Stanton Glantz is such a liar that even the ACS balks: his latest ecig gateway “study”

by Carl V Phillips

Stanton Glantz recently published a paper, Electronic Cigarettes and Conventional Cigarette Use Among US Adolescents; A Cross-sectional Study,  whose conclusions do not even remotely follow from the analysis.  That is hardly news, of course.  In fact, it is probably sufficient to end the sentence with “published a paper”, since the rest is pretty much a given.  But it is interesting to see that this time even some of the semi-respectable anti-THR liars are pushing back against how blatant it is.  I wish I could say that this reflects a new era of tobacco control people consistently calling for honest science, but I seriously doubt that is the case.  Still, it is something.

This is a long post (by the standards of this blog – it is what is needed to do a serious scientific analysis), so I outline it so that you can know what you want to skip if you are in a hurry:  1. The real reason why Glantz’s statistics do not support his conclusion.  2. Addressing a common red herring claim about the ordering of events.  3. Delving deeper into exactly what Glantz is claiming and why it is even worse than the simple headline claim.  4. Coming back to the ACS reference in the title and related press coverage.  5. Some further random technical observations.

The paper was published in one of JAMA’s journals, which some people found shocking — but only those who do not know that most of the population epidemiology studies published in clinical journals are junk.  Glantz and Lauren Dutra (who is listed as the first author, but I am going to presume, based on historical evidence, that Glantz was the primary actor behind anti-scientific garbage and phrase this post as such, but note that coauthor Dutra is equally guilty) looked at cross-sectional survey data about cigarette and e-cigarette use by US teens in 2011-2012, and claimed that it showed that e-cigarettes are a gateway to smoking, though it actually showed no such thing.


Basically what Glantz claimed is that because there is a positive association with some measures of cigarette use and some measures of e-cigarette use, that e-cigarettes are causing people to smoke.  Yes, really, that is basically what he is saying.  This is the same anti-scientific garbage that has been the basis for tobacco gateway claims for most of two decades.  The authors of this entire literature willfully ignore the obvious fact that liking one particular tobacco product means you are more likely than the average person to like another tobacco product, and the more you like one the more you like another.  Well, duh!

To show just how absurd his conclusions are, let’s assume we are in a world where every single person who ever tried an e-cigarette is a smoker who was using them or considering using them to stop smoking.  That is, they are all about THR and smoking cessation, always.  Now consider what Glantz considers to be his main findings from the data (by quoting from the abstract):  “Current e-cigarette use was positively associated with ever smoking cigarettes and current cigarette smoking.”  That would be true in our scenario.  “In 2011, current cigarette smokers who had ever used e-cigarettes were more likely to intend to quit smoking within the next year.”  Certainly true in the scenario.  “Among experimenters with conventional cigarettes [someone who had ever tried one puff], ever use of e-cigarettes was associated with lower 30-day, 6-month, and 1-year abstinence from cigarettes.”  That would be true in the scenario.

“Current e-cigarette use was also associated with lower 30-day, 6-month, and 1-year abstinence.”  That would not necessarily be true in the scenario, but it certainly might be: at a particular point in time, especially early in the history of e-cigarettes use as this is, many people using e-cigarettes to try to quit are likely to still be smokers or very recent switchers, whereas a lot of one-time smokers who are not using e-cigarettes would have already quit smoking.  “Among ever smokers of [>100] cigarettes, ever e-cigarette use was negatively associated with 30-day, 6-month, and 1-year abstinence from conventional cigarettes.  Current e-cigarette use was also negative associated with 30-day, 6-month, and 1-year abstinence.”  Same point as the one prior.

So, every statistic that Glantz considers the to be the best support for his claims is either inevitably true in a world where e-cigarettes are used exclusively to quit smoking, or is very consistent with such a world.  And yet he claims “Use of e-cigarettes does not discourage, and may encourage, conventional cigarette use among US adolescents.”

It is difficult to imagine more glaring scientific illiteracy:  Propose a hypothesis.  Find evidence that is consistent with your hypothesis, but also consistent with the most extreme version of the competing hypothesis.  Declare your hypothesis to be right.  The University of California and JAMA apparently do not expect their researchers to rise to the standards of a middle school chemistry class.  Let’s hope the students who were the subject of the survey understand science better than the authors, or Americans will all be sewing shoes and toys for the Chinese within a generation.

