Monthly Archives: November 2013

Five things Tom Bemis Won’t Tell You About E-cigarettes

by Elaine Keller

“Electronic cigarettes are starting to catch on, with the industry expected to hit nearly $2 billion in sales this year alone. I’m Tom Bemis from MarketWatch with a look at five things e-cigarettes won’t tell you,” he says. MarketWatch is a production of the Wall Street Journal.

He then jubilantly proceeds to announce 5 big fat whoppers about e-cigarettes. Let’s take a look at what Bemis did not tell you about e-cigarettes with some corrections of his disinformation:

Number 5. E-cigarettes really are just for nicotine. Bemis claims that e-cigarettes are easily adaptable to all kinds of substances, notably marijuana, and potentially crack cocaine.

That’s so untrue it is laughable. Bemis appears to be confusing e-cigarettes with devices specifically designed for heating oils or dried ground solids. There are devices designed to vaporize hash oil or solutions of THC. These devices need to reach a temperature of 157 C. (more details)

However, most e-cigarettes operate at about 60 C because they are heating a glycol-based liquid to the vaporization point. (more details)

Therefore, commercially available e-cigarettes are of no use in vaporizing cannabis or other substances. About the only part of an e-cigarette that can be used with one of those other devices is the battery.  So to draw a parallel, my camera uses AA batteries.  So does my TV remote control. Does that mean that my remote control can be easily adapted to take pictures?

Number 4. E-cigarettes are not “Big Tobacco”. Major tobacco companies are relatively late arrivals in this market. Today’s e-cigarettes were invented (or re-derived, depending on who you ask) by a Chinese pharmacist and had been sold world-wide for several years by mostly small, independent companies, when Lorillard purchased Blu ecigs in 2012, the first major move into the market by a traditional tobacco company. So far, they are the only U.S. tobacco company with an e-cigarette product that is sold across the country. The other two of the biggest three tobacco companies are only just now trying out their products in test markets.

Whether major tobacco companies will take over the market remains to be seen. Ironically, the tobacco control activists whose mission is to destroy the established tobacco companies are screaming the loudest for strict government regulation. But if that regulation turns out to be too costly to comply with, all the small, independent companies will go out of business, leaving the market to be dominated by the established major tobacco companies.

Number 3. E-cigarette marketers are not claiming e-cigarettes are “safe” as Bemis seems to believe. They can’t make health claims without running into trouble with the FDA. And furthermore, e-cigarettes don’t need to be 100% safe. They only need to be much safer than the product they are replacing, which they are. The concept is called harm reduction. If people do not choose to stop doing something dangerous (or, as it is commonly phrased, they “cannot quit”), then offer them a way to reduce their health risks. One example of harm reduction in practice is lowing the severity of auto accident injuries by installing seat belts and air bags in cars. Another example of harm reduction is offering methadone, an opiate that doesn’t impair cognitive processing, as a substitute to heroin addicts.

Tobacco harm reduction (THR) is practiced by replacing the most hazardous delivery mechanism, cigarette smoking, with nicotine from other sources. These can include e-cigarettes, smokeless tobacco products, and even pharmaceutical nicotine replacement therapy (NRT) products used indefinitely as a substitute for smoking.  Decades of research show that smokers who switch to modern smokeless tobacco products have do not have a detectably higher rate of any cancer compared to any other former smoker. This is also true for strokes and heart attacks.

And while Bemis mentions that “studies have still showed carcinogens in the vapor that gets inhaled,” that’s not quite right. In a 2009 study, the FDA found some tobacco-specific nitrosamines (TSNAs), in the liquid of a few samples. The largest measure of TSNAs reported in liquid has been 8.2 ng/ml, equivalent to the amount in a medicinal nicotine patch.  These presumed carcinogens are present in such tiny quantities that they are “roughly equivalent to 1/1000 of the concentration of TSNAs in modern smokeless tobacco products

There is zero evidence that “secondary vapor has been shown to cause respiratory and disease problems” as Bemis declares. Even the few reports that claimed to show harmful results of inhaling primary vapor turned out to be lies. (more details) Dr. Igor Burstyn, who conducted a comprehensive review of scientific studies of e-cigarette liquids and vapor, pointed out, “exposure experienced by bystanders is clearly very low compared to the exposure of vapers, and thus there is no reason to expect it would have any health effects.” 

Number 2. E-cigarettes cannot be marketed as a smoking cessation tool, as Bemis claims, without running afoul of the law — specifically the drug marketing regulations of the FDA. E-cigarettes are marketed as a consumer product and as an alternative to smoking. If you replace all of your smoked cigarettes with e-cigarettes, and you no longer inhale smoke, you really have stopped smoking. Really! Even your doctor will agree once he sees that your lung problems are clearing up, you’re using your asthma inhaler less often, and you seem to have more stamina. (further reading on this)

Number 1. Most intelligent readers recognize “Kids love ’em” as nothing short of pure propaganda. According to Bemis, this is because e-cigarettes can be purchased in pleasant-tasting flavors, and only kids like flavors. Does anyone really believe that adults don’t enjoy flavors? Do adults order unflavored ice cream at the 31 Flavors store? Chew unflavored nicotine gum? Chew unflavored any kind of gum?

