Monthly Archives: February 2014

A paragraph-by-paragraph dissection of an unusually good article about e-cigarettes (part 3 of 3))

by Carl V Phillips

Finishing up the series that starts here, I pick up the discussion of how providing clean needles for injection drug users is a poor analogy for tobacco harm reduction.  I used it myself for a long time, but now I tend to avoid it.

First, the reduction in harm is not nearly as impressive.  Switching to smoke-free alternatives lowers the risk from smoking — which THR’s most vocal opponents insist is the absolute worst health scourge in the world — to very close to zero.  Clean needles do a lot to reduce risks that dwarf those of that “worst” scourge, but that alone leaves IDU quite dangerous.  The fact that Philip Seymour Hoffman was (presumably) using clean needles obviously was not enough.  There are more serious harm reduction strategies for IDU, that include safe injection sites, or distribution of rescue drugs combined with avoiding using heroin without someone else there to administer them.  But even in the best case, the residual risk dwarfs that of using smoking-free tobacco products (and indeed, by any reasonable measure, still exceeds that from smoking).  Thus, the analogy sells THR short.

But more important, it implicitly buys into the “everyone should quit, but [shake head, let out a sigh] if they will not, we should make it less harmful” mentality.  That is sometimes described as the philosophy of harm reduction, but this characterization is incorrect.  As I noted previously, the public debate – as exemplified by articles like the one under discussion – covers the range of opinions from A-through-P, with P being merely accepting that statement in quotation marks.  Injection drug use is, in the opinion of almost everyone (almost – keep reading) something everyone should be pushed to quit.

But if we continue a few letters beyond P, we find a recognition that THR is more like harm reduction for sexual behavior, particularly encouraging condom use.  No one in their right mind claims that “everyone should quit having sex, but if they will not….”  (I have to specify “in their right mind” because some public health advocates actively suggest abstinence is the best choice in anti-HIV education campaigns.)  Like tobacco use, sex has great benefits (for many people) and potentially great health costs that can be largely eliminated.  Yes, there are people who believe that sex is usually immoral and so pushing for abstinence, the lowest risk option, is reasonable.  But not nearly as many who have the same deranged notions about tobacco.  For both behaviors it is clear that if you get the risks low enough, abstinence not only harms happiness, but harms health also.

It is worth continuing the digression one step further, to consider the views of those who are the most genuine supporters of harm reduction for illicit drug use and sex work, rather than just using it as a rhetorical point and a way to claim broadmindedness.  They are far past P on the spectrum, and generally do not condemn the high-risk version of the behaviors even as they promote harm reduction.  They also support decriminalization of the behaviors, in sharp contrast with the P-level advocates for e-cigarettes who actively advocate further creeping criminalization of smoking.  Harm reduction is not just about health risk, but about defending people’s rights to not be punished or demeaned for their choices (whether they be high- or low-risk).  The traditional harm reduction community also includes, within the core leadership of the movement, many people who engage in those behaviors, or once did and still strongly identify with them.  By contrast, the influential people and ostensible experts who appear in the public THR debate, as exemplified by the article being discussed, include almost no one who uses tobacco products.  The exceptions tend to be when someone from CASAA (whose policies embrace the true harm reduction philosophy) or from the e-cigarette industry is allowed to have a voice.  This would not happen if the discussion were really about harm reduction.

Solid evidence about e-cigarettes is limited. A clinical trial in New Zealand, which many researchers regard as the most reliable study to date, found that after six months about 7 percent of people given e-cigarettes had quit smoking, a slightly better rate than those with patches.  “The findings were intriguing but nothing to write home about yet,” said Thomas J. Glynn, a researcher at the American Cancer Society.

The first sentence of that is so vague that it is meaningless.  The rest clarifies what it – naively – means:  We do not have useful tightly regimented experiments about smoking cessation using e-cigarettes.  That is true.  And it will always be true.  The conditions “tightly regimented experiments” and “useful” are mutually exclusive in this context.  The success of an “in the wild” harm reduction method, something that requires no formal intervention, and indeed is probably hindered by a regimented intervention, cannot be measured that way. Anyone who thinks that trial (rather than the real world) is the most reliable study to date clearly knows so little about scientific inquiry that they do not deserve to be called “researcher” (let alone “expert”).

We measure the effectiveness of seat belts in reducing harm not by putting people in seat belt clinical trials, but by observing what portion of the population use them (and crossing that with data about how much lower their risks are).  That “nothing to write home about” quip is a gross understatement.  If it were true that e-cigarettes have barely more impact on smoking than NRT, they would be a dismal failure.  But obviously they perform far better than NRT, and thus that study primarily serves to demonstrate the irrelevance of studies like that for understanding what really matters.

In Britain, where the regulatory process is more developed than in the United States, researchers say that smoking trends are heading in the right direction.

More developed?  Yes, the UK has an “indication” for THR in their medicines regulation system, which could allow for an e-cigarette to be approved as a medicine.  But none have been, and it is not clear when one will be (and it will likely be no more than one or two for a very long time).  At the same time, the national regulators arbitrarily issued a threat to ban all non-medicalized e-cigarettes in the near future, which will probably not be implemented but will be fought over.  Of course, that will become moot if Brussels overrides them and issues rules that cripple or effectively ban e-cigarettes, which is a distinct possibility despite the proponents of that action offering no cogent arguments in its favor.  If that is what “more developed” regulation looks like, we are better off taking our chances with anarchy.

“Motivation to quit is up, success of quit attempts are up, and prevalence is coming down faster than it has for the last six or seven years,” said Robert West, director of tobacco studies at University College London. It is impossible to know whether e-cigarettes drove the changes, he said, but “we can certainly say they are not undermining quitting.”

I have nothing to add to that, other than it is so nice to see real scientific reasoning in a discussion about e-cigarettes.  One wonders whether West went so far as to suggest that, though there cannot be certainty, there is decent support for the hypothesis that e-cigarettes did indeed contribute to the trend.  Such knowledge would have ruined the suspenseful movie script narrative of the article, so he might have said it and it was intentionally omitted.