As an illustrative comparison, consider this bit of “science”:  Hypothesis: it is nighttime.  Alternative hypothesis: it morning and very cloudy.  Observation:  no one I can observe is wearing sunglasses.  Conclusion: it is nighttime.  Obviously the observation has done nothing to resolve which hypothesis is true.  There are a lot of observations that could help resolve this question, like looking at a clock or observing what meal restaurants are serving.  But instead of seeking data that would address the question, Glantz sought data that resolved nothing, presumably to avoid the risk (indeed, based on what we know, the inevitability) that real science would not support his daft claims.


Notice that the reason Glantz is glaring wrong has nothing to do with the data being “cross-sectional”, which means that the subjects were not followed over time but just surveyed once.  The cross-sectional nature of the data has been highlighted as the major weakness of the study, though the real scientific problems are those noted above.  A claim that has come out in most of the criticism of the study is that because it is cross-sectional data, you cannot determine whether e-cigarette use preceded smoking or not.  The popular claim is that unless you can show that e-cigarette use preceded smoking, then there cannot be a gateway, and it is not possible to determine the order of use.  This is actually not right for a couple of reasons.

First, a cross-sectional study can determine ordering of past events (subject to the accuracy of subject recall) by asking the right question — e.g., “Which of the tobacco products you have tried did you try first?”  It turns out that the U.S. government survey on which the paper is based did not ask a question like that.  However, it did ask about age at first use, although only for cigarettes and smokeless tobacco, not for e-cigarettes.  It also recorded the current age of the subject.  Since almost all first use of e-cigarettes occurred within a year or two of the survey date, it would be easy to show a large percentage of product users who had already smoked before they had even heard of an e-cigarette.  Glantz pretended that this data did not exist, even as he made claims that using that date would help inform.

But the second problem with this line of reasoning is rather more important:  Ordering does not actually provide evidence of causation, or rule it out.  Activists who want to claim that there is a gateway effect like to pretend that if consuming X preceded consuming Y, then X caused the use of Y.  Obviously that is not true.  The classic counter-observation is that almost every heroin user consumed milk before taking up heroin.

But it is also not the case that if first use of cigarettes preceded any use of e-cigarettes then e-cigarettes could not be causing smoking.  It is entirely possible that someone tried a cigarette but would not have been a smoker had e-cigarettes not existed, but she became a user of e-cigarettes and that caused her to become a smoker.  I am not saying this happens.  It is quite far-fetched, but this is because of empirical evidence and analytic reasoning that have nothing to do with the order.  The point is that merely observing that most e-cigarette users were already smoking when they tried e-cigarettes does not rule out the gateway claim.  Claiming this is not grossly scientifically illiterate like Glantz consistently is — it is a rather more subtle point, and it is an easy honest error for someone who is not expert in causal reasoning to make — but it is still clearly wrong.

Previous commentators have fixated on Glantz’s concession, in the discussion and conclusions, that the cross-sectional nature of the data does not allow conclusions of ordering or causation.  But even this concession reflects further lack of understanding about data and epidemiology on the part of the authors:  Cross-sectional data can be used to determine ordering, as noted above.  But the authors chose to ignore what data they had that addresses that and the survey was not designed to do any better.  It is also quite possible to draw causal conclusions from cross-sectional data, you just have to understand scientific inference a little bit.  (More on this in section 5.)


Going back to the quoted conclusion statement from the abstract, notice that it is even stronger than merely claiming that there is a gateway effect.  It phrases the claim in terms of “discourage” and “encourage”, which draws conclusions about motivations that not only do not follow from the statistics presented, but could not be addressed at all based on the types of questions in the survey.

It gets worse.  I am going to skip over all the random rhetoric and assertions in the introduction (as every good researcher I know always does), and just look at the discussion/conclusions.  The first claim in the discussion of the results is that adolescent use of e-cigarettes is increasing rapidly, something that study did not show, and indeed the dataset it is based on could not show.  Glantz then concludes that the “results call into question claims that e-cigarettes are effective as smoking cessation aid.”  But even if the results had suggested that e-cigarettes were, for some reason, causing more teen smoking to occur than otherwise would have, that would tell us nothing about whether they might also be effective cessation aids.