Most new e-cigarette users try to find a liquid that matches the flavor of their favorite brand of tobacco cigarette. When that proves impossible, they may try a fruit, beverage, or candy flavor, just as an experiment. They often come to prefer the more pleasant flavors and to find tobacco flavors distasteful. Many who switch to interesting flavors report that when they later tried to smoke a real cigarette, they were unable to take more than one puff because they now hated the taste. That would make pleasant-tasting vapor one of the first reported potentially effective measures against relapsing.  While we do not have great data about most e-cigarette users, we know that a majority of those who become dedicated enthusiasts use fruit, beverage, or candy flavored liquid.

I will give Bemis credit for one thing. At least he used the word “tried” rather than “used” when talking about the e-cigarette statistic that doubled among middle school and high school students. Because that’s all it was. Ever tried. Experimentation. We don’t know what proportion of students were using them regularly, because the only question the CDC asked related to frequency of use of e-cigarettes was whether they used one during the past 30 days, on at least one day.

When CDC referred to what they collected data on as “use”, they implied daily, or at least frequent, use on an ongoing basis. We do not know how many kids use one daily. All we know is that it is much lower than the “ever tried” category and even lower than the 2.1 percent of kids who tried an e-cigarette at least once during the 30 days prior to the survey.

Now here is something for Tom Bemis to consider. His presentation was entertaining, energetic, and sounded sincere. However, as detailed above, he is very wrong about a number of verifiable facts. What if, by promoting all of this false information, Bemis has managed to convince even one smoker who was considering switching to an e-cigarette that it would not be in his or her best interests to do so?

And what if that smoker is not inclined to quit without a substitute, even after trying medically recommended methods dozens of times? And what if that smoker develops a tumor or has a heart attack or stroke that would have been avoided if he or she had just stopped inhaling smoke a little sooner? Does that make Tom Bemis morally responsible for their misfortune?

It’s a possibility.

Lorillard’s comments to FDA CTP re possible menthol cigarette ban, a work of art

by Carl V Phillips

[Before praising a document whose primary intent is to keep menthol cigarettes legal, it seems worthwhile to start with clarification and disclaimer: As those of you familiar with the NGO that publishes this blog know, CASAA does not take positions on the regulations of cigarettes. As those of you familiar with my work know, a lot of my current research is about modeling consumer responses to changes in the tobacco market, and as a few of you know, one of my results is about the impact of a menthol ban on the black market and thus on overall consumption.  This post is not about favoring any particular approach to  cigarette regulation nor related to my modeling except to the extent that it covers some of the same ground.]

I suspect that few of you have seen Lorillard’s response to the FDA Center for Tobacco Products filings and request for comments that relate to a possible ban of menthol flavored cigarettes.  But if you have any interest in legalistic scientific documents (or is that scientific legal documents? I am not quite sure what to call these) you are going to want to read it.  It is really a tour de force as such things go.  If there is such a thing as true art in that genre, this is it.  (Links here under 10.21.2013; the ANPRM document is shorter, summarizing details from the other, so it gets to the interesting points quicker and it is more readable.)

The most notable bit of content, from where I sit and for the purposes of THR (see! this is not off topic), is the observation that FDA is not holding itself to the standards it imposes on others, particularly regarding MRTP filings.  The MRTP process is the path that theoretically allows tobacco product manufactures to make claims that a particular product is lower risk than another, as well as a path to introducing new products that meet the standard of being lower risk.  I say “theoretically” because the standards demanded for evidence might be so onerous that nothing can ever meet them.  Some of those standards are clearly valid, like clearly stated methodology and reproducibility of the analysis.  Others are naive, simplistic, or wrong, like blindly favoring some types of studies over others.  Lorillard shows convincingly that FDA fails to adhere to these standards (as well as various standards of good science).

Lorillard argues that when the same phrase is used in multiple places in a piece of legislation — the phrase in question being “scientific evidence” — it must mean the same thing.  FDA has created a very high bar for that in the MRTP process but, the argument goes, is badly falling short of that in issuing their analysis of menthol cigarettes.  This creates a very interesting situation.  Of course, the easy way out is they might just fold on the menthol point and not do anything that would force this contradiction to be litigated.  The best outcome for consumers and public health, though, would be for them to concede (or be forced to yield) that the standard is far too restrictive and legalistic, and effectively prohibits doing science.  Science is a process of trying to figure out the truth as best we can, in contrast with some legalistic processes, which are more about dotting all the i’s and jumping through hoops.

A central argument is about FDA’s conclusions that menthol trialing increase the probability of becoming a smoker compared to trialing non-menthol cigarettes, and as well that menthol increases “nicotine dependence” and reduces success of smoking cessation.  Lorillard is clearly right that the studies cited in support of the first of these claims have important flaws.  They have been used to try to quantify the claimed increase, but are clearly not adequate to do that.  In particular, the studies seem to be claiming (to the extent that they can be interpreted based on the paltry bit that is published — a great deal of what would be needed to make sense of them has not been published) that all association observed is causation, which is absurd.

But here is the thing about the main claim that FDA wants to make:  Anything that lowers the quality of a this tobacco product category for some users (without increasing it for others) will tend to discourage some people from starting to smoke and encourage some people to quit.  (The question about “nicotine dependence” is rather different.)  If menthol flavored cigarettes were caused to not exist, there are some people — characterized by (a) close to indifferent about preferring smoking or not smoking and (b) like menthol — who will be tipped from smoking to not smoking.  Of course, since more people dislike menthol than like it, if menthol flavoring were required for all cigarettes, there would be an even greater effect.