The scientific uncertainties have intensified the public health fight, with each side seizing on scraps of new data to bolster its position. One recent study in Germany on secondhand vapor from e-cigarettes prompted Dr. Glantz to write on his blog, “More evidence that e-cigs cause substantial air pollution.” Dr. Siegel highlighted the same study, concluding that it showed “no evidence of a significant public health hazard.”

The first sentence of this is the leading reason why I credit Tavernise with writing a genuinely good article.  Though buried, this is really the most important thesis of the entire piece, and it takes an insightful neutral party to say it because partisans are too busy seizing scraps.

The insight is further buried by being tacked onto a paragraph about dueling interpretations of a study, neither of which actually looked at the real science.  The scientific reality is that the study was fatally flawed, and should be mainly interpreted as worthless.  This further bolsters Tavernise’s observation about “scraps of new data”, though the reader would never know just how how  paltry those scraps are because the he-said-she-said approach omits any scientific analysis.

That Big Tobacco is now selling e-cigarettes has contributed to skepticism among experts and advocates.  …blah blah blah…
“Part of the furniture for us is that the tobacco industry is evil and everything they do has to be opposed,” said John Britton, a professor of epidemiology at the University of Nottingham in England, and the director for the U.K. Center for Tobacco and Alcohol Studies. “But one doesn’t want that to get in the way of public health.”

Usually the seemingly-mandatory references to evil big tobacco in a story about THR is a tangential throwaway.  In this case, something very insightful comes out of it:  “Part of the furniture.”  It is just there.  It is there because someone put it there a very, very long time ago (we are talking about English university furniture, after all) for purposes that have nothing to do with present reality.  No one thinks about whether it ought to be there.  No one considers moving it.  It just has to be – tradition and all that, mate.

Carefully devised federal regulations might channel the marketing might of major tobacco companies into e-cigarettes, cannibalizing sales of traditional cigarettes, Dr. Abrams of the Schroeder Institute said. “We need a jujitsu move to take their own weight and use it against them,” he said.

Back to the furniture themes about how “public health” has to exert control over the dumb animals (us), and how everything good comes results from commands from the top, not from free choice.  Still, I have to think that Abrams is clever enough to know that large successful corporations are not large and successful because they are stupid enough to let their strength be used against them.

Perhaps what he really meant is leveraging their inclination to promote their low-risk products at the expense of cigarettes (not at the expense of themselves).  That makes a lot of sense.  One could go further and speak of assisting their organic efforts to promote the alternatives.  This is certainly part of the most effective road toward greater THR.  But many anti-industry activists (not so much “advocates” and definitely not “experts”) have hardened their violently anti-THR positions (“skepticism” grossly understates it) because of this.  The A-through-P debate has thus become even more impoverished because the only acceptable opinions about the role of “Big Tobacco” are the ones embedded in the furniture.

And finally:

“If we make it too hard for this experiment to continue, we’ve wasted an opportunity that could eventually save millions of lives,” Dr. Siegel said.

Dr. Glantz disagreed.

“I frankly think the fault line will be gone in another year,” he said. “The evidence will show their true colors.”

Siegel is obviously correct.  Glantz scores about 1/4 correct:  The evidence will show more-and-more over time, of course, as he says.  But he is wrong in believing that very much new will be learned this year.  His innuendo that the new evidence that will somehow be contrary to all the evidence so far is about as anti-scientific as you can get (call it faith-based Bayesianism: having such a strong prior belief that, no matter what the evidence says, your posterior believe is still that all future evidence will show you are right).  Perhaps “genuinely delusional” needs to be added to the list of hypotheses, alongside “sociopath” and “senile”.  But most wrong of all, as he would know if he could correctly analyze even himself, is the notion that the fault line will not be gone.  He and his tiny cabal of extremists will say the same thing in February 2015 (and 2016, and 2017…) as they are saying now, no matter what happens in between.

And, unfortunately, the press will still be reporting their rants as if they represent an expert view.  Even in the surprisingly good articles.

A paragraph-by-paragraph dissection of an unusually good article about e-cigarettes (part 2)

by Carl V Phillips

Continuing from yesterday’s post dissecting this NYT article by Sabrina Tavernise, we pick up with:

Pessimists like Dr. Glantz say that while e-cigarettes might be good in theory, they are bad in practice. The vast majority of people who smoke them now also smoke conventional cigarettes, he said, and there is little evidence that much switching is happening. E-cigarettes may even prolong the habit, he said, by offering a dose of nicotine at times when getting one from a traditional cigarette is inconvenient or illegal.

As noted previously, Glantz differs from some e-cigarette “pessimists” in his sociopathic willingness to repeat obvious lies.  Most notably, there is a huge amount of evidence about switching.  More subtly, there is no basis for claiming most people who vape are also still smoking.  We know that most smokers who have tried an e-cigarette are still smoking, contrary to the “they are a miracle” view, but we have relatively little information on how many e-cigarette users (by any normal interpretation of the term — i.e., not merely someone who has tried one or takes a puff on one periodically) still smoke.  The spotty evidence that exists suggests that most who have become regular e-cigarette users have become non-smokers or have moved far in that direction.

As a minor aside, it is worth noting that in some places, the verb “smoke” is used to refer to vaping an e-cigarette, but in the USA it tends to only show up when the author only did five minutes of research before claiming expertise on the topic (e.g., most local news reporters) or by someone who thinks that smoking is evil and wants to extend that to vaping.  Though it is not presented as a direct quotation, this paragraph appears reflect Glantz being in the latter category.

The last sentence is an out-and-out confession that tobacco control, and “public health” in general, is not about helping people, but about demanding obedience and intentionally hurting people if they are not obedient.  Basically it says, “we intentionally harm smokers, such as by limiting where they can smoke, for the purpose of lowering their quality of life so much that they are better off obeying our diktats.  E-cigarettes offer a way to relieve some of the imposed suffering, and we can’t have that.”  Of course, the same can be said about NRT, but is not.

