Author Archives: Elaine Keller

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

by Elaine Keller

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

It’s a possibility.

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

by Elaine Keller

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

CDC director misleads Medscape

by Elaine Keller

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Don’t Be Fooled by the Canadian Lung Association

By Elaine Keller, with input from CASAA Board

[Note: Carl will resume his series about useful truths next week.  We have a few lies we want to cover first.]

Good health advice is any instruction or set of instructions that, when followed, results in health improvement or the avoidance of illness or injury. Bad health advice, when followed, results in illness or injury that would have been avoided by not following the advice. The public expects organizations that position themselves as leaders in fighting disease to provide good health advice that is based on accurate information.

“Don’t be fooled by e-cigarettes,” states a press release from the Canadian Lung Association (CLA). “These electronic devices could be potentially harmful to lung health” and that smokers should “avoid” them. Is it good health advice to discourage smokers from using an effective method for quitting? Clearly not, since there is overwhelming scientific evidence that smoking is harmful, not just to lung health, but in many ways. They are trying to discourage quitting by any smoker who is not willing and able to do it their way.

If they truly were concerned about lung health, they would have pointed out that there is no doubt that vaping is better for lung health than smoking. Then they would have discussed any actual concrete concerns about vaping and lung health. Instead, they just presented several irrelevant details intended to distract the reader from the truth. It might have been defensible advocacy for the lung association to say something like, “If you have quit smoking using e-cigarettes, that is some progress, but now you need to quit the e-cigarettes.”

But that is not what they did. For example, two paragraphs of the CLA press release are devoted to conjecture that the products might appeal to children. There is no evidence of this, but more important, how does this support what they are supposedly claiming, that there is a health risk? They clearly did not believe they could support their claim about health risk. And for good reason, when you consider the available evidence about e-cigarette effects on lung health.

First, consider what consumers who switched from smoking to an e-cigarette say about their lung health. For example, a University of Geneva researcher wrote, “Respondents reported more positive than negative effects with e-cigarettes: many reported positive effects on the respiratory system (breathing better, coughing less), which were probably associated with stopping smoking.”

Second, what do other sources say? In 2009, the U.S. Food and Drug Administration (FDA) invited consumers to use the agency’s Adverse Event Reporting System (AERS) to report problems experienced with using e-cigarettes. Results were reported in a letter to the editor of Nicotine and Tobacco Research. There had been 1 AE reported in 2008. There were 10 AE reports in 2009, 16 in 2010, 11 in 2011, and 9 in the first quarter of 2012. The types of problems reported are very similar to those reported with pharmaceutical products such as nicotine gum or lozenges, for example, headache, sore throat, abdominal pain, coughing, etc. The author commented, “Of note, there is not necessarily a causal relationship between AEs reported and e-cigarette use, as some AEs could be related to pre-existing conditions or due to other causes not reported.”

The author also mentioned that the number of people reporting ever an using e-cigarette more than quadrupled between 2009 and 2010. If there were any serious health risks posed by e-cigarettes, we would expect the number of AE reports to quadruple as well, but the number of reports dropped in 2011.

Third, the clinical trials that have been completed and that are in progress would be stopped if serious adverse events, such as lung health impairment, occurred. To date, no clinical trial of e-cigarettes has been stopped due to adverse events.

Under the heading, “E-cigarettes are not proven safe,” pediatrician Dr. Theo Moraes, a medical spokesperson for the CLA is quoted, “People who use e-cigarettes inhale unknown, unregulated and potentially harmful substances into their lungs.” Is this statement accurate? No, it’s a lie. It is a lie simply  because we have a quite a good accounting of what is in e-cigarette vapor. Additionally, its implication is a lie. As Dr. Phillips pointed out in an earlier post, before the first study of e-cigarette chemistry was ever done, we were 99% sure that cigarette smoke was many times more hazardous than vapor. People who smoke inhale thousands of chemicals from combustion, many of which are quite hard on the lungs (to say nothing of other parts of the body). Those chemicals are basically absent from vapor.