FDA faces two problems in employing such scientific reasoning, though:  First, as Lorillard points out, they basically preclude it and demand only regimented forms of data collection — no matter how much less informative that might be than other sources of knowledge — rather than actual scientific analysis.  Second, the logic requires acknowledging that people smoke because they like it, some people use menthol because they like it, people quit because they prefer to quit, and such.  This runs directly contrary to the tobacco control industry’s notions of why people smoke (and why they use menthol), which is basically they are possessed by demons.  I actually think that FDA is coming to grips with the fact that they cannot continue to endorse the demonic possession fiction and make defensible policy, but they are not quite ready to step up yet.

You might have noticed my tortured phrasing, “If menthol flavored cigarettes were caused to not exist”.  This was a recognition of the fact that a ban would not actually cause this.  Lorillard also argues, at length and quite convincingly, that banning menthol cigarettes would cause a huge boost in black market sales, and this would have all kinds of bad consequences.  The problem with the black market for society (as opposed to the problem it poses for manufacturers and governments, taking away their profits) summarizes to the truism (my words, not Lorillard’s) that once you ban something, it is impossible to regulate it.  In this case, it means that quality probably decreases (possibly including greater health risk), price decreases (due to lack of tax payments), and the merchants have no reason to avoid selling to minors.

Circling back to the implications for THR-related policy, Lorillard is arguing that all consequences need to be considered.  For MRTP applications, manufacturers are required to assess the effects not just on those who follow the script (switching to a lower risk product) but those who do not (non-users who avoid high-risk products but are inclined to use the low risk product), and show there is nothing that would be considered a problem (though there is no standard for assessing that).  It is a standard that has everyone scratching their head about how to do the assessment.  If FDA is held to this standard for banning menthol, it is difficult to see how they could possibly meet the burden.

Further on this theme, Lorillard argues out that FDA mysteriously changes back to a “we just don’t know enough” attitude on the question of whether consumers perceive menthol cigarettes as being lower risk.  Lorillard points out that the evidence supports the conclusion that there is no such perception (and, indeed, that menthol is perceived as being more harmful), much more solid evidence than supports some of the other claims that FDA declared to be true.

The good news would be for FDA to see the light about their unmeetable standards of evidence, and realize that when they try to do science they do not follow simplistic rigid rules like those, and so relax the MRTP application burden.  The entire Lorillard filing, even though it primarily pursues different mission, is a massive indictment of the CTP’s current relationship with scientific inquiry, as it exists on paper, that effectively prohibits action of any sort.  Unfortunately, experience suggests they will just back off on menthol to avoid the fight.

One additional point:  There is a great subplot about peer review built into this.  Peer review is correctly interpreted as the process by which scientists etc. get the input of others to make their work better, and thus relies on the assumption that everyone is in pursuit of the truth.  The term is often debased and used to refer to a gatekeeping process for journals that in public health and many other fields is more about politics than real peer review.  But whichever interpretation, Lorillard makes the observation, in effect, that FDA only pretended to have their material peer reviewed: They collected comments, but when some of those comments pointed out fundamental problems with their analysis they neither attempted to take advantage of the advice to improve their work, nor treated the criticism as gatekeeping and removed the bits that the reviewers objected to.  This is just one more reason why the phrase “this is peer reviewed” is close to uninformative about scientific quality without further clarification.

Finally, I will note that there are some points in the Lorillard analysis which I disagree with.  But this post is already too long to go into those.  Besides, pointing those out is not my job (unless someone wants to hire me to do it :-).

American Lung Association is assigned the role of chief liar for ACS’s Smokeout

by Carl V Phillips

The American Lung Association (ALA) may soon surpass the American Cancer Society (ACS) as the most dishonest anti-public-health charity in the country.  It would be one thing if their position were, “smokeless tobacco poses absolutely no threat to the lungs (and decades of research show that it poses very little other risk also), while e-cigarettes might affect the lungs and have greater unknowns, and therefore we recommend that those seeking a low-risk substitute for smoking stick to smokeless tobacco.”  But, of course, it is not.  They take a dishonest anti-public-health position on smokeless also.  It is that which serves as the proof that they are not genuinely concerned about e-cigarettes — they just do not want smokers to have a pleasant way to quit smoking.

ALA’s latest lies blitz came out during yesterday’s Great American Smokeout, an ACS project to encourage people to quit smoking.  This project is obviously fine on its face, but ACS’s opposition to THR, the method that best helps smokers quit, demonstrates their fundamental dishonesty on the subject.  They are more interested in punishing smokers than helping them.  And, of course, both ACS and ALA depend on smoking for a lot of their income, both individual donations (“In memory of the dear departed, who would still be with us but for the anti-THR liars who kept him smoking, the family asks for donations to the ALA in lieu of flowers”) and far more important, big government grants and corporate donations.

If you want to read some truth about the Smokeout, please check out CASAA’s press release (which, sadly, did not go viral).

Interestingly, though, ACS seems to assign the role of lying about THR on this Smokeout day to their junior partner and pet, the ALA.  Perhaps they are starting to realize that the lies are going to haunt them.  Thus, we have statements, or more accurately, a series of lies, from Erika Sward, associate vice president for national advocacy for the American Lung Association.