That sentence, and the paragraph in general, illustrate a point about those who accept or even embrace e-cigarettes, but are still part of “public health” or the medical industry rather than really believing in the principles of harm reduction:  Glantz tells these lies because if they were true, his fellow “public health” people would conclude that e-cigarettes are bad.  But a real supporter of harm reduction — and indeed, any decent human being who actually cared about people — would still conclude e-cigarettes are good.  Even if the all lies were true, it would still be the case that some smokers are freely choosing to switch completely to e-cigarettes (good); some smokers, who now can choose to smoke, vape, neither, or both, find that “both” is the choice that is best for them (also good — those making that choice must like it better than just smoking); almost all of those choosing “both” are smoking less (good for their health); and the harm suffered by smokers from not being able to smoke in certain circumstances is also reduced (good, assuming you actually care about people).

Harm reduction inevitably increases total consumption; lower the cost of something and more people will consume it.  For THR, this primarily means that as low-risk tobacco products are developed and people understand them, there will be more total tobacco users.  Some people who would have been abstinent from all tobacco in a world without e-cigarettes — including some who would have never smoked at all — will decide to become vapers.  But in the weird world of tobacco politics, this has an unusual implication:  One of the harms suffered by smokers is having to go outside for a smoke, and smoke-free alternatives reduce that harm too.  The inevitable result of harm reduction, then, means that since smoke-free alternatives lower the cost of smoking a bit, they will cause some smoking that would not have otherwise occurred (albeit, probably very little).

In the “debates” that you see in the newspaper, almost everyone represented is of the opinion that this outcome is wholly bad, differing only in what they think (or pretend to think) about how this cost compares to the benefits.  The opinions that are allowed into the public debate cover the spectrum of views from A (abject hatred of all tobacco products and users, and a fantasy belief they can both be eliminated) through about P (reluctant acceptance that people will use tobacco and a belief that it is not too terrible, so long as it is low risk). Often there will be one line of praise from an enthusiastic user or shopkeeper who is at Z (though often only for e-cigarettes, and he is closer to A for other tobacco products).  Every so often there will be a technical acknowledgment of the benefits of nicotine.  But completely missing from the institutionally sanctioned “debate” is anyone who believes that something that makes people happier overall is good, even if it makes them less healthy compared to abstinence — which is to say, anyone who truly believes in the philosophy of harm reduction.

I will come back to this.

What is more, critics say, they make smoking look alluring again, with images on billboards and television ads for the first time in decades. Dr. Glantz says that only about half the people alive today have ever seen a broadcast ad for cigarettes. “I feel like I’ve gotten into a time machine and gone back to the 1980s,” he said.

I wonder if Glantz realizes that his recall of history that he lived through is as poor as his interpretation of study results?  No one has seen a television ad for cigarettes in the USA since the 1971, when they were banned (which means that well over half the population has not seen such an ad on domestic television). Perhaps Tavernise garbled his point and he was referring to cigarette billboards (though I do not recall seeing any of these for e-cigarettes), which did exist in the 1980s — but, um, also through the 1990s.  I suppose “senile” is a valid alternative hypothesis to “sociopath”.

Of course, that is not the main problem with the claim.  How can touting a smoke-free product that is all about anti-smoking make smoking look alluring? Those “critics” seem to never explain this, and the reporters — even when they are writing a basically solid story — do not bother to ask.

Researchers also worry that e-cigarettes could be a gateway to traditional cigarettes for young people. The devices are sold on the Internet. The liquids that make their vapor come in flavors like mango and watermelon. Celebrities smoke them: Julia Louis-Dreyfus and Leonardo DiCaprio puffed on them at the Golden Globe Awards.

I could have been charitable and skipped this paragraph, but I was so baffled about how it relates to the narrative, or even to itself from one sentence to the next, that I just had to comment.  It seems to be where some leftover sentences got dumped.

Of all the reasons that entertainers are terrible role-models, their choice to vape — or for that matter, to smoke or shoot heroin — is nowhere close to the top. Also, I would have emphasized Jenny McCarthy, who claims (contrary to reality, and at great expense to society) to have expertise on public health, rather than non-political entertainers who just happen to live on camera.  But since Tavernise did not actually go anywhere with this, it is hard to figure out what the point was supposed to be.

The first sentence is made substantive by the next paragraph:

A survey from the Centers for Disease Control and Prevention found that in 2012, about 10 percent of high school students said they had tried an e-cigarette, up from 5 percent in 2011. But 7 percent of those who had tried e-cigarettes said they had never smoked a traditional cigarette, prompting concern that e-cigarettes were, in fact, becoming a gateway.

As has been discussed extensively in this blog, these statistics have been widely misinterpreted, including by the CDC itself.  But this paragraph is worse than usual.  Notice the switching between percent of the entire population and percent of that percentage.  Most readers are going to interpret this as saying “10% had tried, and 7/10 of those had never smoked (i.e., 7% of the population had tried e-cigarettes and had never smoked)” when actually it says “a mere 7/100 of those who tried e-cigarettes had never smoked (i.e., 0.7% of the population).”  Moreover, not only is the gateway claim unsubstantiated, but is not supported by this observation at all:  Someone who has tried an e-cigarette and does not smoke is obviously not a gateway case.

“I think the precautionary principle — better safe than sorry — rules here,” said Dr. Thomas Frieden, director of the C.D.C.

That is not what the precautionary principle says.  That phrase is used incorrectly at a rate that may even exceed the misuse of “epicenter” or “socialist”.  While it is not well-defined, the actual precautionary principle basically says that we should not allow someone to inflict involuntary harms on others, particularly if the action is difficult to reverse, without first providing evidence that the harms are acceptable.  For example, the burden of proof should not be on those who fear that building massive “renewable” energy facilities causes harm, defaulting to allowing it them until someone proves it they are harmful, but rather on the builders to do the research in advance to show they are not too harmful, defaulting to forbidding it until that is established.  It is a reasonable standard for the environmental impact situations for which that principle was created.  It is not relevant to consumer products. The consumers are making a free choice that affects only themselves, and there is nothing irreversible about it.

This illustrates how “public health” treats people as adversaries rather than the basis of concern, and how the mainstream media never calls them on it.  A company that wants to site a noxious facility is in an adversarial relationship with people who might be hurt by it, and so there is a need for regulation about whether the action is allowed (as opposed to just quality control and truth in advertising rules, which are almost always appropriate) and the precautionary principle is arguably appropriate.  This does not describe choices about tobacco products (or soda, food, etc.), where the decision maker and the only “victim” of consequence are the same person.  This is perhaps the defining characteristic of the “public health” political faction, conflating individual choices with adversarial situations with imposed harms.  (Aside:  extremist “free market libertarians” make exactly the same mistake — conflating personal choices and actions that impose major external impacts — but conclude that because the former should be free, the latter should also.)