The substances in e-cigarette liquid are well known, and all ingredients are government-approved for human use (though not specifically in the form of e-cigarettes, of course). They include USP grade propylene glycol and/or vegetable glycerin, water, approved food flavorings, and (optionally) pharmaceutical-grade nicotine. Numerous toxicology studies have been conducted on the liquids and on the vapor, and none have found quantities of any chemical that are believed to be substantially hazardous.

The infamous FDA initial lab test is mentioned in the CLA press release, without pointing out that the “detectable levels of carcinogens” match the levels in FDA-approved nicotine patches. The “carcinogens”, tobacco-specific nitrosamines (TSNAs), are present at similar trace levels in any product that contains nicotine because nicotine is extracted from tobacco. The “toxic chemicals” turned out to be a non-harmful quantity of one chemical in one sample. Also not mentioned is the fact that the only two brands tested were the two companies that were in the process of suing the FDA, which is a red flag for bias.

Bottom line: Dr. Moraes is either deliberately misleading the public or is woefully uninformed about the contents and nature of e-cigarettes. He certainly does not understand the purpose of the products. “There are many nicotine replacement therapies approved by Health Canada to help someone quit smoking; the e-cigarette is not one of them,” he stated.

The nicotine replacement therapies (NRTs) approved by Health Canada are not aimed at helping people to quit smoking. They are aimed at treating “nicotine addiction”. They provide a reduced quantity of nicotine on a temporary basis, which is then further reduced and ultimately discontinued. E-cigarettes are not intended to treat nicotine addiction. They are used as a replacement for smoking that doesn’t require nicotine cessation.

Which works better? The vast majority of smokers who try to quit by cold turkey or using recommended medical interventions resume smoking. The published research probably overstates how often these “approved” therapies work, and even it agrees that they are nearly useless. As one example:  “Approximately 75% to 80% of smokers who attempt to quit relapse before achieving 6 months of abstinence. Of the remainder, relapses may occur years after a smoker initially quits.”  Consider what passes for “success” for NRT, such as a study comparing 6-month abstinence rates of those using NRTs versus those not using NRTs. In the first phase of the study, rates were 9.4% in the NRT group versus 3.5%. In the second phase, the rates were 6.9% in the NRT group compared with 4.3% in the non-NRT group. The authors stated, “NRT use was associated with improved chances of long‐term abstinence when controlling for nicotine dependence.” Both of these studies, as well as numerous others and simple common knowledge, also tell us that there are some smokers who are much less inclined to become abstinent from nicotine.

The critical difference between the “approved” approaches and typical e-cigarette use is that e-cigarettes do not involve becoming abstinent from nicotine. Once e-cigarette users have replaced all of their smoked cigarettes with e-cigarette use, they have stopped smoking. Because they are not required to become abstinent from nicotine, those who are more dependent or who simply are less inclined to give up the beneficial effects of nicotine, can continue to experience those benefits without destroying their health by smoking.  We do not know what portion of all smokers who seriously try to switch to e-cigarettes succeed at it, but we do have good evidence that the rate is pretty good — certainly better than quit rates using “approved” methods — and that lots of people who would not have quit smoking using those other methods have quit by using e-cigarettes.

To summarize the evidence, e-cigarettes: (i) have not been shown to harm users, based on either actual outcomes or what we can predict from the chemistry; (ii) appear to be much more effective at smoking cessation than “approved” methods, even for those who would consider quitting nicotine entirely, and (iii) are clearly more effective for those who want to quit smoking but do not want to quit nicotine.

In the final analysis, the CLA, like the American Lung Association, is a liar. The CLA says “don’t be fooled,” but the evidence says that the CLA is the one trying to fool the public. If the CLA were truly concerned about lung health, it would be doing everything possible to help smokers stop smoking as quickly as possible. If they genuinely believed that e-cigarettes left some tiny fraction of the lung risk for those who quit smoking, then they would try to address that. Instead, the CLA is actively discouraging smoking cessation by misinforming Canadian citizens about the speculative risks of using e-cigarettes and overstated claims about everyone can easily just quit nicotine entirely.

