by Carl V Phillips
Perhaps as a tribute to our nation’s great accredited schools of public health, the Florida Department of Health recently blasted the world with junk science claims based on incorrect research methods and basic innumeracy. What they were trying to do was issue dire warnings about children using e-cigarettes, but mostly I think they succeeded in issuing a different warning to parents: Do not let your children study public health!
The Florida exaggerations are already being used in anti-e-cigarette propaganda. For example, they appear in the actual language of the bill to effectively ban e-cigarette sales in NYC (it would ban flavors, which are obviously rather critical to the product.) (See this recounting of the language.) The claim was that 40% more high school students tried e-cigarettes in 2012 than the year before, which is not actually what the data shows. According to the Florida DoH Fact (sic — and LOL) Sheet about this (not dated, but clearly from earlier this month since that was when it was press-released), their surveys found that 6.0% of such students had tried an e-cigarette in their 2011 survey and 8.4% in 2012, which they described as a “40.0%” increase. Numerate readers will immediately notice that (a) the uncertainty in the survey means that there is absolutely no way they can make a claim with three significant figures and (b) the third digit is undoubtedly wrong, and probably the second too, since they apparent rounded the other results to two sig figs and then did the calculation. (Credit to the above news story for correctly rounding this to 40%.) So, basically, public health people lack grade 7 level math/science training.
Rather worse in their reporting is describing this ever use statistics as “prevalence of this behavior”, meaning they did not understand the one semester of epidemiology they took in public health school either. The word “prevalence” is inappropriate, and thus misleading, when describing an “ever” statistics. Since “ever” ratchets (once you are in that category, you can’t go back), it is basically inevitable that there will be an increase in a population that is 3/4 the same people from one year to the next. This misreporting may partially explain why the equally innumerate people in the NYC Health Department misinterpreted the result (lied) by saying the number who tried e-cigarettes that year had increased by 40%. And, of course, if they had emphasized the more useful number, that 8% of high school students reported ever having tried an e-cigarettes, even just one puff, the number would not have been impressive at all.
The statistics are not legitimately reported even if we believe the point estimates are exactly right. After we consider random sampling error (not reported), response bias (clearly a problem, but completely ignored), and measurement error (I know that I always gave random data when asked to do some intrusive survey like this when I was in school) the results are pretty meaningless. The only reason that we should believe the trend at all (that there has been an increase) is that it is pretty much inevitable, not because if their data. Needless to say, given these basic errors in reporting, we should doubt the accuracy of their numbers also.
But even if we start with their basic numbers and ignore their errors and sensationalism, what can we make of it? How many of those who tried e-cigarettes were regular smokers? Quite possibly all of them, since the rate of current smoking is higher than the number who have merely tried an e-cigarette, but we will never know because they suppressed that information (which they apparently do have). How many of them had tried at least one puff of a cigarette? I would guess approximately all. How many of them are of legal age to use tobacco products, as many high school students are? Again, they intentionally hid all that information. It is difficult to see such obvious omissions as mere incompetence — they are clearly intended to mislead readers.
Similarly, they lied about current use. They did this mainly by referring to “tried at least one puff in the last 30 days” as “current use”. Moreover, their numbers for recent trying (which is what this really is, not “use”) are very low — half or less the figures for “ever tried”. So, of course, the propagandists did not mention them, hoping that sloppy readers would mistake “ever tried” for “uses”.
It is interesting to note that as a portion of those who had ever tried, those who had taken one puff within 30 days dropped substantially from 2011 to 2012. Since many of those who have only tried e-cigarettes on a few occasions must have done so within any given month, this shows that a rather small fraction of those who have tried an e-cigarette did it very often after that (let alone qualified as genuine “current users”). This is especially true for the 1.8% of middle school students who had tried in the last month (compared to 3.9% who had ever tried), since they would have had relatively few total months in their history that they might have tried them. Nevertheless this was breathlessly reported as having “increased by 20.0%” (emphasis and that same sig fig error in the original), and it is that statistics that has been repeated in subsequent propaganda, rather than the low absolute numbers.
What can we make of this? Well, we know what the ANTZ want to make of it, as quoted in the press release (attributed to the American Cancer Society):
We do know that e-cigarettes can lead to nicotine addiction, especially in young people who may be experimenting with them, and may lead kids to try other tobacco products, many of which are known to cause life-threatening diseases.