Focusing on the speaker rather than the message for a moment, here is where some knowledge about the history of THR would be useful.  The CDC and those who currently control it were blatant anti-THR liars long before e-cigarettes came along.  Everything they say about e-cigarettes needs to be filtered through that background knowledge.  Interestingly, that is not true of Glantz, who was largely silent about THR before e-cigarettes, even as he was authoring some of the most extreme anti-smoking lies.  This lends credence to the theory that he hates e-cigarettes because he genuinely believes they encourage or glamorize smoking, which he obsessively hates, or even that they just mimic it.  By contrast, Siegel was aggressively anti-THR before e-cigarettes, and that contradiction is more difficult to explain.

E-cigarette skeptics have also raised concerns about nicotine addiction. But many researchers say that the nicotine by itself is not a serious health hazard. Nicotine-replacement therapies like lozenges and patches have been used for years. Some even argue that nicotine is a lot like caffeine: an addictive substance that stimulates the mind.  “Nicotine may have some adverse health effects, but they are relatively minor,” said Dr. Neal L. Benowitz, a professor of medicine at the University of California, San Francisco, who has spent his career studying the pharmacology of nicotine.

Ok, fine.  But notice the non sequitur — another one that is common in the discussions and not just an artifact of Tavernise’s article.  The first sentence is about addiction, but the rest are about consumption, whether there is “addiction” or not.  It points out the fact that not only does “addiction” not have a real definition, but most of the time that it is used, it means nothing more than “engaging in a behavior that the speaker believes is immoral.”

Another ingredient, propylene glycol, the vapor that e-cigarettes emit — whose main alternative use is as fake smoke on concert and theater stages — is a lung irritant, and the effects of inhaling it over time are a concern, Dr. Benowitz said.

Um, sort of.  Its most common other use as an aerosol is fake smoke — it has a zillion non-aerosolized uses.  The aerosol is also used in some inhaled medicines.

Perhaps the reporter should have quoted someone with expertise on exposures other than nicotine regarding the non-nicotine aspects of the exposure.  It is true that the exposure is great enough and sufficiently novel that problems might be discovered, and it is worth watching for them.  But that conclusion, from someone who actually knows about exposures other than nicotine, is about keeping an eye on it, just in case, not the alarmist “are a concern” that feature story reporters prefer.

But Dr. Siegel and others contend that some public health experts, after a single-minded battle against smoking that has run for decades, are too inflexible about e-cigarettes. The strategy should be to reduce harm from conventional cigarettes, and e-cigarettes offer a way to do that, he said, much in the way that giving clean needles to intravenous drug users reduces their odds of getting infected with the virus that causes AIDS.

Therein lies a very interesting question.  Is THR really all that similar to injection drug use harm reduction?  And do the public health (to say nothing of the “public health”) people who support smoke-free alternatives really believe in the core values of harm reduction.  Yes and no.

The adoption of the phrase “harm reduction” in the tobacco context was a conscious reference to approaches like needle exchanges for IDU.  The comparison was certainly useful for getting the concept established, and I used it many times for a decade.  But with the term established (and with hopes of getting institutions that support IDU harm reduction to also support THR having proved a dismal failure in spite of focused efforts by me and others — another thing that is useful to know about THR), the analogy now seems to do more harm than good.

More on that in the next post.

A paragraph-by-paragraph dissection of an unusually good article about e-cigarettes (part 1)

by Carl V Phillips

Most of what gets published in newspapers about tobacco products is complete garbage, written by someone whose research and critical thinking abilities seem to be at about the level of a middle-school report.  Thus, this article about e-cigarettes in the New York Times by Sabrina Tavernise was extremely refreshing.  By virtue of that, it is a great opportunity to explore some of the common misconceptions, oversimplifications, and narrow thinking that appear in the intelligent discussion of the topic.  Dissecting the usual drivel gets pretty useless after a while, but this is different.

After introducing Stanton Glantz and his protegé and reluctant antagonist, Michael Siegel, the Tavernise continues:

These experts represent the two camps now at war over the public health implications of e-cigarettes. The devices, intended to feed nicotine addiction without the toxic tar of conventional cigarettes, have divided a normally sedate public health community that had long been united in the fight against smoking and Big Tobacco.

Reporters like to turn slow-moving, complicated, and broad political fights into movie scripts.  Perhaps this paragraph is just an example of that.  But there does seem to be a genuine misconception that the fight about THR is new, and that there is something unique here.  In reality, that fight has been going on a long time, and the “public health” political movement has jumped the shark on this and numerous other issues (“Big Food”, 20 ounce sodas, smoking in cars, helmet laws, you name it) and has lost the support of many who are genuine public health advocates and researchers.  This is important context for understanding this fight.  There is, in fact, nothing unique going on here.

Also, it is not entirely fair to the anti-THR faction to claim they are represented by their court jester, Glantz.  Many of them are just as dishonest and evil as he is, but are not cartoon villains who spout easily verifiable lies.  It probably is reasonable to use Siegel as a representative voice in the narrow fights about e-cigarettes, but he is not a supporter of harm reduction more generally, or of individual freedom.  This may make him the “public health” faction’s pro-ecig guy, but missing from this entire movie script are the many voices from outside that faction.

The essence of their disagreement comes down to a simple question: Will e-cigarettes cause more or fewer people to smoke? The answer matters. Cigarette smoking is still the single largest cause of preventable death in the United States, killing about 480,000 people a year. Dr. Siegel, whose graduate school manuscripts Dr. Glantz used to read, says e-cigarette pessimists are stuck on the idea that anything that looks like smoking is bad. “They are so blinded by this ideology that they are not able to see e-cigarettes objectively,” he said. Dr. Glantz disagrees. “E-cigarettes seem like a good idea,” he said, “but they aren’t.”