If you smoke, or care about someone who does, don’t be fooled by the CLA or ALA.  (And definitely make sure that you and people you know avoid supporting them financially.)

Stanton Glantz hates smokers

by Elaine Keller (with contributions from other CASAA board members)

Stanton Glantz tries to project the image that he is anti-smoking, but his words and actions tell a different story: He hates smokers. Why else would he go to so much trouble to prevent them from escaping from the practice of inhaling smoke?

The word “smoking” specifically refers to the practice of inhaling smoke. Thus, to quit smoking means to stop inhaling smoke, not necessarily to become abstinent from nicotine or even from tobacco. The experiences of millions of former smokers who switched to e-cigarettes, smokeless tobacco, or some other non-smoked source of nicotine such as long-term use of NRTs serves as evidence that nicotine abstinence is not a requirement for the health improvements that come with smoking cessation.

One indication of the contempt Glantz feels toward smokers is his post about the thousands of letters that e-cigarette users submitted as comments in response to the FDA’s request “to obtain input on certain questions related to the implementation of section 918 of the FD&C Act (21 U.S.C. 387r), as amended by the Tobacco Control Act (Pub. L. 111-31).”

Lie #1: Glantz characterized the FDA’s Docket ID: FDA-2012-N-1148 as a request for comments on “treatments for nicotine dependence,” which implies that the topic is limited to products aimed at complete nicotine cessation. However, the request for comments was much broader. Specifically, the FDA was requesting comments in connection with a report Health and Human Services must submit to Congress, a report that will discuss three categories:  (A) total abstinence from tobacco use; (B) reductions in consumption of tobacco; and (C) reductions in the harm associated with continued tobacco use. “Also the report must include recommendations on how FDA should coordinate and facilitate the exchange of information on these `innovative products and treatments,” including providing a “fast track” method for approval.

Glantz either does not understand the purpose of e-cigarettes or he deviously pretends to misunderstand. E-cigarettes were not invented for the purpose of treating nicotine addiction. Their purpose is to serve as a replacement for smoking, supplying the nicotine without the damaging constituents in smoke. Eliminating the carbon monoxide and thousands of other products of combustion results in a reduction in the harm associated with continued nicotine use.

Consumers who obtain some of the nicotine they need from e-cigarettes as a result smoke fewer tobacco cigarettes, and many eventually stop inhaling smoke altogether. Smokers who completely switch to an e-cigarette have, in a literal sense, quit smoking. But Glantz chooses to misinterpret “quit smoking” to mean “quit nicotine.”

Lie #2: Next, Glantz complained that the individual testimonials submitted included claims of “therapeutic benefit.” Given the type of information the FDA specified in the Federal Register notice, the submissions were very appropriate: The consumers who commented discussed an innovative product and related how that product helped them to achieve total abstinence, reduced use, or reductions in harm. Some may have stopped all nicotine use, either by switching to an e-liquid containing zero nicotine, or by giving up the practice of vaping. But the abstinence or reduction being sought by e-cigarette consumers is from inhaling smoke, not necessarily from tobacco use or from nicotine. These reports can only be construed as health (not really therapeutic) claims because we already know that stopping smoking is healthy, but no testimonial is going to change the fact that we already knew that.

Lie #3: Glantz is either obfuscating or demonstrating that he failed to understand the basis for the ruling in the Smoking Everywhere, Inc. and Sottera, Inc. d/b/a NJOY court case: “The fact that the e-cigarette companies and their trade association have been encouraging their consumers to submit public comments to a docket about smoking cessation products can be read no other way than the e-cigarette companies and their trade association are promoting their products as having therapeutic benefit,” he declared.

We know Glantz read the emails that at least two e-cigarette companies were sending to their customers because he included copies of those emails in his comment to the FDA. Specifically, those emails asked customers to share their stories with the FDA if e-cigarettes had a made a positive difference or had a positive impact or on their lives. There is nothing in those emails that could be construed as a health claim or knowledge of the customer intending to use the product to treat a disease or condition. It is not illegal, unethical, or immoral for vendors to urge their customers to submit a comment describing how their product has changed the customer’s life. “Life” is not a disease. And there is no procedure code for “positive impact” or “positive difference.”