Of course, we most certainly do not know that e-cigarettes can lead to addiction. There is not the slightest piece of evidence to support that claim. Notice that the Florida data itself shows that most of those who try e-cigarettes have not tried one in the last month — if this is addiction, then that ANTZ word has become even more meaningless than it was before. Nor is there any evidence that e-cigarettes cause anyone to use other tobacco products. And, of course, only cigarettes and their minor variations (not “many” products) are known to cause life-threatening diseases (though it was amusing to see the implicit claim in that that e-cigarettes do not cause such diseases).
Honest people looking at this data can conclude almost nothing meaningful, other than that e-cigarettes exist. Is it possible that all the students who are using e-cigarettes are current or former regular smokers using them for THR? Yes — it is consistent with what was reported that every last one of them is. Could experimentation with e-cigarettes be causing other net reductions in risks in this population? Yes — those who are experimenting are the ones who are most likely experimenting with other drugs or behaviors that can do a lot of harm. If using an e-cigarette is displacing underage drinking, it is contributing even more to harm reduction than it does when it displaces smoking.
E-cigarettes are used by people almost exclusively to replace a much more harmful behavior. Students are people. Why then, exactly, is the assumption that when they are using them, there is net harm? Of all the drugs or other youthful dalliances that kids might be engaging in, it is difficult to imagine one that is less harmful than e-cigarettes (or smokeless tobacco), except maybe coffee, and even then it is not clear which is less harmful.
Tobacco harm reduction, anti-THR lies, and related topics 
I do wish that you would stop using the word ‘harmful’, Mr Phillips. You know very well that that word is a trap. It is used to cover THE LACK of significant harm. A much better word would be ‘dangerous’. You could then ask the question, “In what way are ecigs dangerous to health?” If they are not, or cannot be shown to be so, then you have half won the argument. The reason is that Zealots would then be required to show adequate proof of their claims that ecigs MAY lead to tobacco smoking. The errors in the study which you quoted would be even more obvious than they are.
Hmm. I see where you are going with that, I think. But I am not sure “dangerous” gets you there. The goal would be to find a word, X, that means something like “causes a somewhat high probability of a substantially bad outcome”, such that very low probability risks fall outside of the definition, alongside zero risk. Unfortunately, I am not sure “dangerous” fits that, since it is frequently used to describe very low-probability exposures, like bathtubs, slippery floors, or cliffs. Moreover, I am not sure we win even if we find X because the liars’ response to “it is not X” will inevitably be “but it is not harmless”, leaving us just where we started. (Still, notice that when it is the focus of what I am saying, I tend to put an appropriate adjective in front of “harm” or “risk” to create the very category you are suggesting.)
As you probably have noticed, I consider the ANTZ game of pretending that some exposures in the world are absolutely free from harm, and these are not among those, one of the fundamental anti-THR lies. It tends to reflect that most of these people are the clueless/crazy people who want to, say, destroy Golden Rice because of some minor speculative risk, and ignore the enormous benefits. (Seriously — read Twitter feeds of these people and notice that they are the same people.) That is why I think the “net” concept (which I happen to use in this post) is rather more important than the choice of words in the “harm” family. It is a useful observation that when someone chooses to use a low-risk tobacco product their choice is almost certainly providing them net benefits. This contrasts with cigarettes or alcohol, where an argument can be made (not necessarily right nor universal, but at least plausible) that the user does not realize that he is setting himself on a path that does net harm in the long run.
The other angle on it that my instinct tells me is most important is comparative perspective: Smoking is causes more health risk than all but a few things that a relatively small number of people choose to do, whereas smoke-free product use creates harm/risks that are in the range of many other non-“harmless” behaviors like eating french fries or dessert, or traveling, or spending time being ANTZ rather than being out exercising.
“We do know that e-cigarettes can lead to nicotine addiction”.
Really? Of which study?
Which study shows that nicotine (without the other chemical compounds in tobacco smoke) can make a HUMAN addictive?
Which?
Yes. Though the point is actually rather stronger than that in two ways: There are no studies that show e-cigarette use, absent former smoking, has any characteristic, property, or effect, because there have basically been no observations of that phenomenon, other than a few reports that it may exist. Second, there is no study that shows that anything leads to nicotine addiction because there is no scientific definition of “addiction”. However, I would be a bit hesitant at attributing the appeal of smoking to “other chemical compounds” — we do not really know for sure that is the critical factor.
