the American Lung Association and the American Cancer Society). Omitting testimony is lying, censoring testimonies is a form of lying, and being willfully ignorant to the point of lying to be right is a sickness much worse than smoking. It’s a lower form of egotistical behaviour with the potential to harm others. I think banning or preventing a smoker access to an alternative such as the ecigarette is equal to mass murder. I know that sounds nasty, but think about the self deceiving psychopathic mental process afflicting a serial killer and compare it to someone keeping a smoker from accessing a device that could save his/her life. “Acting irresponsible” just isn’t strong enough to describe such a person.
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Glantz is heavily involved in trying to cut tobacco smoking from Hollywood movies. His whole agenda is to denormalise tobacco smoking. Because electronic cigarettes “look like” tobacco smoking, he sees vaping as a threat to his agenda.
Glantz is merely taking advantage of the fact that the electronic cigarette industry can’t not afford to pay for clinical trials. He spouts the “no clinical proof”, but there’s a fundamental flaw in that whole argument that I wish THR advocates would see.
What is frustrating is that reasons given to ban electronic cigarettes and nicotine solutions are based on non scientific evidence. A single bottle of ejuice (out of hundreds) is found to have some toxin, and that’s somehow justifcation to ban all of them. A single person reports nausea, and that’s some how justifucation for a ban. One guy’s battery explodes, and that’s justification to ban all the millions of ecigs.
But literally MILLIONS of individual success stories are completely ignored.
The flaw in spouting the lack of clinical trials is the question as to; why electronic cigarettes have to be proven as “cessation” aids anyway? Why do they need to be regulated as either a “tobacco product” or as a some kind of “therapy”?
Why can’t they be regulated as their own form of recreation product, as caffeine or alcohol is? The only reason I see is because of the history of nicotine in tobacco cigarettes. See this parody on Coffee Leaves ;
Tobacco Smoking cessation is a definite by-product of electronic cigarette usage. That should be recognised, particularly from a THR point of view, but I don’t think that should be a prerequisite for legality.
The anti-tobacco groups will always exploit the ecig industry’s inabilty to finacially afford a clinial trial. Which is why ecigs shouldn’t be marketed as a cessation aid.
E-cigarette usage is NOT a gateway to tobacco smoking and there is plenty of evidence showing that they contain 99% less toxins than tobacco smoke. All that is needed is a regulatory framework to ensure good product standards.
Mav, You are probably right about your explanation for why Glantz decided to start attacking e-cigarettes when he had not been particularly anti-harm-reduction before. Also, your observation about which individual stories count is spot on, and I had not really thought about that — I will mention it in the next post.
Admittedly I haven’t followed Glantz’s all that closely except to come to the conclusion that he is essentially a kook (that’s probably not at all fair, but it is what it is).
Could it be that he is simply among the true believers, much like a fundamentalist Christian believing in creationism. I remember years ago watching a documentary put out by Seventh-day Adventist that went into great detail as to how the world was created in 7 days. It was an amazing display of twisting the facts to fit into a preconceived idea. The thing is they really believed it because for what-ever-reason they had to. I don’t think of it so much as ignorance but a deep neurosis. Their well being seems to hinge on……… believing, and of course convincing everyone else into believing, because surely everyones well-being must also hinge on it (okay, I’m in desperate need of a phycologist)
Glantz seems more that type then one of the TC industry type that knowingly lie for a variety of unsavory reasons (mostly money). I wonder if he could very well believe what he is saying and simply ignores reality just as the creationist do.
Yes, that is pretty much my current hypothesis about him. He is a 1970s throwback, after all. Most of those who were part of the original anti-smoking efforts, back when they were fighting for things (like basic education and, ironically, harm reduction) that were perfectly reasonable, have drifted away. But for him, it may be a matter of personal identity.
Glanz in his limited capacity of logical reasoning is just starting to understand that he has a large and expanding problem. He is loosing the crowd. If we look logically at the belief systems he has constructed, they hinge on a major belief that smoking causes cancer and heart disease. What makes tobacco smoke unique when compared to cooking smoke, burned toast and the campfire roasting marshmallows with the kids, comes down to the term “Tobacco specific”. What is tobacco specific? The nicotine is the only product that supports tobacco specific and the carcinogens or the interactions of oxidized nicotine on aceto-chlorine receptors with the release of endorphins, [the happy sauce, that makes the heart beat faster in concert with feeling happy] to sell his endothelial dysfunction fantasies. What is wrong here, is that you can not attack the nicotine without attacking the products such as patches and candy sold by his most generous benefactors. Truth be told nicotine has an ignition point that is below it’s boiling point, so very little of the original nicotine contained in a cigarette survives in the smoke. So the” tobacco specific carcinogens and toxins” most linked to cancers and heart diseases in smoking, are much more highly concentrated in the medicinal nicotine, than they are in the smoke of a cigarette. If he produces studies in concert with harms, he has to explain why an identical product can be classed as a medical treatment, leaving little to entitle his many stipends down the road and indeed leaving him the target for future pharma promotions, should he stray from the stable. How he grew a general belief that anything he or his cult brethren participate in is attached to empathy or concern for others, is a mystery beyond all comprehension. His ability to carry on that charade, is entirely at risk, when the crowd of those seeking alternatives to smoking find a product that they can accept and defend, above the most vigorous acts of fear mongering the can conjure. And therein lays the rub. His hands are tied here in relation to what he can promote, in the way of e-cig fear, so he either accepts e-cigs as official alternatives, or he watches his retirement plan, reveling in the lap of luxury, fade into the breeze.