The discussion then wanders off into an irrelevant discussion of nicotine, addiction, and animal experiments.  It is a good sign that someone is not really trying to do a scientific analysis — but rather is reporting some statistics as an excuse to editorialize about their political beliefs — when they wander off like this.  All of us who write about political scientific topics sometimes try to present a big-picture analysis of the implications of all the science.  That is fine.  But it should not be tacked onto a research report.

And, finally, “The results of our study together with those from [Glantz’s equally mis-concluded] study in Korea suggest that e-cigarettes may contribute to nicotine addiction and are unlikely to discourage conventional cigarette smoking among youths.”  But these results are perfectly consistent with the teens in the study population only using e-cigarettes for THR, as noted above.  Moreover, there is absolutely nothing in the study that addresses the question of addiction (whatever that means).

Notice also that the phrasing is forward-looking (“are unlikely to discourage” rather than “did not, in 2011, discourage”), though there is nothing in the analysis that speaks to predictions about the future.  The introduction of mobile phones did not, at first, discourage the use of landlines or even cause the decline of payphones, but that was the very predictable future.  Similar predictions should be made about e-cigarettes even if youth use to date does not yet show that pattern (not that we can conclude that it does not from the present analysis).  That is, even if e-cigarettes were not reducing youth smoking in 2011 does not mean that they will not be doing so soon.

Basically none of the conclusions of this paper follow from the analysis.


And I am not the only one who thinks so.  The New York Times article about this paper, following a summary of what Glantz claims, notes:

But other [sic] experts said the data did not support that interpretation. They said that just because e-cigarettes are being used by youths who smoke more and have a harder time quitting does not mean that the devices themselves are the cause of those problems. It is just as possible, they said, that young people who use the devices were heavier smokers to begin with, or would have become heavy smokers anyway.

“The data in this study do not allow many of the broad conclusions that it draws,” said Thomas J. Glynn, a researcher at the American Cancer Society.

When the ACS says you are going too far in your anti-THR lies, you know you have not just jumped the shark, but have flown clear off the planet.

As is usually the case with study authors who are not really trying to contribute to science, the claims to the press were even more egregious than those in the paper:

Dr. Glantz says that his findings show that use of e-cigarettes can predict who will go on to become an established smoker. Students who said they had experimented with cigarettes — that is, taken at least one puff — were much more likely to become established smokers if they also used e-cigarettes, he said.

“One of the arguments that people make for e-cigarettes is that they are a way to cut down on the smoking of cigarettes, but the actual use pattern is just the opposite,” he said.

But, of course, there is nothing at all in the data or the observation quoted there that supports the conclusion.  E-cigarettes might be used entirely to cut down on smoking, and still be associated with smoking.  Indeed, it would almost be inevitable: those who are not inclined to smoke much or at all will not use a substitute to cut down.

But David Abrams, executive director of the Schroeder Institute for Tobacco Research and Policy Studies at the Legacy Foundation, an antismoking research group, said the study’s data do not support that conclusion.

“I am quite certain that a survey would find that people who have used nicotine gum are much more likely to be smokers and to have trouble quitting, but that does not mean that gum is a gateway to smoking or makes it harder to quit,” he said.

Yup.  Moreover, it almost certainty the case that those who smoke weed, drive unsafely, perform poorly in school, etc. are much more likely to be smokers.  As I have previously pointed out, it is theoretically possible to control for propensities (use covariates like these) to estimate whether one behavior is in fact increasing another, rather than just being a shared propensity.  But such real science is waaaay over the heads of the tobacco control “researchers”.

The study did have a bright spot: Youths who used e-cigarettes were more likely to plan to quit smoking. Dr. Abrams highlighted that finding, but said it was impossible to tell whether students who planned to quit actually did, because the data did not track this.

Funny, I did not notice that in the conclusions that Glantz wrote.  This is actually the only observation from the data that relates to the THR points that Glantz emphasized.  Abrams is, of course, right that we do not know whether the intentions were acted upon.  But the fact that e-cigarettes are associated with the goal of quitting is strong support for the claim — contra Glantz — that even among teens they are being used for harm reduction.


Finally, for those who are interested (and as some notes for myself), a random collection of more technical observations.