The exaggerated toll from smoking and the “preventable” trope, in this context, matter little, so I will not dwell on them.  The notion that anti-ecig activism is motivated by vaping looking like smoking is far too narrow, and falls into the movie script simplification:  That seems to be what Glantz is motivated by, but it does not generalize.  The main motivation seems to be that THR stands in the way of “tobacco-free world” goals, as I have discussed at length, and is bad for business (it hurts the revenues of institutions and individuals who depend on concerns about smoking, and to a lesser extent those who sell anti-smoking products).

Science that might resolve questions about e-cigarettes is still developing, and many experts agree that the evidence so far is too skimpy to draw definitive conclusions about the long-term effects of the devices on the broader population.

“The popularity is outpacing the knowledge,” said Dr. Michael B. Steinberg, associate professor of medicine at the Robert Wood Johnson Medical School at Rutgers University. “We’ll have a better idea in another year or two of how safe these products are, but the question is, will the horse be out of the barn by then?”

The first bit of that seems like a simple statement of fact, but it is not. Following on the issue of whether e-cigarettes reduce smoking, the incorrect implication is that research on current behavior could tell us much about that.  But then notice the unacknowledged switching from the question of smoking cessation to the question of exactly how hazardous e-cigarettes are in themselves (which, incidentally, we also will know very little more about “in another year or two”). This conflation and changing of topic is a common tactic by anti-THR activists and a common error by non-activist commentators.  These are very different questions.

Equally interesting is the “horse out of the barn” metaphor, which seems to represent a common view.  First, it illustrates the ruling class attitude of “public health”, suggesting that their job is to control dumb animals, rather than to advise free and rational people.  Second, is patently wrong.  THR products can and will be improved upon over time.  And have been: worry about nitrosamines in smokeless tobacco (probably overblown, but leave that aside) has resulted in a huge reduction in their concentration over the last few decades.  E-cigarettes will be improved and the current technology will probably be mostly displaced by others.  In the extremely unlikely event that something very hazardous is found, many people will rationally choose to switch products, as happens all the time with other goods.  There is nothing irreversible here other than the embrace of THR and the rejection of the abstinence-only orthodoxy.  That, of course, is the main motivation of anti-THR.

After a couple of paragraphs about FDA regulation:

And many scientists say e-cigarettes will be truly effective in reducing the death toll from smoking only with the right kind of federal regulation — for example, rules that make ordinary cigarettes more expensive than e-cigarettes, or that reduce the amount of nicotine in ordinary cigarettes so smokers turn to e-cigarettes for their nicotine.

Activists who trust only themselves and believe they should control people do say that (though I would not suggest they should be described as either many or scientists).  But is it even a little bit plausible?  THR will replace smoking because it lowers the risk and keeps a lot of the benefits.  It is certainly true that high taxes on cigarettes (having nothing to do with “the right kind of federal regulation”) make e-cigarettes more appealing (just as high taxes on smokeless tobacco make that approach to THR less appealing).  But in most jurisdictions, the starter e-cigarette products are not cheaper than smoking, but people are still making a rational choice to switch.

What is more interesting to people who look beyond rich countries, is the issue of offering affordable THR products to the rest of the world.  Even if there were not cigarette taxes that made them price competitive, e-cigarettes would be affordable to Westerners.  But their real resource cost is so much higher than cigarettes that they are prohibitively expensive for most of the world’s population.  Since the article is exclusively focused on the USA, it is understandable that this is not mentioned, but it is still bothersome to make such general statements about tactics when they are only relevant to a small fraction of the world’s tobacco product users.

As for reducing the nicotine in cigarettes, this madness has been a pet fantasy of a few dozen people who now have a lot of influence.  But unless the goal is to actualize Glantz’s fantasy world where e-cigarettes are used primarily as a supplement to smoking rather than a substitute, it is insane.  Smokers who just want nicotine will switch products anyway.  With less nicotine in cigarettes, some people who want to smoke will smoke more, while others will supplement (and that does not require e-cigarettes, by the way: enroll in a stop-smoking program and get free nicotine patches, slap one on, keep smoking).  And, of course, the black market will benefit nicely from being able to offer not just a cheaper product than is available legally, but one that is higher quality — that is, assuming there is not an easy DIY recipe (“I have a bottle of inexpensive e-cigarette liquid in this hand and a cigarette without enough nicotine in my other hand.  Hmm….”; possible added bonus: flavored cigarettes!).

“E-cigarettes are not a miracle cure,” said David B. Abrams, executive director of the Schroeder National Institute for Tobacco Research and Policy Studies at the Legacy Foundation, an antismoking research group. “They need a little help to eclipse cigarettes, which are still the most satisfying and deadly product ever made.”

Despite being a card-carrying tobacco controller, Abrams has emerged as one of the most cogent voices on the topic.  It is not entirely clear whether he is responsible for the unfortunate preceding paragraph, about trying to lower the quality of cigarettes.  The quote seems to endorse it, so perhaps.  But maybe he is just pointing out that these particular products are not for everyone. Somehow lost in the fanaticism on both sides is the simple fact that like the THR products that predated them, e-cigarettes appeal to some people but not everyone.  As noted above, we are missing a lot of useful data, but we do know that most smokers who have tried e-cigarettes are still smokers.  People who find them appealing — and those who breathlessly call them a miracle or the greatest health technology breakthrough since penicillin — seem to overlook this.

I will skip over the standard background paragraph on e-cigarettes and uncritical reporting of the breathless predictions about the market from the usual stock flogger (who seems to exemplify the unawareness cited in the previous paragraph).  In the interests of length, I will also break here and resume this in my next post, picking up with:

Pessimists like Dr. Glantz say that while e-cigarettes might be good in theory, they are bad in practice. The vast majority of people who smoke them now also smoke conventional cigarettes, he said, and there is little evidence that much switching is happening. E-cigarettes may even prolong the habit, he said, by offering a dose of nicotine at times when getting one from a traditional cigarette is inconvenient or illegal.

Demonization of tobacco users (or, just because it is a puff piece does not mean I cannot analyze it)

by Carl V Phillips

Vapers are delightedly tweeting this bit of satire from The Daily Mash, entitled,”Put cancer in e-cigarettes, say non-smokers.”  The conceit is that THR causes non-smokers to lose their feeling of superiority, forcing them to frequent crack houses to recapture that old feeling (a gateway theory?).  I saw it tweeted as “anti-smokers” rather than “non-smokers”, but this actually missed the point:  The characters in the story are not anti-smoking; they like smoking and its ill-effects due to the schadenfreude.