Moreover it is difficult to see how restrictions on claims that can be made in marketing a product could possibly be relevant to these submissions.  Is Glantz claiming that FDA experts and other government officials need to be protected from hearing consumers’ claims because it would somehow harm their delicate sensibilities or trick them into believing something?

By contrast, while it may not be illegal, it certainly is immoral and unethical to do what Glantz has done and bear false witness: to accuse a person or a company of an imaginary misdeed, and then urge the Federal authorities to punish the accused.

Lie #4: Glantz stated, “The e-cigarette companies cannot have it both ways.” He implied that vendors must choose between having their products regulated as tobacco products or as therapeutic drugs. Again, this is not what Judge Leon’s opinion indicates. The same product could be regulated in two ways. To claim that the product treats a disease or condition, the product would need to be approved by the FDA for that purpose and labeled accordingly. There is no reason why the same product could not continue to be sold, sans any health claims, as a tobacco product. Many products have multiple purposes.

Lie #5: As Carl Phillips discussed in a previous posts, Glantz falsely accused vendors of suborning claims of therapeutic benefit from their customers. As proof, he cited CASAA’s “What to Say” section in our Call to Action.
CASAA is not a vendor or a trade association. If Glantz cannot understand that, he needs to purchase a good dictionary and look up the definitions of the words in our full name. The Consumer Advocates for Smoke-free Alternatives Association represents (and is largely comprised of) people who consume smoke-free alternatives as a means of tobacco harm reduction (as well as those who might someday do so).

It is very much in keeping with CASAA’s mission to encourage consumers to advocate for their own health and well-being by letting the FDA know what types of products they tried and what types of products worked in helping them to achieve total abstinence, reductions in consumption, or reductions in harm associated with smoking. The U.S. Constitution protects their rights to express their experiences and opinions.

The sad thing is that the vendors have to carefully select their wording to avoid telling the truth—e-cigarettes do work, and work much more effectively for the purpose of refraining from smoking than approved treatments for nicotine addiction.

Even sadder is the fact that e-cigarette users, having finally found a way to stop smoking, are in danger of losing the very thing that made this possible. It seems that people like Glantz would prefer that former smokers who used e-cigarettes as their quitting method stop using them—even if that means taking up smoking again.

The problem with Glantz (and others like him) is not just that the claims are lies.  We can set aside his despicable tactics and think about his apparent despicable goals.  What purpose would be served by censoring success stories in any forum?  The publication of success stories serves to encourage smokers to try e-cigarettes, and some of those who try will quit smoking as a result.  There is no other apparent result.  People who do not use nicotine are not encouraged to start.  No one is encouraged to avoid any other method for quitting smoking.  The only possible explanation for Glantz hating this so much is that his real goal is not to reduce the number of people who smoke, but to make sure that smokers suffer.  He objects to harm reduction because it reduces the harm suffered by those who are the target of his hatred:  smokers and other nicotine users who will not obey his demands and just become abstinent.

FDA misdirection endangers lives of adolescents (and others)

by Elaine Keller

The most subtle and possibly most effective form of propaganda from a single exposure is the use of misdirection as a way to impact an audience’s Subconscious. Like “smoke and mirrors” used by magicians, this form of propaganda requires focusing the audience’s Conscious attention in one place while the real impact is made in the Subconscious. — Melanie Anne Phillips & Chris Huntley

Here are some interesting facts about Pfizer’s smoking cessation medication, varenicline, sold under the brand names of Chantix in the US and Champix in Canada and Europe:

  • Linked to an increased risk of suicides, suicide attempts, aggressive and unusual behavior.
  • In 2009, the FDA began requiring a boxed warning for serious mental health effects.
  • Suspected of causing serious accidents and falls, potentially lethal cardiac rhythm disturbances, severe skin reactions, acute myocardial infarction, seizures, diabetes, and psychosis.