One additional observation about cross-sectional studies I did not want to belabor above:  It turns out that some of the most effective and convincing observational epidemiology studies, in terms of being able to draw causal conclusions, are cross-sectional.  I speak of disease outbreak studies, where a group of people come down with some relatively uncommon infectious disease and the CDC’s EIS (a good unit of CDC, in contrast with their nanny state units) interviews people to determine their recent exposures.  They discover things like, “everyone with the disease visited Africa recently” or “almost everyone who got the disease recalls eating a particular brand of salsa in the past month” or, even better, “the people at the gathering who got sick mostly ate some of the chicken that was served, while those who did not get sick did not.”  These cross-sectional studies lead to very solid causal conclusions.  There is nothing magic about one study design versus another — all can be misinterpreted in terms of drawing unsupported causal conclusions and all can be correctly interpreted to draw valid causal conclusions.

Further on the topic of temporality:  I will be a little more emphatic to the pro-THR activists who keep repeating the claim that if someone smoked a cigarette before puffing an e-cigarette, she cannot be a gateway case:  Please quit it!  That is not legitimate reasoning.  If our side is going to traffic in junk science like that, how are we any better than the tobacco control industry?  Obviously it is true that if someone tried a cigarette first, then e-cigarettes did not cause her to smoke her first cigarette.  But you are letting the simple concept “cause must precede effect” confuse you about what the effect in question is.  We are not interested in what causes someone to smoke her first cigarette, we are interested in whether it causes her to become a smoker.

Does this make that point obvious enough?:  Just because someone had a case of salmonella before ever eating chicken does not mean that eating chicken did not cause the salmonella she has now.  How about this?:  I smoked some cigarettes long before I ever tried snus; but if I were to take up smoking now, it would clearly be because I acquired a taste for tobacco use thanks to snus, and I clearly would be a gateway case.  (And why would that never happen?  That is the logic I have argued for more than a decade, most recently here:  Since I did not become a smoker because I preferred abstinence to enduring the costs of smoking, why would preferring snus use to abstinence cause me to switch to my least-preferred option?)

There are some rather embarrassing flaws in the survey itself.  The questions about trying e-cigarettes (asked in 2012) give as the examples “…such as Ruyan or NJOY”.  Seriously?  The last time I saw a Ruyan-branded product was several years before that.  This probably did not bias the answers, but it tells us a lot about how out of touch our government “experts” are about e-cigarettes.  But it is the case that by 2012 the question should have indicated that the category of interest included disposables, kits, and mods, since it is possible that the local teen lingo in some places would consider the question as asked to not include all of those.  Of course, more useful still would have been to ask about those subcategories separately rather than wasting time in the “other tobacco products” asking about kreteks and other insignificant products.  (And that is to say nothing about the utter chaos created by including “snus” in the “other” grouping rather than in with the rest of smokeless tobacco, but that is a disaster for other analyses, not this one.)

One sentence in the discussion subtly betrays the authors’ weak thinking and inability to separate their own rhetoric:  After pointing out that e-cigarettes contain nicotine, they state, “The adolescent human brain may be particularly vulnerable to the effects of nicotine because it is still developing.”  But they claim the paper is about e-cigarettes causing teens to smoke, not about whether they are harmful in themselves.  The standard practice in tobacco control is to throw every argument they can think of against the wall to see what sticks, regardless of whether a claim is accurate or even if the collection of claims are internally inconsistent with one another.  They try to pull back on this lying when they pretend to be doing science, but even when they are mostly successful, they just cannot help themselves.

The authors’ use of covariates is naive and simplistic.  This is typical for people who do epidemiology without understanding epidemiology (i.e., most people who do epidemiology), and is definitely not unique to tobacco control activists.  Most notably, they controlled for age as a covariate.  This simply makes no sense.  If there is a relevant real difference across ages in this analysis (as there almost certainly is), it does not call for a half-hearted age standardization, but for stratification into age groups so we learn what is different about importantly different groups.  On the other hand stratifying by race has no apparent justification, and is just arbitrary window-dressing (that is, assuming they corrected for the oversampling of some racial groups as they claimed to).  They did not stratify where it would be useful and did stratify where it served no purpose.