This contrasts with professional anti-smokers — or more accurately, the tobacco control industry, anti-tobacco extremists, or ANTZ — who also favor keeping tobacco use harmful, but for somewhat different reasons.  As noted from the start in this blog, anti-THR has several motives, all of them perverse, and none of them having to do with health even though the anti-THR liars cloak themselves with the title “public health”.

The anti-THR activists consider tobacco use to be some kind of moral failing or otherwise just want to eliminate it, and thus prefer to keep it as harmful as possible.  For the less-bright majority of that crowd, this is for motives as base as those in the Daily Mash story:  They are annoyed that tobacco users will not obey, and want them to suffer for their temerity.  But the smarter tobacco controllers, those who talk about “endgame” or “tobacco-free by 2030”, know that low-risk alternatives guarantee that they will fail:  So long as tobacco use is highly harmful (i.e., smoking), everyone has a good reason to quit.  While it is unlikely they will all do so, there is a chance.  But low-risk tobacco products have benefits that greatly exceed their costs, and so people do not have an incentive to quit, and sensible politicians have no reason to support measures to discourage use.  Moreover, the realization that tobacco use is becoming low-risk will inevitably cause a backlash against the entire anti-tobacco industry and their lavish use of our tax money.

But unlike the characters in the Daily Mash story, the tobacco control industry cannot ever admit their motives.  Even if they preferred telling the truth over lying (though there is no evidence that suggests this is the case), they would have to lie about this one.  The mere admission of their real motives would derail the entire enterprise.  Of course, the cannot make e-cigarettes more hazardous than they are, like the characters in the story wish, but they can try to trick people into believing that e-cigarettes and smokeless tobacco are high-risk, and thus encourage them to smoke instead.  As long as most tobacco users are smoking, the tobacco control industry can continue to profit and dream.

In a less puffy piece that also pursued the theme of people feeling superior to smokers, the New Republic called for an end to campaigns to stigmatize smokers.  It likened the stigmatization of smokers to the stigmatization of people with HIV/AIDS.  This is a valid moral equivalence.  In both cases, it is about a behavior that someone is choosing to engage in, which happens to be something that a tiny minority violently objects to as immoral.  In both cases, that tiny minority uses the health risk (and the grossly exaggerated tiny spillover risk to others) as a convenient tool for making it appear that their motives are something other than hatred.  This allows them to enlist the support of others who vaguely disapprove of the behavior, but not so much that they would deny others their free choice based on that disapproval, let alone would intentionally inflict punishment on the “sinners”.  The article seals the comparison by looking at the stigmatization of lung cancer victims.

The article fails to note that the portion of lung cancer is caused by smoking is smaller than the portion of HIV infection that is caused by various demonized behaviors.  Nor does it point out that anti-smokers are exactly the same violent and hate-fueled people as gay bashers — which of those two a particular person turned out to be is just an accident of what subculture he grew up in.

Unfortunately, some of the analysis is the article is not so good.  It suggests that tobacco control efforts have played a large role in reducing smoking, when actually almost all the credit goes to simple knowledge and rational consumer choice.  It also conflates genuine effects of smoker demonization with statistics like “Most non-smokers would be reluctant to date someone who smokes (72%).”  There are perfectly legitimate reasons for making that personal choice that do not imply a dislike of smokers, let alone a desire to inflict psychological violence on them or schadenfreude.

The hook for the New Republic story, and a companion piece, was the CVS move to stop selling cigarettes.  The quotes about that in the articles, and to a lesser extent the articles themselves, show more of the naivety about it explored in my previous post.  It is amusing that those praising the move simultaneously describe it as “courageous” and “principled” and also claim it will be good for business (or naively believed that because CVS stock price upticked, it proves it was good for business).  I suppose it is not too shocking that those innumerate people cannot figure out the laughable contradiction there.

Of course, that does not explain why removing a product from the shelves — with a predicted substantial loss in revenue — is good for business.  As I noted before, it appears that the answer is that it gets them more corporate customers for their much-higher-margin medical service businesses.  But why? Basically because the business leaders have been strong-armed by the tobacco control industry (particularly including its units in government) into pushing their medical service suppliers to not sell cigarettes.

This creates an amusing contradiction for the doctrinaire free-marketeers, some of whom praised the CVS decision as a free choice of a business in the market.  When market decisions are caused by tax-fueled campaigns to force companies to change their behavior, what exactly does “free market” mean? Also, how perfect is the market if the CVS customers who are companies make decisions based on non-market influences that would not affect individuals (there cannot be 1000 people in the country who avoid buying from CVS when they offered the best value, just because they sell cigarettes)?

But while the free-market extremists get a lot of things wrong, the core points about markets are right.  In particular, the more merchants stop selling cigarettes, the greater the profits for those who still do (volume will clearly increase, and per-unit profit will also inch up due to the reduced competition). Thus, however much political pressure there is to make the “free” decision to stop selling cigarettes, there will be an equilibrium when that is not enough to offset the available profits and cause more merchants to exit the market.  My suspicion is that the “endgame” types have no idea that this is the case.

Finally, for those who have been missing my writing about THR for the last week and a half, it is because you are not reading EP-ology, where I posted two pieces on the topic (as well as other interesting stuff).

CVS and cigarettes, an embarrassing Rorschach test

by Carl V Phillips

Presumably anyone who reads in this area is already aware that the CVS drug store chain announced that they will stop selling cigarettes and other tobacco products.  The practical consequences of this are almost nil, but the response to it are rather educational.  It is a veritable Rorschach test (though not exactly the same, since no one seems to have said “it looks like a butterfly” or likened the announcement to some bit of the female anatomy).