Despite all the bad news highlighted above, Pfizer will be testing Chantix on 12 to 16-year old adolescents. Here are some examples:

Central KY Research. Up to $805 for completion
Mid-America Clinical Research.
Clinical Trials Gov

How in the world did we get from “this drug is unsuitable for first-line use in smoking cessation” to the idea that it might be a good thing to try the drug out on adolescent smokers?

Perhaps this headline on WebMD provides a clue: Stop-Smoking Drug Doesn’t Raise Risk of Psychiatric Hospitalization, Study Shows

The WebMD article describes two FDA-sponsored studies that looked at the medical records of 14,000 VA patients and 20,000 DoD patients that were prescribed Chantix. “Overall, the studies found no increased risk of psychiatric hospitalization in Chantix users,” states the article.

So where is the propaganda technique in all this? The misdirection lies in the word “hospitalization.” The average person doesn’t realize that the majority of serious, even deadly, psychiatric problems do not involve hospitalization.

Curt D. Furberg, M.D., Ph.D., professor of Public Health Sciences at Wake Forest Baptist, commented, “The FDA hospitalization studies were flawed because they could not capture most of the serious psychiatric side effects, including suicide, depression, aggression and assaults. These can be catastrophic events but do not normally result in hospitalization.”

Is it ethical to expose children between the ages of 12 and 16 to a drug linked to depression, suicide, aggression, assaults, and serious accidents? An indication that doing so might be asking for trouble is found in a 2007 report from The National Center on Addiction and Substance Abuse at Columbia University (CASA).

The CASA analysis also found that among teens ages 12 to 17, twice as many smokers as nonsmokers suffered from symptoms of depression in the past year. Teens who reported early initiation of smoking were more likely to experience serious feelings of hopelessness, depression and worthlessness in the past year. The report also notes that smoking at a young age is related to panic attacks, general anxiety disorders and post-traumatic stress disorder.

So if you take a group of smokers that already has a tendency to experience depression, panic, anxiety, etc., and give them a drug that has been known to trigger these experiences even in adults with no previous history of mental illness, what should you expect will happen?

In fact, nicotine’s documented beneficial effects include relief from depression and anxiety as well as improvements in attention, concentration, and memory. If an adolescent has been using nicotine as a form of self-medication for these problems, it stands to reason that abstinence will exacerbate their situation.  The harmful effects of Chantix have been known to continue even after discontinuing the medication. Thus, there is a possibility that nicotine, or new medications based on nicotine, will be rendered ineffective for treatment of mood and/or cognitive impairments by exposure to Chantix.

The $805 payment for participation in the clinical trials is a serious ethical concern.  Presumably this amount is paid to the parents, rather than to the adolescent participant. To some families, this amount is a substantial sum that might represent enough incentive to participate in a harmful study against his or her better judgment.

It is entirely foreseeable that some parents of 12 to 16 year old smokers interested in an $805 reward might not be able to understand all of the warnings, disclaimers, and legal release papers required for participation in the research project. Imagine how they will feel if their child develops a serious mood disorder, injures someone else, or commits suicide.

There are much less risky ways to quit smoking.  If the standard treatments leading to abstinence have been ineffective, there are THR products with a proven record  of minimal health risks. Unfortunately, the Tobacco Control Industry (TCI) appears to be dedicated to the concept of “complete nicotine cessation at all costs.”  Given the Chantix track record of serious illnesses, injuries, and deaths, the costs can be astronomically high.

The TCI is so intent on pursuing their myth that everyone wants abstinence that they will violate the norms of medical ethics and human decency in hopes of achieving their goal of prohibition.

“Smoking” and “nicotine” are not synonyms

posted by Elaine Keller

The truthful statements in Justin Rohrlich’s story Smokeless Tobacco Advocate Rails Against ‘Frauds, Extremists, Liars’  were based on a two-hour-and-ten-minute phone interview with Smokefree Pennsylvania’s Bill Godshall. (How Rohrlich managed to gather so much information from Godshall in such a short phone call escapes me, but I digress.)