There are other variables in the dataset that would be interesting to stratify on, but the authors presumably have no idea what they are, or just did not care enough about even pretending to do useful science to bother with them.  Most notably, there are questions about perception of the risk from e-cigarettes.  They are not very good, asking just less, equal, or more compared to smoking, rather than dividing out “less” enough to make sure someone understood the difference between 99% less and just a little less.  Still, any differences in behavior between those who think e-cigarettes are as bad as smoking and those who know better could tell us something about conscious THR efforts.

The authors also seem to have no idea how to properly interpret or report random error test statistics (p-values and such).  Yawn.  That is pretty much the rule in public health and medical journals.  The remark in the discussion about the difference in power between the Korean and U.S. studies should elicit a smirk from those who understand statistics, but I am not going to try to explain the joke here.

In the inappropriate discourse into nicotine in the discussion, the authors refer to it as “highly addictive” without ever suggesting what they mean by “addictive”, much less what constitutes “highly”.  To pretend that they are doing science, they attach a reference after this, but it is just to a political commentary piece, not something that could be a basis for a scientific claim (which is pseudo-scientific, in reality).  Such anti-scientific behavior in the public health literature is so ubiquitous that it might seem not worth mentioning (it is not the only such example in the paper), but it is important to at least try to push back against anti-science like this occasionally.  I would certainly never let a student get away with either meaningless rhetorical claims or misuse of references like this.  (I sometimes wonder if authors like these just never had a decent teacher, or if someone out there is mortified by his failure.)

One tantalizing observation that is not analyzed (surprise!) is the very low portion of so-called former e-cigarette users who were currently heavy smokers.  That is, very few people tried e-cigarettes, gave up on them, and remained heavy smokers at the time of the survey.  This could just mean that the heavy smokers did not bother to try e-cigarettes, but it could also mean that large portion of those who were heavy smokers and tried became non-heavy smokers.  That is, THR worked!  (Indeed, if I were as unconcerned with good scientific reasoning as is Glantz, I would declare that this is what it shows, and would be standing on firmer ground than he is with his conclusions.)  This is a place where the cross-sectional nature of the study (and the absence of enough retrospective questions) really is the problem:  If the data followed people over time, or if the survey asked whether someone used to be a heavy smoker, this could easily be resolved and the causal role of e-cigarettes in reducing heavy smoking could be fairly effectively inferred.

30 responses to “Stanton Glantz is such a liar that even the ACS balks: his latest ecig gateway “study”

  1. “The paper was published in one of JAMA’s journals, which some people found shocking — but only those who do not know that most of the population epidemiology studies published in clinical journals are junk. ”

    Particularly those associated with authors whose names begin with G and end with Z. While Glantz’s Helena study wasn’t about e-cigs, it was of about equal quality to this one and won an even higher level of acceptance. The *only* thing that brought it into any real question at all was the existence of a responsible editor of the BMJ’s Rapid Response section at the time. Unfortunately I don’t think JAMA offers such a venue, do they? And have they **EVER** allowed this sort of “critical corrective” analysis to be published in their journal about a previously accepted and published article? I doubt it.

    Unfortunately for Vapers, the standard of scientific quality that has been so thoroughly accepted for studies in support of smoking bans is now being applied to studies supporting bans on e-cigs. The key that needs to be found in both cases is how to bring the correct information before the eyes and focused minds of a public that’s inundated with propaganda from “authorities” on the other side. Fortunately for Vapers there are at least a moderately respectable number of authorities such as yourself who are willing to challenge the Glantzes. Now you just need to find venues of equal visibility to display those challenges.

    – MJM

    • Carl V Phillips

      Saw it already. It is one of the several examples I refer to where someone reaches the right conclusion (that Glantz’s conclusions do not follow from his observations or analysis) but, ironically, their own conclusion, though correct, does not follow from their own analysis.

  2. regarding the part about: “But it is also not the case that if first use of cigarettes preceded any use of e-cigarettes then e-cigarettes could not be causing smoking.”