The immediate practical consequences of the move are:  (a) CVS will lose $2 billion/year in revenue, by their own estimate; (b) some smokers will have to make an extra stop if they want to buy both toothpaste and cigarettes; (c) C-stores and other competitors will thus gain about $2 billion/year in revenue; (d) some C-store may also increase their profit margin on cigarettes because they no longer have to price-compete with a nearby CVS.  It is probably also the case that: (e) tobacco companies will increase their profits a bit because CVS’s size allowed it to negotiate better wholesale prices for cigarettes than their average competitor.

Of course, none of those could possibly be the motive for the decision.  To the extent that I have seen cogent explanations of the motives, it appears to have happened because CVS’s biggest cash cow and growth area is not retail, but providing insurance-like services to big companies.  Apparently their clients and potential clients (presumably strong-armed by the tobacco control industry) pressured CVS into making the move.  Assuming this is true, it was a symbolic gesture in which they decided to take something away from their peon retail customers in order to please (not even materially benefit) their big corporate customers who offer much bigger margins.

Of course, that is not how they spun it to the public.  It very convenient when you can spin a sacrifice you are forced to make (in order to get some benefit) as a good thing in itself rather than a price paid.  So, of course, CVS claimed exactly that in their (transparently false) public statements — it was a principled decision because they did not feel that people should be buying cigarettes the same place they are buying medicines.

The most obvious hypocrisy in that spin has been pointed out by pretty much every commentator on the topic, even those that know little about tobacco:  CVS sells — right up front in their most prominent displays — unhealthy snack foods, “energy drinks”, candy, and so on, so this is clearly not about removing products because they are unhealthy.  A more sophisticated take on the hypocrisy comes from the observation that they are removing not just cigarettes, but smokeless tobacco.  If this were really about health, they would have kept the latter and steered would-be cigarette purchasers to this low-risk alternative.

What is most interesting, however, is how the tobacco control industry went gaga over this move that had only symbolic consequences.  The Robert Wood Johnson Foundation added it to their animated timeline of the most important moments in the history of tobacco control (and apparently did so within minutes of CVS’s announcement — not that this proves that the surprise announcement was actually an orchestrated conspiracy or anything).  Then @RWJF_PubHealth tweeted about this addition approximate once per hour, and even paid to promote the tweets (must be nice to be able to pay to get people to look whenever you update your website).

The Rorschach test tells us the tobacco control industry is so starved for anything they can call a victory that they celebrate this useless gesture.  They are beside themselves with delight that smokers who are shopping at CVS will now have to go cleeear to the nearest C-store to buy cigarettes. To the present generation of tobacco controllers, this is all they can add to the list that includes such genuinely important moments as the 1964 Surgeon General report, the groundbreaking epidemiology on smoking from the 1950s, and….  Well, actually those are really the only things that ought to appear on a story of the great moments in anti-smoking.

Of course, that RWJF timeline is not actually about successes of tobacco control (i.e., events that reduced smoking), but successes of the the tobacco control industry (i.e., events that demonstrated and/or increased their power and wealth, or inflicted punishment on tobacco users for their sins, even though almost all were inconsequential in terms of reducing smoking).  In that sense, I suppose, this was a victory for them.

While desperation for something to claim as a victory, along with boasting about their ability to exercise power, probably explain most of the TCI reaction, to some extent it is genuine innumeracy (albeit intentionally-cultivated — i.e., lie-based — innumeracy).  Notice that the above list of consequences of CVS’s move did not include “there will be less smoking”.  This is because of the obvious fact that one fewer retailer of cigarettes has absolutely no effect on the demand for cigarettes, and it is the demand that matters.  Or, as I tweeted about it, “#CVSQuits selling cigarettes. Tobacco controllers demonstrate their continued failure to understand supply is not demand by celebrating.”

Part of the core myth of tobacco control is that there is no demand for tobacco, and that the reason people consume it basically demonic possession.  So, the “reasoning” goes, since demand is not causing consumption — contrary to what anyone with a modicum of knowledge about economics or human beings would conclude — then it must be supply.  Ergo, eliminate some of the supply and you eliminate some of the consumption.

But it is not just the TCI who saw what they wanted to in CVS’s move.  NJOY and other e-cigarette companies, as well as many vapers, celebrated this as a victory for e-cigarettes.  Huh?  There are some reports that CVS specifically promised they would also not sell e-cigarettes after the removal date, though there are also contrary reports on this point.  But either way, the fact that they are removing low-risk tobacco products along with cigarettes does not exactly suggest that they will be restocking the back wall with a different low-risk tobacco product.  Moreover, it is not as if the TCI bullies who leveraged this move in the first place are going to let up on e-cigarettes, and so CVS will probably be pressured into not selling them either.  E-cigarette merchants and cheerleaders need to figure out that each restriction on cigarettes should be interpreted not as “more for us”, but as “you’re next”.

Indeed, the backlash resulting from a (very hypothetical) principled stand by CVS — were they to insist that e-cigarettes are pro-health and therefore they are going to sell them — would probably be increased as a result of them already caving on cigarettes.  Once you cave to someone’s political pressure — giving up billions in revenue to get some goodwill — they own you.  The revenue is gone, but they can still take away the good will that justified the loss, and so they have even more power over you than they did before.

So while it is possible that CVS will be stocking e-cigarettes instead, it seems ridiculously optimistic to assume they will, or even to conclude that it is more likely to happen given the removal of cigarettes than would be the case had they kept them.  And this is to say nothing of the fact that it is better to have e-cigarettes displayed next to where people are buying their cigarettes so they might spontaneously choose to try the former.  Bottom line:  What some elements of the e-cigarette community saw in the inkblot also suggests they suffer from some of the same problematic thinking as the TCI — not nearly as badly, for sure, but remarkably similar.

The final category of reaction I will note is that of every single smoker who was quoted in the mandatory “we asked this random shopper” section of news reports about the move.  Unsurprisingly, the reaction was basically, “Really? Oh well, I guess I will have to buy my cigarettes somewhere else.”  There were barely even any hints of annoyance.  You could almost hear the subtext: “My dry cleaner does not sell cigarettes. My bank does not sell them, nor does McDonalds.  Now my usual drug store won’t either.  But so what?  It is not like I can’t go to a gas station / 7-11 / other drug store / etc.”  In this population — the people who know best, after all — it never even crossed their mind that change in one source of supply would have any effect on demand.

Is a Glaxo acquisition of NJOY in the works?