As a representative of one of the “Frauds, Extremists, Liars,” Danny McGoldrick, the Vice President of Research for the Campaign for Tobacco-Free Kids, was invited to comment, probably with the intention of bringing “balance” to the story.

To make any sense whatsoever of McGoldrick’s statements, you need the trANTZlator  that Carl recently introduced for the common Anti-Nicotine and Tobacco Zealot (ANTZ)  phrase, “smoking cessation.” Anyone who applies the common meanings of the words “smoking” and “cessation,” would think it is obvious that this phrase refers to the stopping (i.e. “cessation”) of the inhaling and exhaling of smoke.

*Gong* Wrong. When ANTZ people say “smoking cessation”, what they really mean is the act of stopping the use of any form of nicotine. Get it? Smoking = nicotine. Nicotine = smoking.

This is how Danny McGoldrick managed to testify at a legislative hearing on Tobacco Harm Reduction (THR) in Oklahoma with a straight face:

“…if the tobacco companies want to promote smokeless tobacco or anything else as a smoking cessation product, they can do this through the Food and Drug Administration like other cessation products by demonstrating with science that their products are a safe and effective way to quit smoking.”

“If the evidence is anywhere near what they claim, this should not present a problem for them,” he told the panel of lawmakers.

“There’s no evidence that people use smokeless tobacco to quit.”

There’s that bugaboo that Carl discussed in two previous posts: There is never no evidence (Part 1) and There is never no evidence (Part 2.) McGoldrick’s claim is nonsense from a scientific perspective.

If by “quit,” McGoldrick means “quit inhaling smoke,” it’s hard to believe that a man who holds the title of “Vice President of Research” was unable to track down any of the following articles, published in peer-reviewed scientific journals.

Effect of smokeless tobacco (snus) on smoking and public health in Sweden: “Snus availability in Sweden appears to have contributed to the unusually low rates of smoking among Swedish men by helping them transfer to a notably less harmful form of nicotine dependence.”

Is Swedish snus associated with smoking initiation or smoking cessation? “We investigated whether Swedish snus (snuff) use was associated with smoking cessation among males participating in a large population based twin study in Sweden. Snus use was associated with smoking cessation but not initiation.”

Randomized, placebo-controlled, double-blind trial of Swedish snus for smoking reduction and cessation: “Swedish snus could promote smoking cessation among smokers in Serbia, that is, in a cultural setting without traditional use of oral, smokeless tobacco.”

The association of snus and smoking behaviour: a cohort analysis of Swedish males in the 1990s: “We found clear associations between the two habits. For the younger cohort (age 16-44 years), snus use contributed to approximately six smoking quitters per smoking starter attributable to snus. For the older cohort (age 45-84) there were slightly more than two quitters per starter.”

These are far from the only published scientific evidence that snus can be used for smoking cessation. If what McGoldrick really meant was that it is unlikely or unknown whether snus can be used for nicotine cessation, that’s another story. But what he said was “smoking cessation.” So either he is lying about there not being any evidence, or he is extremely incompetent at his job.

Even respected government agencies are guilty of using “smoking” and “nicotine” interchangeably, and therefore misleading the public. All FDA-approved “smoking cessation” products are aimed at a goal of nicotine cessation. There are three problems with this approach: 1) It doesn’t work for over 90% of smokers that try to quit, 2) It isn’t necessary to become abstinent from nicotine to achieve smoking abstinence, and 3) Smokers who switch to a low-risk alternative enjoy the same health improvements as those that used nicotine abstinence to stop smoking.

There are many published scientific reports on the beneficial health effects of switching to smokeless tobacco.

Smokeless tobacco: a gateway to smoking or a way away from smoking: “Sweden has low rates of smoking and a lower rate of respiratory diseases and lung cancers by comparison to other developed countries.”

Health risks of smoking compared to Swedish snus: “Although few in number, these seven studies do provide quantitative evidence that, for certain health outcomes, the health risks associated with snus are lower than those associated with smoking. Specifically, this is true for lung cancer (based on one study), for oral cancer (based on one study), for gastric cancer (based on one study), for cardiovascular disease (based on three of four studies), and for all-cause mortality (based on one study).”