    I think I get your point here (to my shame, not something I had really though very much about before as I think prior to this I would be inclined to jump to stronger conclusions if I saw data where normal cigarette use proceeded e-cigarette use in most cases.)

    but even so, wouldn’t it be the case that this kind of temporal ordering makes it ‘less likely’ for there to be a lot of true ‘gateway’ (current smoking in those who would otherwise never have smoked) if most current smoking young people surveyed who had tried e-cigarettes had trial of cigarette smoking (or better, a sustained period of cigarette smoking) before their current phase of cigarette smoking?

    largely because previous trial or cigarette smoking history acts as a proxy for all those other unmeasured internal and external factors which other researchers have used to predict likelihood of future smoking e.g. in the more complex propensity matching type studies you allude to.

    so while I agree there could theoretically be some cases like those you describe (having a temporal ordering of normal smoking before e-cigarette use but still being true ‘gateway’ cases), I’m struggling with the idea that these sort of cases would be the majority or even a substantial minority…

    • Carl V Phillips

      Well first off, as I have written extensively, there is really no good reason to believe there would ever be a gateway. It is an empirical point, of course, and it is not impossible, and therefore perhaps could be found. But on its face the idea is batshit crazy. Sometimes it is interesting to scientifically study things that seem batshit crazy, and sometimes they turn out to be real, but not usually. Our prior should be that gateway seems like such an unlikely phenomenon that we need some pretty convincing evidence that it is happening before we believe it. The problem, of course, is the tobacco controllers frequently start with absurd notions and hold them as such strong priors that they are more premise than hypothesis.

      With that in mind, imagine that somehow e-cigarettes cause many of those who try or use them to want to smoke (which, of course, means absent e-cigarettes they would never have chosen to smoke, but because they used e-cigarettes they do choose to smoke). At our current point in calendar time, most such people — selected to be those who would even consider using tobacco at all — will have already tried a cigarette or even enough to qualify as “have smoked”. This is simply because cigarettes have been popular forever. So right now, if there were any gateway, it would mostly be among those who have already smoked. That might change over time, of course, but right now anyone without a strong aversion (which makes them an even more unlikely gateway case) has already tried a cigarette.

      As for the “more/less likely” question in equilibrium (when one product is not new), it is hard to answer because the phenomenon seems vanishingly unlikely in the first place. It would still be an empirical question that hinges more on which product is more popular to try first. If it remains the case that cigarettes are more popular to try first and we pretend that there are e-cigarette gateway cases, then it will remain the case that most gateway cases tried smoking first. Moreover, it is not obvious that those who tried e-cigarettes first were more likely to be gateway cases — e.g., it might mean they have such an aversion to smoking that they would never be persuaded to start (even in this fictitious world where anyone is persuaded to start by using a substitute). I am fairly sure you could write down descriptions of more response types in which the ordering was “right” than I have written down where the ordering is “wrong”. But this does not tell us much about which are more likely. And neither is the empiricism because pretty close to none of those types are populated (at least more than trivially). It is kind of like asking “doesn’t it seem more likely that trolls are green?” Perhaps it is the case that more of our legends about trolls put them as green than other options, but the argument is still unsolvable logically and unworldly empirically.

  3. Pingback: Stanton Glantz Is Such A Liar That Even The ACS Balks • The Spinfuel News Blog

  4. I’m almost afraid to kick this hornet’s nest, but what happens when the rate of electronic cigarette users of high school age skyrockets? I think its inevitable, and it’s going to give Glantz all the ammunition he wants.

    The spike in adolescent electronic cigarette use is coming. I see it in vape shops now, and even without such salient evidence it should be obvious. Clearly, many people like nicotine. Without the threat of immense harm, there will be an uptick in nicotine use. Approximately half of Americans smoked during the 50’s. Let’s make the assumption that half of Americans would smoke without the emergence of data that proved unequivocally that cigarettes are dangerous, and the anti-smoking campaign that followed. The smoking rate is roughly around 18%? For the sake of the high number of unaccounted for variables, let’s say that leaves a conservative guess of about 25% or so of folks who would smoke if it weren’t dangerous.

    Now let’s consider the reality that the anti-smoking campaigns have created for adults that nicotine is dangerous. That’s not going to change for most folks, largely because they aren’t paying attention. These folks quit smoking decades ago. It’s no longer a part of their lives, and they couldn’t care less.

    But the CHILDREN! (Yes, I’m using that word very deliberately.) My two year old uses my cell phone more effectively than my mother. The children are much more tolerant of these sorts of paradigm shifts. Unless something VERY drastic happens in the next few years, today’s children will see electronic cigarettes, in whatever form they exist, for what we (the vocal minority) currently know them to be. Inevitably, people will choose to use nicotine at significantly higher rates.