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Glantz is tied to the Robert Wood Johnson Foundation and LOVES those grant funds they dole out ‘to fit their agenda’. He’s not going to do anything to jeopardize that money train. ….. For those that do not know, that foundation was set up by the original/past owner of Johnson and Johnson and they OWN at 250 varied pharmaceutical companies. They make the no smoke products. That foundation ALSO set up Tobacco Free Kids which is their lobby group. Follow the money of any ‘anti’ and you’ll find one giant club of RWJF grant receivers and/or past employees.
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Isn’t there a significant body of knowledge that shows that hearing stories about the success of others and a sense of community are highly determinative in success rate of habit change?
So in suppressing success stories isn’t he “putting his finger on the scale” in a passive-aggressive attempt to cherry pick the data?
It’s very easy to get the result you want, if you only accept data that supports your claims.
Yes, it clearly is the case that others’ success is contagious. I have been working on modeling that effect: http://ep-ology.blogspot.com/2012/10/agent-based-model-of-thr-adoption-and.html
And yes, that is a good point: If someone successfully suppresses information about success stories then they will indeed slow the adoption of THR. Not that Glantz limiting what is posted on his own blog will have a major effect on that, but the efforts in general could.
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I’ve always been among the pioneers in my social circle, so I was among the first who tried the e-cig as a tobacco substitute.
One definition issue needs to be dealt with. Technically, when you go e-cig and don’t smoke tobacco anymore, you have actually stopped smoking. That needs to be acknowledged first and foremost.
Morally, however, a lot of people aren’t happy if you freely admit to enjoying nicotine through e-cigs. To them you haven’t really quit, because they want you to be completely abstinent from anything that remotely looks like smoking. Sure, the vapor looks a lot like smoke, but those moral lighthouses should perhaps consider if they judge people based on their skin color too?
The frequent bans on chewable tobacco underscores this. It is by far one of the most safe ways of getting nicotine into your body, although there’s a small increase in mouth cancer incidents. Still, it is safer than smoking tobacco. Yet the abstinence-only lobby have banned this because – it seems – they just don’t want anything tobacco to be remotely connected with being “safe” or even “safer”. So now there’s the e-cig that in all likelihood is even safer than chewing tobacco, and they’re trying to ban that too. The moral posing should be obvious.
Once I made the switch to e-cigs I didn’t go back to tobacco. I quite prefer the e-cig, and at this time I’m using nicotine fluids in it. I have 7-8 converts in my immediate social circle and almost all of them have stopped using any tobacco (and two have stopped entirely … or as entirely as a smoker can ever manage; I don’t know the future). Most coverts in my social circle prefer the e-cigs to real tobacco, a few prefers the tobacco and won’t use e-cigs or are for one reason or other dissatisfied with the e-cigs and consider them a last resort (during driving, flying, at school, etc.).
On balance it should be clear that there’s a tremendous harm reduction potential in e-cigs. And it will be realized fully only if there’s a beginning acceptance that even if it looks like smoke it’s a harmless vapor. Also, when many more public places get policies explicitly allowing vaporizers e-cig users won’t have those unpleasant dealings with security personnel. Right now a lot of vapers are treated as if they smoked and they’re being told to “stop whatever it is they’re doing”.
Your experience sound like the opinion-leadership that is at the quiet core of the THR revolution, so thanks for sharing that; it is a very nice example of the model I have presented, and it is always good to hear from reality. A little clarification: The evidence does not actually support the claim that American or Swedish style smokeless tobacco increases mouth cancer risk. In assessing the somewhat broader motives of the ANTZ, you might want to check out the first post or About page on this blog.
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>>if the lights came on at that moment we would conclude that that switch causes the lights to come on
Well, that’s what it looks like but in fact the purpose of switches is to turn things off. It’s electricity that makes the light come on, not the switch.
No, flipping the switch is a cause of the light coming on. The fact that there is electricity “ready” to flow is also a cause. For a fairly complete but easy to read explanation of what a cause is, see: http://ep-ology.com/2015/03/11/working-paper-phillips-gateway-effects-why-the-cited-evidence-does-not-support-their-existence-for-low-risk-tobacco-products-and-what-evidence-would/
You epidemiologists just don’t understand causality. I can buy a switch in a store and flip it as many times as I like and it won’t put a single light on. The electricity is the cause, the switch (if there is one) is a condition.
You didn’t do the assigned reading, did you? I think you will find that it points out what you got wrong there.
It is my experience, having dealt with a lot of scientists in a lot of different fields, that the real scientists among epidemiologists have a better understanding of the concept of causation than others — almost certainly because it is so much more complicated than in most fields. (Note that this does not refer to the vast majority who are cranking out epidemiology studies, who are utterly clueless about what they are doing. I am talking about the tiny minority who are real thinking scientists.)