Lung cancer mortality: comparing Sweden with other countries in the European Union: “There were 172,000 lung cancer deaths among men in the EU in 2002. If all EU countries had the LCMR of men in Sweden, there would have been 92,000 (54%) fewer deaths.”

Summary of the epidemiological evidence relating snus to health: “After smoking adjustment, snus is unassociated with cancer of the oropharynx (meta-analysis RR 0.97, 95% CI 0.68-1.37), oesophagus (1.10, 0.92-1.33), stomach (0.98, 0.82-1.17), pancreas (1.20, 0.66-2.20), lung (0.71, 0.66-0.76) or other sites, or with heart disease (1.01, 0.91-1.12) or stroke (1.05, 0.95-1.15). No clear associations are evident in never smokers, any possible risk from snus being much less than from smoking. “Snuff-dipper’s lesion” does not predict oral cancer. Snus users have increased weight, but diabetes and chronic hypertension seem unaffected. Notwithstanding unconfirmed reports of associations with reduced birthweight, and some other conditions, the evidence provides scant support for any major adverse health effect of snus.”

Again, the above are just examples. Anyone can access PubMed’s search system and find many more studies.

Rohrlich’s story states, “Danny McGoldrick just can’t wrap his head around the idea of Big Tobacco’s collective conscience telling it to guide people to smokeless for their health.”

Actually, what McGoldrick can’t wrap his head around is the concept of how Tobacco Harm Reduction works. Or perhaps he just doesn’t want to.

North Dakota’s Lies Freeze Out Smokers and Former Smokers

posted by Elaine Keller

On November 6, North Dakota citizens will vote on adopting a drastically revised version of the state’s anti-smoking law, “Initiated Statutory Measure No. 4 Relating to Prohibiting Smoking in Public Spaces and Worksites.” Absentee balloting has already begun.

Chelsey Matter, a West Fargo respiratory therapist, served as chairwoman for Smoke-Free North Dakota’s sponsoring committee for the initiated measure which required 13,457 signatures on a petition to place the measure on the ballot. SFND appears to be an ad hoc committee made up of members of various anti-smoker groups. Notice that I labeled the groups “anti-smoker” rather than “anti-smoking”

At one time, such groups claimed they were only concerned with protecting the health and safety of bystanders. Now it is clear that the goal is much broader. Their “denormalization of smoking” really means the “demonization of smokers.” And if smokers are demons, it’s OK to punish them, in some of the worst possible ways, even after they have stopped smoking.

The ballot item reads as follows;

Initiated Statutory Measure No. 4

This initiated statutory measure would amend chapter 23-12 of the North Dakota Century Code. This measure would prohibit smoking, including the use of electronic smoking devices, in public places and most places of employment in the state, including certain outdoor areas. It would provide notification and enforcement responsibilities, along with penalties for violations.

YES — means you approve the measure summarized above.
NO — means you reject the measure summarized above

The ballot language itself and the propaganda issued by the anti-smoker groups that initiated the measure contain some blatantly false claims as well as implied false claims.

FALSE CLAIM 1: Workers currently have no protection against smoke in the workplace.

Supporters claim the ballot measure is needed “to assure smoke-free air for all workers and most public places,” implying that most or all North Dakotas have no clean air in which to work.

THE FACTS: North Dakota’s Century Code is the codification of all general and permanent law enacted since statehood. Under the current law, Chapter 23-12-09, “Smoking in public places and places of employment,” smoking is prohibited in all enclosed public areas, with few exceptions.

FALSE CLAIM 2: Electronic cigarette vapor is identical to conventional cigarette smoke.

The proposed new version of the law adds “e-cigarette” to the definitions section and revises the definition of “smoking” to imply that vapor is the same thing as smoke.

THE FACTS: A recent study published in Indoor Air compared exhaled smoke to vapor. In vapor they could detect only 6 of the 20 highest concentrations of chemicals found in smoke.