    Smoking rates will drop, but that drop will more than be made up for with electronic cigarette use rates. Is that necessarily a bad thing?

    Looks like I’ve written another book, and again it’s only relevant to one small part of your complete post. Sorry about that! I do think it’s interesting that Glantz has latched on to this tactic (and this data set), however. I think it’s about the only legitimate argument he could make for removing electronic cigarettes from the market. To prove that electronics will cause higher rates of use for the real thing would indeed be a game changer for a lot of people. Unfortunately for him, the data just doesn’t bear the results he wants.

    (Do you think he’s smart enough to use this data set repeatedly BECAUSE of its shortcomings? The data is so bad, he can bend it in so many ways!)

    • Carl V Phillips

      Well, I’ve already written that book a few times. I have presented the predictions about the future equilibrium (I think your prediction is about right) and assessed which factors changed it from the past to the current (you miss a few of them, btw). I don’t agree that what we currently call e-cigarettes alone will get back to that long-run equilibrium, but the combination of existing and new THR products will, by my prediction.

      I don’t think you are right about adults, particularly former smokers. A lot of them never stopped longing for cigarettes and are likely to try a low-risk alternative once it becomes popular. You might be underestimating the power of propaganda — which is not likely to diminish for at least a generation — on children. It is not really so much like tech toys. But eventually the truth will trickle down, or each cohort will get old enough to outgrow the propaganda.

      So all of this adds up to several key bits of pro-ecig rhetoric being wrong. They are mostly used by people to quit smoking now, but that will not always be the case. And they (and the various other tobacco products) will increase the total number of tobacco users. Eventually ecig proponents are going to have to start making more sophisticated arguments than merely “it is better than smoking and it always is a substitute for smoking, and therefore….” (No, it is not a bad thing by any normal ethical judgment, but that will have to be argued.)

  5. A ‘higher nicotine-use prevalence caused by THR’ is a good example of future issues (or more correctly, future ammo for the PH industry), although there are worse.

    We can already see that in Sweden: there is probably a state of equilibrium there already by now, and smoking is at ~12%, Snus use at ~21%. Since some are dual-users the total nicotine-using prevalence is said to be around 28% (though is hardly worrying if 30%). This has been described as showing ‘more’ nicotine use by TCI authors, while others point out this is far lower than original levels of nicotine use (for other comparable countries, as this sort of past usage measurement is difficult in a country that always had a high alternative product use).

    We might even see a greater figure than this for ecig use in other Western countries, in time. Even so, it will not be ‘more’ nicotine use – as CVP pointed out it will be less than the previous high levels in the 1950s and 60s. The timescale is affected by restrictions on alt products, but not the ultimate result. In the UK, which is the only place I’m comfortable with guessing about, we will probably see an eventual 60% of smokers switching to ecigs. If Snus was permitted, and either not banned here or Swedish exports not so rigidly controlled as they are (making a black market difficult), then we could probably add another 10% for Snus substitution on top of that.

    Population-level nicotine use is a non-issue anyway. It’s a useful bit of ammo but has about as much substance as any of the other propaganda.

    Something unrelated I’d like to interject here is a point that does not have much visibility: when we talk about a smoking prevalence of 18% in the USA, it also needs to be recognised that the US is a country with an ST tradition, so THR is already widely practised there; remove ST and you’d see a higher smoking prevalence. It’s probably possible to calculate that figure and it would likely raise smoking prevalence to over 20%. I’d like to make that point because others have suggested it is easily possible to get below the 20% prevalence figure with regular tobacco control policies and point at the US as an example; but it can’t be used for that purpose because a percentage of smokers or would-be smokers have ‘already switched’.

    • Carl V Phillips

      Sorry for the delay in posting this. I was trying to focus on some other stuff yesterday. I am so close enough to agreeing with all of this that it is worth discussing a few points. You are quite right about the USA. The same people who like to lie that smokeless is just the same as smoking also like to pretend it does not exist when voicing their statistics. Total tobacco use is still above 20%. Indeed, the uptake of smokeless in the 2000 pretty much perfectly matched the decrease in smoking. That is not clear evidence causation, of course, but it seems safe to infer quite a lot of intentional switching.