She throws in all the usual lies about there being no regulation of e-cigarettes, that we do not know what is in them, that flavors are designed to appeal to kids, and such.  She demonstrates her fundamental ignorance of the topic by claiming that one company sued the FDA in 2009 and it was because they did not want to be regulated (what they did not want, of course, was for e-cigarettes to be banned).  Further ignorance (or perhaps a blatant lie) can be found in her claim that there are no state regulations of e-cigarettes (yes, really, she claimed that).

The ALA’s core lie in their current disinformation campaign seems to be this one:

Some manufacturers have promoted the devices as a safer alternative to regular cigarettes and as a way to quit. But there is scant evidence to support those claims, Sward said.  “The FDA has not found any e-cigarettes to be safe and effective in helping smokers quit,” Sward said. “All of that is based on the companies’ own assertions. What the American Lung Association sees is a new product but the same industry and the same old tactics.”

Of course, no manufacturer can make health or cessation claims in the USA, despite the fact that there is overwhelming evidence that such a claim would be accurate.  Of course that “FDA has not found…” bit is literally true — the classic tactic of the worst kind of intentional liar is to find something that is literally true but causes the reader to believe the falsehood that the liar wants to communicate.  You know what else the FDA has not found to be safe and effective for helping smokers quit?  Going cold turkey, which is the method that is most often successful, by far.

And, of course, it is not the companies that are making the claims about low risk and effective cessation.  It is not merely that the companies are not responsible for “all” such claims — they are not even, in any way, tied to most of them, which come from independent researchers, consumers, and CASAA and other consumer advocates.

The whining about the industry might have deserved the benefit of the doubt if ALA and ACS had embraced e-cigarettes during the many years that the “same industry” was completely uninvolved in the category.  If that had been the case, we might conclude that while they are more interested in hurting the tobacco industry than in helping smokers (or, perhaps more likely, failing to hurt the tobacco industry, but using them as the devil-figure to support fund-raising), they might still want to help smokers.  But given their opposition to THR products in general, this is obviously not the case.  They still want to use “the industry” as a devil for fundraising, of course, but it is clear that they also want smokers to suffer (which is also good for fund-raising).

I recently heard an authoritative rumor that a very high executive at one of these organizations (that is as much as I will say about the source) was caught declaring that their hostility toward e-cigarettes comes because, “we cannot fund-raise for s**t off of them”.

So, everyone, what do you think (just talking off the top of my head here):  Is it time to organize a boycott of the ALA?  If they are willing to go along with ACS hanging them out as their surrogate liars, they are asking for it. I would bet that the friends and families of the millions of Americans who practice THR make a few donations to them.

MD Anderson Cancer Center lies about and e-cigarettes and other tobacco products

by Elaine Keller

In a press release dated November 7, 2013, the University of Texas MD Anderson Cancer Center purported to debunk myths about tobacco. However, the end result was to perpetuate some myths and to introduce a few new ones.

The first heading is Tobacco Myth #1: Almost no one smokes any more. Lewis Foxhall, M.D., vice president for health policy at MD Anderson makes a good point that although the prevalence rate has been reduced from 42% of adults in 1964 to 19% of adults in 2011, the number of adults who smoke is still too high.

The details tell a more interesting story, though.  Most of that decrease happened a long time ago, and the number of smokers hovered around 46 million from 1990 through 2009, with the small reductions in the percentage of the population who smokes matched by increases in the size of the population.  It turns out that the decrease in the percentage roughly matched the increase in the popularity of smokeless tobacco as a substitute for many years, though it was difficult to conclude with confidence that THR was responsible for the progress. This changed when use of e-cigarettes began rising, and the number of adult smokers began dropping in 2010 (to 45.3 million) and continued into 2011 (to 43.8 million). (Source)

Continuing under the first heading, long-time ANTZ Ellen R. Gritz proceeds to perpetuate the myth that “the exorbitant and seemingly unlimited advertising dollars spent by tobacco companies” is the driving force behind youth initiation of smoking.  The obviously-false premise that no one actually likes to use tobacco, forces the ANTZ to concoct the tired myth that advertising must exert some magical power over people.

The basic claim is silly on its face, and the details make it worse.  Tobacco advertising is one of the most highly regulated forms of marketing. Cigarette ads were banned from television on April 1, 1970, which was a huge gift to the tobacco companies, who could save the cost of advertising without losing customers to their rivals who were also forbidden from spending much.  It is not clear that total sales were reduced much at all.  But having a large enough advertising budget became pretty easy, since without buying television ads, but far the most expensive advertising, and later not being able to buy many other types of ads, there was not all that much to spend on.

And where are kids seeing these ads?  According to Ad Age Media News, R.J. Reynolds states that “the company will only advertise in magazines where at least 85% of readers are 18 and older when data are available on readers older than 12. For magazines that offer only data on readers 18 and older, the company buys ads if the median age of the audience is 23 or older. Lorillard, the third largest maker of cigarettes, has similar restrictions on its magazine advertising. The largest tobacco company in the U.S., Philip Morris USA, a subsidiary of Altria, does not advertise tobacco in print, according to spokesperson.” (Source)

The next heading, Tobacco Myth #2: e-Cigarettes, cigars and hookahs are safe alternatives implies that smoking tobacco cigarettes is no more hazardous than using any of the three named alternatives. The press release continues, “Fact: All tobacco products, including e-cigarettes and hookahs, have nicotine. And it’s nicotine’s highly addictive properties that make these products harmful.”

