CDC director misleads Medscape

by Elaine Keller

Centers for Disease Control and Prevention (CDC) Director Thomas R. Frieden, MD, MPH, sat down with Medscape during the recent National Health Research Forum in Washington, DC, to mislead the public about electronic cigarettes. http://www.medscape.com/viewarticle/811616  The following includes some of his comments and my corrections of the lies.

Medscape: There is a growing health concern about the electronic cigarette and how it is being marketed to consumers… What is the CDC doing to address this concern?

Dr. Frieden:  “What we are doing first is tracking…and we are seeing some very concerning trends.”

This is a misleading non sequitur and only the first half of the statement is true.  CDC has done no apparent research on marketing.  They are doing some tracking, but only about usage, not the reasons for usage.  And their data suggest nothing that is “very concerning”.

The CDC tracking he refers to seems to consist of their National Youth Tobacco Survey.  It asked youth whether they have ever tried an e-cigarette and whether they used an e-cigarette during the 30 days preceding the survey, even if only once. In addition, they asked youth whether they smoke conventional cigarettes. In order to make the numbers for trying e-cigarettes seem high, they intentionally avoided comparing them to the (much higher) numbers for youth smoking.  They also claimed there is a causal connection between e-cigarette experimentation and initiation of smoking, as well as claims that non-cigarette flavors are particularly appealing to youth, but they did not collect any data that addresses those claims at all — they just made them up.

Here is what the CDC is not reporting about e-cigarette use (some of which they do not know because they did not ask, and some of which they do know but avoided reporting):

• How many students use e-cigarettes regularly or daily?
• Among students who currently use e-cigarettes, how many are also smokers, or are former smokers who switched to e-cigarettes?
• Among students who have ever tried e-cigarettes, how many prefer candy or fruit flavors, or even use them at all (let alone were attracted due to those flavors)?
• How students are obtaining e-cigarettes?  Which merchants are refusing to sell to them and which are not?  Are the products they are using the ones that are actively advertised?

Dr. Frieden:  Use of e-cigarettes in youth doubled just in the past year…

Misleading! The only statistic that doubled was “ever use” which is really ever tried.  This category will inevitably increase for a novel product, even if there is no significant regular usage. If one student tries a puff, he is forever in that category, and if a second student tries a puff the next year, the statistic would double. This number grew from 3.3 percent in 2011 to 6.8 percent in 2012. However, the percent of youth in grades 6 through 12 who used an e-cigarette (even so much as one time) during the 30 days preceding the survey was only 2.1 percent.

Dr. Frieden:  “…and many kids are starting out with e-cigarettes and then going on to smoke conventional cigarettes.”

False. The CDC collected no data that would support this allegation.  Perhaps more important still, even if someone tried an e-cigarette and went on to smoke does not mean that the e-cigarette caused the smoking. Most people — quite possibly everyone — who follows that pattern would have started smoking anyway.  There is no reason to believe that e-cigarette use would make smoking more appealing, since we know that it generally makes smoking less appealing.  The whole reason e-cigarettes exist is to make smoking less appealing!

Assessing whether use of one product causes the use of another (rather than just precedes it) is quite difficult, which makes it easy for people like the CDC to lie for political reasons.  If it is true — if anyone is honestly interested in the answer, rather than just wanting to lie about it — we will know once e-cigarette use becomes so popular that we see an increase in smoking.  Past 30-day smoking rates have been steadily declining for youth between ages 12 and 17, dropping from 8.7 percent for males and 9.3 percent for females in 2009 to 6.3 and 6.8 percent, respectively, in 2012 (source).  Likewise, smoking initiation rates dropped from 6.2 percent for males and 6.3 percent for females in 2009 to 4.7 percent and 4.8 percent, respectively, by 2012.  If youth e-cigarette use is causing more smoking (rather than further reducing it, as it does with adults), this trend will reverse.  It seems impossible that this will happen.

Dr. Frieden: “Nicotine can be a very addictive drug, so we want to make sure that e-cigarettes don’t lead to another generation of kids becoming addicted.”

There is no basis for this claim.  There are strong arguments that nicotine (as opposed to cigarettes) is not addictive, and certainly no evidence to the contrary.  (See the previous post by CVP, for more on this topic.)

Though we do not know what he means by “addiction” we can guess at it and propose some real analysis that CDC seems oblivious to. They need to assess how many of the possible “addicts” (daily use might be a necessary condition for addiction, but it is not sufficient) were already regular smokers. Telling us that 9.3 percent of those who tried an e-cigarette (that may or may not have contained nicotine and perhaps tried only one time) were non-smokers provides no information at all about e-cigarette addiction. One way to get some notion of whether nicotine via e-cigarettes is addictive would be to track the number of never-smokers who became regular, daily users of e-cigarettes that contain nicotine. The CDC has not researched daily use or even whether the e-cigarettes being used by youth contain nicotine.

Dr. Frieden:  “In addition, if smokers want to quit, we know that there are FDA-approved medications that can double or triple their likelihood of succeeding.”

Been there, done that. The majority of adult smokers who turn to e-cigarettes have already tried FDA-approved medications more than once. One advantage of e-cigarettes is that the nicotine dose can be tailored to keep withdrawal symptoms under control.  Also, the only medicines that help more than a miniscule fraction of smokers (the case with NRTs) have major bad side effects.  I would be very interested in Frieden’s basis for claiming that these are better than e-cigarettes.

Dr. Frieden:  “Also, we need to make sure that people who have quit smoking don’t get hooked back on nicotine by starting up with e-cigarettes and then go on to smoking conventional cigarettes.”

Not likely. Many former smokers struggle with strong urges to smoke for years after quitting. Not having a satisfying substitute is the major risk for relapse. E-cigarettes with nicotine help prevent relapsing to conventional cigarettes. There are no reports of people who had quit smoking taking up e-cigarette use and then returning smoking conventional cigarettes.

It is bad enough that people who are paid anti-THR liars make claims like this.  But Frieden works for the U.S. government, and so has a legal obligation to tell the truth.  His moral obligation to tell the truth is also stronger since when he makes statements that contradict the facts, it will likely affect policy and thus hurt the public.

[For more on Frieden’s lying, see also this post by Michael Siegel.]