      My prediction is that when low-risk products gain greater popularity and high-quality products are mass produced, tobacco use will basically rise to the peak levels that have been demonstrated cross-culturally: 50-60%. I find it difficult to imagine that what we now call e-cigarettes will have the level of penetration you predict, but the combination of products will reach that, and probably more.

      The smart people in the TCI (a tiny minority, and not the people who are always chattering, but they are there) have probably figured this out. But they cannot do much with it. To predict that most everyone who likes nicotine or the other effects of tobacco will start using tobacco when its risk is trivial is to admit that people like it. They cannot afford to break with their fiction on that point — it would collapse the whole house of cards.

      The Swedish total usage prevalence is probably best compared to what we would predict for a population “like Sweden” but absent smokeless. They might well have the lowest usage prevalence in Europe — but a little bit! — just as they lead lots of statistics on health and safety. So total tobacco usage would be much lower than it is now (but the bit that matters, smoking, would still be higher).

      • Just in case it may have been misunderstood, my prediction is that 60% *of smokers* will eventually switch to EVs (electronic vapourisers), not 60% of the population. Of course, the timescale is key, given the harsh restrictions that will be placed on this process to mitigate the economic burdens placed on government and the major industries affected.

  6. I suspect that Glantz et al have ulterior motives. They do not care that their research is obviously faulty. I have seen so many statements from tobacco control which treat ecigs as though their only purpose was to be ‘a cessation device’. By use of this false paradigm, these people hope to take control of ecigs and claim ‘ownership’ of them. That is the only reasonable way in which the recent EU directive, as it relates to ecigs, can be understood. For example, the directive mandates that the maximum strength of ecig liquid should be 20 mg/ml. Two reasons for this were promulgated by the zealots, a) that 20 mg/ml was the average which vapers found to be satisfactory, and, b) that 20 mg/ml provided the same ‘nicotine hit’ per puff as a standard cigarette. (These two suggestions were not put together in the same place – they were promoted separately)
    What the directive did not consider was that people might decide to swap to ecigs for a variety of reasons – to avoid smoking bans: on the grounds of costs: for taste reasons: because they are becoming fashionable (vis: celebrity use). It must be true that grabbing ecigs for their own use and profit would be a massive prize for the tobacco control industry.
    That seems to me to be the objective of Glantz et al.

    • Carl V Phillips

      A goal of seizing them for purposes of crippling them I certainly find to be a reasonable story. This is typical. They basically did it with cigarettes, propagandizing a cherished consumer good into a “disease vector”. Their game of trying to deny e-cigarette users the right to define their own behavior (imposing their own jargon and such) is another example — as well as being per se unethical by any accepted standards of research about people. However, the ship has probably sailed on them being able to profit from this. They had their chance on that, but they decided to keep digging themselves in deeper as the enemy of real public health, and I don’t think they can come back from that.

  7. Below the belt, MjM!

  8. With reference to my post above about tobacco control wishing to grab ‘ownership’ of ecigs for their own purposes and profit, may I quote as follows (H/T Simon Clark):

    A motion at a meeting of the British Medical Association Scotland will call for the Scottish Government to introduce severe restrictions on where e-cigarettes can be used and sold.

    According to a report in the Scotsman today:

    Electronic cigarettes should be banned in enclosed public places and not be sold to under-18s, a conference of doctors will hear this week.

    The motion adds that e-cigarettes should only displayed for sale alongside other nicotine replacement therapies.

    The full motion reads:

    That this conference is concerned at the current lack of regulation of electronic cigarettes and, whilst welcoming the decision by the MHRA to regulate electronic cigarettes as a medicine, calls on the Scottish Government to:

    i. include e-cigarettes within the products banned from use in enclosed public places
    ii. prohibit the sale of e-cigarettes to those under 18 years
    iii. ensure that e-cigarettes are only displayed for sale alongside other nicotine replacement therapies.

    You will note that item iii. would give complete control over the retailing of ecigs to the medical profession in one way or another. Thus, indirectly, tobacco control will be able to control prices and supply to their own advantage.

    This is only a motion to be debated, but I doubt very much that it will not be carried, given the likely character of the delegates to the BMA’s conference.

    (NB also the fact that the MHRA has back-tracked on its initial statement that it WILL treat ecigs a medicines. It now says that it will bear in mind the EU position and keep and eye on developments.

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