False: Nicotine is not what makes smoking harmful. What makes smoking harmful is the tar (solid particles in the smoke), carbon monoxide, and other chemicals of combustion that cause the lung disease, heart attacks, strokes, and cancers linked to smoking. Nicotine does not cause any of these diseases. In addition, this blog has repeatedly explained the several reasons why the “highly addictive” is also nonsense.

Nicotine is not 100% safe — it poses basically the same risks as caffeine and other mild stimulants. It does cause a temporary increase in heart rate and blood pressure, but it does not cause hypertension. Nicotine is probably harmful to a developing fetus (though the research on the effects of nicotine ex-smoking is limited) and it is claimed to have detrimental effects on the adolescent brain, but the support for this is quite thin.

Cigars and pipes are intended to be smoked without inhaling. Research shows that smoking-caused disease risks are lower by about half among cigar and pipe smokers who don’t inhale than they are among cigarette smokers. E-cigarettes do not produce smoke at all, and as far as we can tell are close to harmless for a non-pregnant adult.  Moreover, nicotine also has beneficial effects. (Source)

Under the same heading, Alexander Prokhorov, director of the Tobacco Outreach Education Program at MD Anderson tells some whoppers. “The tobacco industry comes up with these new products to recruit new, younger smokers, and, they advertise them as less harmful than conventional cigarettes.”

First of all, e-cigarettes were invented (multiple times) as anti-smoking efforts by people outside the tobacco industry, most recently by a Chinese pharmacist  who wanted to quit smoking, but was unable to tolerate nicotine abstinence, even after watching his father die of lung cancer. It is even more absurd to make that claim about cigars and pipes, which predate cigarettes by centuries.

And if Prokhorov does not know that e-cigarette (and cigar and pipe tobacco) companies cannot advertise their products as less harmful than conventional cigarettes, I have to wonder: On what planet has he been living? If an e-cigarette company makes health claims, the FDA can order their products to be removed from the market until after they undergo the lengthy and costly New Drug Approval process. What company would not simply comply with the request to remove the health claims?

Prokhorov’s last statement, “But once a young person gets acquainted with nicotine, it’s more likely he or she will try other tobacco products,” is the classic argument of someone who knows there is nothing wrong with the drug he is attacking. There is no basis for the belief that e-cigarette use leads to smoking conventional cigarettes. The same fear was expressed when the FDA was considering approval of nicotine replacement therapy products. Despite the fact that nicotine patches, gum, and lozenges were not only approved, but became available over the counter, there are no known cases of new nicotine addictions attributed to their use. Researchers looked at the issue as it relates to e-cigarette use and determined that due to the slower elevation of nicotine in the blood stream from e-cigarettes, they are unlikely to hook new users. (Source)

“At this time, it’s far too early to tell whether or not e-cigarettes can be used effectively as a smoking cessation device,” lied Paul Cinciripini, professor and deputy chair of behavioral science and director of the Tobacco Treatment Program at MD Anderson. That will come as surprising news to the hundreds of thousands of smokers who have effectively used e-cigarettes for smoking cessation, many of whom were very interested in quitting but found that other options all failed them.

Under Tobacco Myth #3: Infrequent, social smoking is harmless, David Wetter, Ph.D., chair of health disparities research at MD Anderson states, “If you are a former smoker, data suggests that having just a single puff can send you back to smoking.” If this overblown claim were true, it stands as a great argument for switching to e-cigarettes. Among those who totally switch to e-cigarettes, the desire to take that one puff is low, and indeed, those who use e-cigarettes that do not remind them of smoking (particularly by using non-tobacco flavors) find that when they try that single puff on a cigarettes, it is terribly unappealing.

Now if the anti-nicotine crowd manages to convince a gullible public and captured regulators that all those shelves of yummy-sounding flavors exist for the sole purpose of addicting non-smoking youth to e-cigarettes, such flavors will be banned. In that case, it is possible that former smokers will be more vulnerable to this relapse scenario because they will be stuck with e-liquid that tastes like tobacco and reminds them of smoking.

But the press release saved the biggest whopper for last: Tobacco Myth #4: Smoking outside eliminates the dangers of secondhand smoke. “Even brief secondhand smoke exposure can cause harm.”  First, if they really believed this, they would be pushing hard in favor of e-cigarettes, which do eliminate the dangers of secondhand smoke. But, of course, they know this is not really true. The reduction in air quality from outdoor smoking is far less than the reduction in air quality from being inside, where the concentration of toxins (entirely apart from smoking) is many times as high as it is outside, even if there is a whiff of cigarette smoke in the air.

William Saletan wrote about the topic in a Slate article, having looked at two studies of outdoor smoke exposure recommended by former EPA scientist James Repace as proof of the dangers of outdoor cigarette smoke exposure:  “Again, the data confirm common sense. The more open the space and the farther away you are, the lower your smoke exposure. To get the kind of exposure you’d suffer indoors, you have to stand within two feet of the smoker.  Move seven feet away, and you’re “close to background,” i.e., breathing normal air. I recommend greater distance than that, just to be safe. But you don’t need to ban smoking throughout Central Park.” If people at MD Anderson make a habit of keeping their face within two feet of others when standing outdoors (assuming they are not planning to kiss them), it might be an even more anti-social habit than their habit of lying to people about THR.