Nicotine addiction has been extensively studied, from investigations of the absorption and metabolism of nicotine in smoke to its wide range of effects on neurotransmitter chemicals in the brain.
Animal studies indicate that pure nicotine is only weakly addictive but data on human drug use indicate that the addictive potential of tobacco is very high.
http://ec.europa.eu/health/scientific_committees/opinions_layman/tobacco/en/index.htm#4
The fundamental problem is that when “addiction” is extensively studied, everyone is studying a somewhat different phenomenon because there is no accepted definition of the term. That makes for bad science, and even more so when there is so much politics involved. That brain scan research — often called “brain porn” by the experts in the field — does not really show much that is useful about anything. It is fancy and looks impressive to observers (like scenes in a movie where a science lab has bubbling test tubes and a jacobs ladder) but it does not translate into anything very useful. As for rats, they are a pretty sketchy model of human biology and obviously even weaker for trying to make sense of human preferences.
This is not to rule out the possibility that there is something importantly different between exposure to extracted nicotine and exposure to the the rest of the tobacco leaf. But it does mean that pretty much everything that passes for science on the topic is junk. The most useful science on the topic is actually the evidence that suggests that many e-cigarette users who found smoking completely enthralling, such that substitution was the only way they were willing to quit, but find they can take or leave e-cigarettes after having switched for a while. This is a far far more useful observation than the brain porn or rat studies. Still, it would be premature to draw any specific conclusions, particularly general or strong ones.
And I would think that the EU has so thoroughly demonstrated its bias and unreliability on these issues that no one would want to cite them.
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We need an actual study on the effects of e-cigs, not these little studies on the effects on high school students or addiction. We need an overall study that shows the good and the bad of e-cigs that everyone agrees on, that isn’t biased in anyway.
What do you have in mind? We have the sales data. We have enough survey and testimonial research to show that almost all users are using them to replace cigarettes. That definitively demonstrates that they are doing what they are supposed to be doing, which is the good. What study could tell us anything else that matters much (in terms of the overall impact)?
September 8th, the results of a large scale clinical trial, conducted by the University of Auckland (NZ) and Health New Zealand, will be presented in Barcelona during the European Respiratory Society annual meeting.
This might prove useful, depending on the outcome
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Reblogged this on Nhaler News.
@Junican
Perhaps the word you seek is ‘risky’. It implies more danger rather than less danger, though. A more accurate way of describing ecig use is that it has ‘uncertain risk’.
@Rursus
You say, “Nicotine addiction has been extensively studied”. This is fundamentally untrue. For example, there is no published clinical trial of nicotine administration to humans. I do of course use this in the correct sense, which means the administration of nicotine to at least a small sample of 100 never-smokers, if 1,000 or more (a proper study) cannot be arranged, and then observing the results. Trials involving smokers, ex-smokers, or non-human subjects are utterly irrelevant since smoking may create dependence on nicotine, and we also know that animal models of nicotine activity are not relevant to humans.
It is very interesting indeed to consider exactly why no study of nicotine in humans has ever been published even though there is tremendous interest in this area. I used to think this was due to ethics considerations, but this is a little naive. The reason is far more likely to be that such studies have been carried out, but, like the CDC’s study of 800 people that showed all tested positive for (probably, mostly dietary) nicotine, which was subsequently buried as deep as possible, the results do not fit with commercial imperatives (referred to by some people as ideology; but personally I believe that ideology is easy to get when the mortgage needs paying and the kids need feeding).
Studies with negative results don’t get published.
Anecdotal evidence at this time, in any case, is that nicotine is not reinforcing unless/until delivered with a cocktail of up to 9,600 other compounds including multiple synergens, boosters, and pyrolytic products in cigarette smoke. (Latest research identifies that many compounds in both the smoke and the raw material although the total for smoke is not given; the previous total identified in smoke was 5,300.)
http://www.crcpress.com/product/isbn/9781466515482
To paraphrase Prof Killeen: “Nicotine is not addictive – and nobody can prove me wrong at this time”. It may or may not be dependence forming – but until there is *a single trial of nicotine in humans* then there is no evidence either way. And since no trial has been published – we probably already know the answer.