[Update: Not that I expect anyone is still reading this post, but just in case:  It turns out that the Pinney move was actually a move to drop Glaxo as a client and replace them with NJOY, which was one of those classic power-politics negotiations. I have yet to see any public acknowledgment about it, but that seems to be what happened.  Thus, half the clues supporting my hypothesis turned out to not be real.  Thus this seems much less likely than I originally thought.  Still a good question about how they plan to acquire drug trial skills, though.]

by Carl V Phillips

[I should lead off by saying that I have no evidence about the speculation in the title other than what I am presenting here, and that nothing here is meant to express judgment about whether this would be good or bad, though we might address that point later.]

Making and selling fast moving consumer goods (FMCG; basically anything that you might buy in a grocery store or C-store) is very different from making and selling medicines.  In addition to the obvious matter of navigating the medicines regulatory process, the distribution network and sales methods are very different, and the manufacturing and supply chain controls are much less flexible and more exacting.

So why would NJOY, a company that has mastered FMCG manufacture and sales, show enthusiasm about pursuing medicines approval for their products in Canada and seemingly support medicines regulation in Europe?  (Note that in the USA, they remain a leader in fighting against state and local restrictions that would hurt their FMCG business and consumers, and of course were the co-plaintiff in the lawsuit that prevented medicines regulation in the first place.) Medicines approval, marketing, distribution, and manufacturer are not part of their core expertise, and are expensive skills to acquire.

By the same token, one of the reasons pharma companies have not jumped into the e-cigarette space is that they are generally not all that good at selling FMCGs, though J&J’s consumer division certainly does a good job with Band-Aids and such.

Enter synergy.  How could NJOY possibly feel comfortable jumping into the medicines space?  Perhaps because they (a closely-held company that thus could easily cut such a deal) are discussing acquisition by someone who knows how to do it.

Why GlaxoSmithKline?  Today NJOY announced that they are hiring Pinney Associates — former home of FDA’s tobacco chief, Mitch Zeller, among other players — a consulting firm that is closely associated with Glaxo.  It is difficult to imagine that happening without Glaxo’s explicit approval, and difficult to imagine NJOY making that choice among such firms unless the connection was intentional.  Glaxo also has other advantages over their competitors, including being in the NRT space (along with J&J and others, of course) and having a near monopoly on asthma and COPD drugs, the medicines products that are most similar to e-cigarettes and that could yield some cross-technologies.

Of course, all this is also compatible with some sort of strategic alliance that does not involve full-on acquisition.  Presumably Glaxo would prefer an acquisition, but it is conceivable that NJOY’s owners might prefer to keep building their own small empire rather than joining a larger one.

One advantage of truth over lies: it seldom contradicts itself

by Carl V Phillips

As regular readers know, the tobacco control industry will say anything they can think of that might further their cause, regardless of whether it is true.  The downside of this — other than the fact that it means they fit the definitions of both “sociopath” and “evil” — is that lies frequently contradict each other.

There are a million examples of this, of course.  I find the most notable one to be the claim that there is a worrisome “gateway” effect from smoke-free products to smoking (which is not true) and yet there is a concerted effort to deny that smoke-free products are low risk compared to smoking (which would tend to create a gateway effect, since you might as well smoke if that is true).

A closely related problem is that sometimes the tobacco controllers want to report the truth, and the truth very frequently contradicts the sociopath lies.  A recent favorite lie that has been flogged by Stanton Glantz and used by others to attack e-cigarettes is the claim that they are often used merely to cut down on smoking, and cutting down does not reduce your risks.  More specifically, Glantz is claiming that the heart attack risk does not decrease and phrasing it to trick the reader/listener into believing that the claim is that risk does not decrease it all.  Even setting aside the fact that cutting down is a typical transition state on the way to stopping, this is simply not true.  Apparently the somewhat more honest tobacco controllers at the CDC did not get the memo that this is the lie of the month, because they just tweeted:

(‏@CDCTobaccoFree) No smoking is safe, but risk of heart disease & heart attack greatly increases w/number of cigarettes smoked.

For any readers who might be as innumerate as Glantz (though I cannot imagine there are any), “increases with the number of cigarettes” is exactly equivalent to “decreases when you cut down”.

By the way, for those interested in the truth, it is this:  The risk of cancer increases close to linearly with the number of cigarettes smoked (cut the number smoked by half and you cut the risk by half).  Cardiovascular risk, including heart attack, increases much more sharply with the number smoked and then gets flatter, which means that cutting from 20 to 10 does not cut this risk in half — not even close — but it does decrease it.  Other diseases seem to fall in between those functions.

We do not actually have very good data on smoking less than about 10 per day and almost nothing useful below 5, so it is hard to be sure.  But there are good reasons to believe that the cardiovascular risk from smoking just a handful per day could be in the neighborhood of half of that of smoking a pack a day.  (Strangely, this means that CDC was arguably overstating the benefits of cutting down without quitting.)

So there is a good reason to push on to zero after cutting down.  But it is obviously a lie to claim there are no benefits to cutting down.

Dick Puddlecote traces a tobacco control lie (this is what conflict of interest looks like)

by Carl V Phillips

Sometimes just tweeting something is not enough.  Thus an entire post to tell you to go read Audit Trail Of A Public Health Lie at the Dick Puddlecote blog.  It is an excellent quick investigative report in which he shows how an anti-tobacco researcher promised an anti-tobacco funder a particular result from a research study and (surprise!) delivered it.

This is the level of ethics that dominates anti-tobacco (including anti-THR) “research”.

I often note that the worst financial conflicts of interest are not — contrary to the ANTZ’s ad hominems — sources of grant funding.  Rather, they are being salaried by an organization that has a particular political opinion or, comparatively rarely, owning IP that will become more valuable as a result of the study.  (Ideological conflicts of interest, which are generally ignored, are worse than even these.)  But when I put those at the top of the list I am setting aside the clearly worse absurd extreme scenarios, like someone is holding a researcher’s family hostage to force her to get a particular result or, say, the funder demands a particular message and the “researcher” promises to provide it.

The latter descries the role in society of marketers, not scientists.  Well, that is, unless we are talking about tobacco control industry “scientists”.