The most random observation from my recent meetings

by Carl V Phillips

As a follow-up on my Truth and Reconciliation post, I wanted to add an observation that has struck me about potential common ground, and that after many observations feel an irresistible urge to write about.  (Why is such an urge at all unusual?  Read on.)

I have spent a lot of time at gatherings of public health people, as well as “public health” people and ANTZ.  I worked all day in their company for many years.  I have also spent a lot of time at gatherings of tobacco industry people, in their workplace, at conferences, etc.  I have obviously also been around many gatherings of other people, particularly Americans but also those from many other countries.   Thus, I am able to make the following observation and, in the spirit of Sunday’s post, declare it with as much confidence as would be possible from some fancy statistical analysis:

Men who work in public health and “public health” have in common with men who are in and around the tobacco industry the fact that they have approximately 100% incidence of hand-washing after going to the bathroom.  This contrasts with a baseline of less than 50% for Americans; the baseline is noticeably better in most other modern countries (love that American exceptionalism) but still far from 100%.  This contrast holds even if we narrow the comparison group by omitting bars, ballparks, and such, and  restrict the comparison to other people of similar social class, other places of business, other professional conferences, etc.  The baseline for those populations is better than the 50%, but still far short of 100%.  Professional “businessmen” types may actually have a worse average than bar patrons.

Naturally my data is censored — I have little data on women.  Also, I am pretty sure I have observed a similar pattern (far above average compared to the population) at vaper gatherings, but I do not recall for sure.  Perhaps someone could help me fill in the knowledge gaps.

This may not seem all that important, and of course this is somewhat a joke (the discussion, not the research results, which are definitely true), but it is not nothing.  Hand washing is an indication of basic intelligence/awareness (to know the value of it) and concern about health.  But even more, it is a concern about doing right for others, since it generally protects others’ health more than one’s own (washing your hands periodically is good for your health as well as others’, but doing it specifically after going to the bathroom is targeted at others).   Presumably  this explains why people in more sociopathic professions do not do it.  There are clearly a few flamboyant sociopaths in tobacco control, and there are undoubtedly some high-functioning ones in the tobacco business, but these are a tiny minority, as proven by these hand-washing observations.  (Kidding about that “proven” thing — all this positive talk about ANTZ had me channeling their scientific methods.)

So what can we do with this observation?  The greatest impact should be among ANTZ, realizing this point of commonality when they think that people in the industry are evil.  (Note: it is quite clear to me that they are, on average, far nicer and more honest than people in “public health” — and I do mean far, it is not even close — but this is harder to code into concrete data than the hand washing thing.)  This won’t get to the core ANTZ, of course, who do not read and otherwise try hard to avoid learning anything about tobacco use, probably realizing that it would interfere with their religion.  But the fellow travelers who have been tricked into supporting the ANTZ agenda might find the commonality interesting.

So what can those of us on the honest and truth-seeking side of this divide do with this observation?  Maybe not much.  We already would have predicted that “public health” people would wash their hands — even those who care not at all about real public health would want to put on a show of caring about it.  But perhaps this is a hook that could lead to further recognition of commonalities that could lead to accepting that truth & reconciliation concept.

Or perhaps it is useless, and I merely wasted three minutes of your day.  But it might be worst than that:  Now that I planted this observation in your head, you may not be able to resist pursuing the comparative research in populations you observe. Sorry about that.

Sunday Science Lesson: mistaking necessity for virtue in study design

by Carl V Phillips

Yes, I have written versions of this before, but I never tire of the topic, mostly because of how much damage the errors do to science and health policy.  I get reminded of it every time I travel through a European or European-influenced airport.

Most scientific knowledge (which is just a fancy way of saying “knowledge” — I am just coopting the phrase from those who try to imply that the adjective is meaningful) comes from easy observations — e.g., “there are a lot more women than men in this population” requires only looking around.  Sometimes a bit of knowledge of interest gets a bit more complicated and we need to actively use measurement instruments — e.g., “this is heavy” is easy, but “this has a mass of 44.21 kg” requires careful methods and a good scale.  Finally, something that we want to know might be completely beyond our ability to assess without complicated methods — e.g., “does a lifetime of exposure to E double the risk of disease D” requires a complicated statistical analysis of thousands of people.  The point here is that just because those methods are necessary for the latter does not mean they are necessary — or even useful! — for easier observations.

To elaborate on the concept, I will start with my favorite analogy to it:  Airports/stations need to communicate to thousands of people when their plane/train/bus leaves and where to board it, and until we all have reliable connectivity in our pockets (good realtime phone apps personalize our information and can make this all moot), this will continue to be provided using overhead displays.  These were originally written and updated by hand, and then replaced by some amazing and clever mechanical devices, and are now video monitors.  But fundamentally nothing has changed, and that is the problem, because airports are not train stations, or more particularly, flights are not train trips.