The amounts of the six chemicals measured in vapor could be expressed as whole numbers only by converting to parts per BILLION (ppb). All were far, far below harmful limits. For example, formaldehyde was present at the equivalent of 13 pennies out one billion (ten million dollars worth of pennies.) The Alberta Ambient Air Quality Objectives for formaldehyde is five times higher.

Furthermore, since vapor is not produced by the process of combustion, it does not contain the harmful tar, carbon monoxide, particulates, and thousands of chemicals found in smoke. A U.S. Federal Court judge told the FDA that there is “no evidence to show that electronic cigarettes harmed anyone.”

FALSE CLAIM 3: Vapor exposes bystanders to the dangers of nicotine.

An opinion piece written by one of the measure’s proponents stated, “… there is no study that shows what a safe level of nicotine is and, personally, I don’t believe there is one.”

THE FACTS: Nicotine may be the least harmful of any of the ingredients in smoke. But even if it were more dangerous, the point is moot, because exhaled vapor does not expose bystanders to nicotine. In the Indoor Air study, researchers could detect nicotine only by capturing exhaled vapor before it mixed with air in the chamber.

The quantity of nicotine measured was a mere 1.04 ppb; the OSHA Short Term Exposure Limit is about 1500 times higher.  And the only way a bystander could come into contact with this tiny, tiny amount would be to lock lips with an e-cigarette user as he or she exhales.

FALSE CLAIM 4: E-cigarette users are trying to get around anti-smoking laws.

The revised definition of ‘smoking” claims that e-cigarettes are used for the purpose of “circumventing the prohibition of smoking in this Act.”

THE FACTS: The only way someone can be “circumventing the prohibition” of any action would be to actually be doing the prohibited action. Using an e-cigarette is not smoking. In fact, most e-cigarettes are former smokers who use the devices to avoid relapsing to smoking.

FALSE CLAIM 5: The new law will protect health and improve the economy.

According to a news item, Matter says the Smoke-Free North Dakota committee decided to move forward because of the positive health and economic impact a smoke-free law would have on the people of North Dakota.

THE FACTS: The measure will endanger the health of many people and negatively impact the hospitality industry.

Banning the use of e-cigarettes indoors endangers the health of former smokers who may be tempted to relapse if sent out into the elements with the smokers. Many smokers first discover the safer devices when they see them being used where smoking isn’t allowed. Banning indoor use removes an incentive for smokers to switch to a low-risk alternative.

The measure removes exemptions for bars, outdoor stadiums, tobacco shops, private rooms in hotels and motels, and private nursing home rooms. California Governor Jerry Brown recently vetoed a nursing home smoking ban, stating it would be “reasonable to allow elderly smokers to remain inside during inclement weather.”

The measure does not allow hotels and motels to set aside some designated rooms for smokers. If this measure is passed, North Dakota will provide no overnight shelter for smokers (and users of smoke-free e-cigarettes) outside of private homes.

The law will change the definition of “enclosed area” to prohibit smoking in most designated outdoor smoking areas. The original definition was meant to apply to indoor areas only.

“Enclosed area” means all space between a floor and ceiling that is enclosed on all sides by solid walls or windows, exclusive of doorways, which extend from the floor to the ceiling.

To be exempted from inclusion in the definition of “enclosed area” where smoking is prohibited,  outdoor shelters would provide inadequate protection from the elements.

“Enclosed area” means all space between a floor and a ceiling that  has thirty-three percent or more of the surface area of its perimeter bounded by opened or closed walls, windows or doorways. A wall includes any physical barrier regardless of whether it is open or closed, temporary or permanent, or contains openings of any kind, and includes retractable dividers and garage doors.

Many businesses made a considerable financial investment in constructing and heating shelters to protect the health of their employees and their patrons.

In Norse mythology, Hell is a cold, freezing place. Sending paying hotel guests, restaurant patrons, sick people, and former smokers out in the elements is downright rude. But given the nature of North Dakota winters sending anyone outside and simultaneously reducing the size of shelters to less than 33% walls could be life-threatening.

Public health officials may have a responsibility to reduce the smoking rate, but nobody gave them the authority to accomplish it by hastening the demise of smokers.