Consider what you naturally know and can easily remember when you arrive at an airport or train station.  Most obvious to you, you know your identity, which is sufficient to find your vessel (using the phone app, though it has always been sufficient to visit the check-in desk), but we still need displays which are quick to access, instantly updated, and always available.  To make the displays usable you need to know something other than your identity.  You surely know where you are going and approximately when you are leaving, and this is all you need to identify your flight.  There are seldom multiple departures from one airport to a particular other airport at close to the same time (particularly since you also easily remember which airline you are flying).  This does not work so well for trains, however, because it can be that almost half the trains leaving a station make a particular stop because every train going a particular direction passes that station and stops.

This also means there is a difference in what can be communicated via the monitors, because planes land in just one place, whereas the same train stops several or dozens of places and not all can be listed.  Thus, train stations are forced to have their passengers to drill down further and make an effort to remember something that is not quite so intuitive: the exact minute of the scheduled departure time, which is how they identify the vessels (usually along with one target destination, either the end of the line or the most major station on the way, which is intuitive to remember).

You probably see where I am going with this:  American airports and those following their style display departing flights based where they are going, alphabetically by city.  This a great system since everyone knows where they are going and is so skilled at searching by alphabetical order that they can quickly glance to the right range of the list to find the city name.  European-style airports have been designed by people who seem to think they are train stations, and list flights by the minute of departure.  This is a bad system because it requires passengers to make the extra effort to remember or check the exact minute of departure, and to step through a list of ordered numbers with varying gaps, which is much harder than alphabetical order because you cannot use instant intuition like “I am going to Philadelphia, so I will start direct my glance to 3/4 of the way through the list”.

Like a complicated cohort study or clinical trial, the train-style listing is a cost necessity under particular conditions.  But such necessity is not a virtue of the method.  “It is needed at train stations, so it is the best we can do there” clearly does not imply “it is always best.”  Similarly, “we cannot figure out whether this exposure causes a .001 chance of that disease without a huge systematic study and a lot of statistic analysis” does not mean “we cannot figure out that e-cigarettes help people quit smoking without such a study”.  Even more absurd is the “reasoning” that leads to: “we cannot figure out which medical treatment works better without a clinical trial” and therefore “we cannot figure out if people like e-cigarettes without a clinical trial”.

Needless to say, the latter statement in each sentence is obviously false, and the proposed equivalences are moronic.  Just because the extra complication and effort is needed to ask a hard quantification does not mean that it is needed for an obvious qualitative conclusion.  Anyone who actually understands science at the grade-school level realizes that different research is needed to answer different questions.  It makes a bit more sense to use a clinical trial to try to understand adoption of THR than it does to use a particle accelerator to do it, but not a lot more.

Yet, of course, it is just such innumeracy that appears in the public discourse.  Just as habit leads many people to ignore common sense and insist that train-style displays at airports make sense, “public health” indoctrination also eliminates the common-sense level science that is taught in grade school.  It is reassuring to note that the claims about a particular type of study always being best, or even merely always being needed, are not made by actual scientists.  They always come from political activists or medics, and occasionally from incompetent epidemiologists (not actually a redundant phrase — just close to it).

I think this analysis also extends into dealing with thought-free analogies in regulation, such as “we do X with cigarette regulation and therefore should do it with products that are different in almost every way other than being tobacco” or “we require X for medicines that serve only to eliminate a disease, and therefore should require it for products that people use for enjoyment.”  I will leave that extension as an exercise.

Is heat-not-burn destined to become a serious harm reduction alternative?

by Carl V Phillips

I, along with most THR advocates, have long been a bit skeptical about heat-non-burn (HnB) alternative cigarettes.  These are devices that apply heat from some source (like an external burning coal or a heating element) other than combustion to a cigarette-like stick of tobacco, vaporizing nicotine and other constituents, but without creating/releasing all the toxicants that result from combustion.  It has never been entirely clear where in the space between smoking (which they are clearly healthier than) and smokeless tobacco or e-cigarettes (which they are clearly less healthy than) they fall, so the rule of thumb has tended to be “call it halfway”.

Previous HnB products have released more carbon monoxide than cigarettes, though less of almost every other toxicant.  You might have seen the studies of hookahs (which are a HnB device, albeit one that is not always so well controlled) that reported this, and this was also true for the mass-produced cigarette-like devices that existed some years ago (and never caught on with smokers).

But during my recent series of meetings, I had a brief conversation with someone who insisted that I would be wowed by the low toxicant profile of the HnB products that are being developed.  I have no reason to doubt the claim, though I will wait to see something concrete.  I have been promised an opportunity to do so, and will report on it to the extent I am allowed by confidentiality.

Assuming it is true, it will have some interesting implications.  The “halfway in between” level of risk was, frankly, just not good enough.  If someone was going to make a fundamental change in their choice of product, I was inclined to dig in and say “go with approximately 99% less harmful, and don’t waste your effort on something that is still really harmful”.  But what if it seems like it is 80% less harmful, but far more appealing to many smokers than a completely smoke-free(*) alternative?  That is a tough one.

(*Note:  Exactly what deserves to be called “smoke” is complicated.  I recently heard the argument that e-cigarette vapor technically meets the definition of smoke, though this depends on which definition (some it does, some it does not).  The cloud of particulates generated by a HnB is even more ambiguous.)

To date, it was never necessary to even worry about the residual risk of THR products.  The ANTZ, of course, have all their rhetoric about “net population effects”, and the FDA is now echoing that.  But for products that are 99% less harmful, that is obviously complete nonsense.  The risk is so low that it can just be rounded to zero for any practical (honest) purpose.  But something like, say, 20% as bad as smoking does not round to zero.  It is obviously enormously better than smoking for would-be smokers.  But if it attracted would-be users of the low-risk products who like smoking back to something in between, the impacts would have to be calculated.

Of course, if it attracted them to make that free choice, it would mean that it was making them happier, which by any ethical standard would be considered a good thing.  Unfortunately, real ethical standards are largely absent from the discussion of tobacco.

Sorry — I have nothing to offer today other than questions and musings.  I will try to get back to asserting definitive answers in my next post.

Big Lies and Reconciliation

by Carl V Phillips

Hi.  I’m back.  Did you miss me?

I am still not quite home from almost a month of travels (tomorrow, finally!), but am currently existing in what feels like the belly of the beast, Geneva.  Since it costs the equivalent of over $10 for a beer here, I do not exactly feel like going out partying, so one quick post to ease this blog back to life.  After numerous meetings I have reams of notes I would like to post more about, so no shortage there, to say nothing of my backlog of reading.

Numerous times over the last few weeks, including in a newspaper interview I just gave, I found myself trying to explain the Big Lie concept.  One of the problems in explaining the politics of THR to someone new to the topic is that you have to be careful not to sound tinfoil-hat to them.  Those of us in this space get used to the fact that the “public health” people do not actually care about people’s well-being — or even about their health, that (many) tobacco companies are the right side of this issue, and that most of what most people “know” about low-risk tobacco products is lies.  But if you try to explain that to someone who does not already trust you, it is pretty difficult.

The phenomenon at work here is the Big Lie:  If someone tells a minor lie, it is not all that difficult to show people it is wrong.  But if they go big, and tell an enormous lie (or body of lies, because it is impossible to isolate a single lie at that level) they might just get away with it.  People are willing to believe that someone might tell a small lie.  But they often cannot conceive that anyone would be bold enough to tell an enormous collection of blatant lies and stick with it, and so they just cannot accept that it is happening.  The thinking goes, “if this were all lies, someone would catch them at it and point it out, of course, so it cannot be all lies.”  This means, ironically, that when someone does catch them at it and point out the lies, people refuse to believe the claim.

To this day, many Americans still refuse to believe that all the stated justifications for the invasion of Iraq were lies.  It is trivial to provide evidence that there was no connection between the Iraqi government or people and the 9-11 attacks (which was clearly known at the time), that they had no WMDs (which was fairly apparent at the time and now proven beyond a doubt), that the war would hurt us not benefit us (fairly obvious at the time, rather more so now), that it would be bad for the Iraqi people, etc.  But it is very difficult for people to believe that many supposedly respectable people would tell lies so big, so bald, and so costly, so they just did not believe it.  Many still do not believe it, because it is hard to believe and even harder to admit that you were so badly fooled in the first place.

By contrast, give misinformation (you will call it sloppy miscommunication or a lie, depending on your politics) like “you will be able to keep your old insurance plan” (rather than the accurate “you will be able to keep your insurer, but they must upgrade your plan to meet the new minimum standards, but don’t worry because it will be better, and also cheaper unless you are lucky enough to be among the most wealthy and healthy”) and everyone is all over it.  Little lies/errors are fun to fight about.  The Big Lie is too scary to contemplate.

Thus, the tobacco control industry, under the guise of “public health”, manages to mislead a lot of people about THR, about their real motive, and about who the real good guys are, and to get away with it.  After all, if that were all a lie, how could they possibly get away with it?

In one panel session I was on at the South Africa meetings last week (more on the meeting later, but I will note that it was a serious grown-up meeting, and this question was not just rhetorical banter), someone asked if there was any chance that the tobacco control people would be held to account and punished for all the harm they are causing.  I responded (with all due caveats that what was suffered in that country was of an entirely different level horror and that I was not suggesting equivalence) that the best we could hope for was Truth and Reconciliation.  No American will ever be punished for the crimes that got us into Iraq or that were committed there (punishing Private Manning for exposing some of those crimes does not count, obviously).  And no one will be punished for the even greater loss of life caused by anti-THR.

Thus the Truth and Reconciliation approach is the only sensible strategy for us.  The tobacco control industry has lost the war, and will not last another generation, but the dead-enders will keep fighting and causing harm until their dying day if their only alternative is to admit that their core messages and mission have been lies since at least the start of this century (let alone to stand trial for it, which would be both fair and impossible, of course).  I am not suggesting that there can be any formal committee or confessions, obviously.  But as more and more “public health” people, governments, and others come over to the truth and recognize that the 21st century will see a world with billions of happy tobacco users, most of whom avoid the health hazard of a lifetime of smoking, it is time to unilaterally reconcile with the dead-enders and just let them die in peace.

Don’t get me wrong.  I am not going to stop calling out their lies when it is useful for helping others understand the truth.  But often the best way to disempower your enemies (and perhaps keep them from fighting to the last breath) is to forgive them, even if it comes without them confessing to what they did.  And if the strategic advantages of that are not enough, well, just think about how deviously satisfying it is to actively announce your forgiveness of someone who has not yet admitted they have done anything that warrants forgiveness. :-)