Tag Archives: Burstyn

Sunday Science Lesson: So how would you estimate how many deaths are caused by smoking?

by Carl V Phillips

This continues from last week’s post. In that post, I pointed out what a death caused by smoking even means. (Recall: It technically means a death hastened by even one second. This means that basically every death in an ever smoker could be included, though this is clearly not how people interpret the figures and even those who are trying to exaggerate the number do not actually game it this way. Still, it is not clear what the claims do mean.) I then explored what data you would ask for if you could have any data you wanted to answer the question, a critically important thought experiment in epidemiology that is almost never done. (Recall: You would want to run an alternative history of the world where no one smoked but all else was the same, and compare the death counts.) Today I am going to move from that into what we can actually do with the data we can get, and why it fails to do a very good job answering the question. Continue reading

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Post publication peer-review: Correction to Burstyn (2014) and related matters

by Carl V Phillips and Igor Burstyn

[Igor Burstyn is an Associate Professor at Drexel University School of Public Health and a member of the CASAA Board of Directors. His research that is described here was sponsored by CASAA.]

Burstyn (2014), “Peering through the mist: systematic review of what the chemistry of contaminants in electronic cigarettes tells us about health risks”, BMC Public Health, is probably the most read scientific paper on e-cigarettes and among the most read in the history of tobacco harm reduction. It is often described as the most important paper on e-cigarettes, being the first to point out that there is ample existing evidence that the non-novel chemical exposures from vaping – which are used to concoct alarmist propaganda — are inconsequential. So imagine our surprise when, after well over 100,000 people had viewed the paper at the journal’s website and countless more via other means (the announcement of the publication of the working paper version remains the most read post on this blog), it went through journal peer-review, and each of us poured over many revisions, one astute reader caught a bright-line error in the results. It is recounted in the following text by IB: Continue reading

Glantz vs. Burstyn – hardly a fair fight

by Carl V Phillips

Ok, I am giving in to all the lobbying I have gotten to respond to Stanton Glantz’s inane attack on the Burstyn study.  I will call it my Sunday Science Lesson for the week.

I am not going to bother to submit at Glantz’s page because though Glantz makes is page look like a blog, it really isn’t — he censors out any comments he does not like.  (That, of course, is not true here — he or anyone who agrees with him is free to respond in the comments without fear of censorship.)  Indeed, at the time of this writing the only comment allowed, despite several readers of this blog reporting that they wrote comments, was one by a clueless supporter of Glantz who clearly did not even read the paper (I am not addressing that, but it is addressed by Konstantinos Farsalinos here).

[UPDATE: Not too long after this post was published, several comments submitted on Glantz’s post that had already been posted in comments in this blog but had not been left unapproved by him for days were allowed to post.  Funny that.]

I am pretty sure that Prof Burstyn is not going to be interested[*] in wandering over to see the ramblings of Glantz and other anti-scientific extremists, so this will also serve the purpose of letting him know what was claimed.

[*The passage from Alice’s Adventures in Wonderland comes to mind:

“But I don’t want to go among mad people,” Alice remarked.  “Oh you can’t help that,” said the Cat. “We’re all mad here. I’m mad. You’re mad.” “How do you know I am mad?” said Alice. “You must be,” said the Cat, “or you wouldn’t have come here.”  ]

My first observation is that Glantz’s attack serves as  a testimonial that he recognizes that Burstyn’s paper is important and a threat to anti-scientific lies about e-cigarettes.  Glantz responded about four hours after the paper became available — not really enough time to seriously read a new paper, let alone think through how to comment on it.  This was a clear example of panic.  The panic was not about the study being used in advocacy or showing up in newspapers — that will happen slowly, over the course of months or years, so there would be no need to hurry.

No, it was quite clear that he was panicked about the ANTZ’s useful idiots hearing about it and possibly learning something their puppet masters did not want them to know.  I am talking about the people working in county public health departments, GP medics, etc., who genuinely care about health and thus would support THR if they knew the facts, but whose misplaced trust has made them victims of the anti-THR liars like Glantz.  If they heard about this before they could be pre-propoagandized, they might learn something.  So Glantz’s junk response was rushed out through the (not-entirely-secret) secret communication channels that are used to keep the useful idiots in line.

(For those who do not know, the ANTZ mostly communicate through these secret channels, in contrast with the behavior of truth-seeking or public-interested advocates, who communicate openly.  They do this because (a) they know that if the made their claims in the light of day, their lies would be ripped to shreds and their useful idiots might rebel and (b) like most political (i.e., not truth-seeking) groups, they like to create the illusion of a consensus by instructing hundreds of seemingly unrelated people to “spontaneously” make the same observations to the press, hiding the fact that this is really just a few thousand people trying to look like they are a broad political movement.)

So, I award one point to Burstyn for Glantz’s panicked reaction.

Skipping first to the end, and Glantz’s only substantive claim in his attack:

The analysis also ignores the high levels of ulttrafine particles e-cigs generate that can trigger inflammatory processes and trigger heart attacks and respiratory problems.

This is actually LOL funny if you are enough of a geek.  Those two links (in the original, of course) are to fairly arcane statistical analyses of epidemiologic data, so they cannot actually tell us anything about mechanisms (like inflammatory processes), only observable population outcomes.  However, if Glantz were not so averse to using honest science, he actually could have actually supported this claim using relevant evidence about the tissue effects that has been done by tobacco companies (example).  But his citations and all the research that actually supports his claims are about the effect of combustion products.

The lung and heart problems result from solid particles, whereas e-cigarettes produce liquid particles (aka aerosol or droplets) which have entirely different properties.  Some types of small solid particles can lodge deep in the lungs, creating problems over time, or travel into the bloodstream, maintaining their form, and do damage elsewhere.  Small liquid particles do exactly the same things as larger ones in the lungs — they transfer the liquid through the lung (there is nothing to lodge), which is then diluted into the blood (there are no longer any particles).  Indeed, it appears that small droplets are probably better because devices that apparently deliver smaller droplets (e.g., using bigger batteries) seem to be preferred by consumers (though I would expect that in Glantz’s anti-humanitarian view, “preferred by consumers” is a bad thing).

Glantz presumably knows that e-cigarettes produce liquid particles, since it is right there in Burstyn’s paper, as well as being common knowledge about e-cigarettes.  Moreover, Burstyn points out that chemistry studies that have been used to suggest there are inorganic solids in the vapor are misleading, since they do not assess what molecular form the metals were in; he points out that they were most likely dissolved salts (i.e., part of the liquid).  Thus, apparently Glantz’s problem (this is the LOL part if you are geeky enough) is that he does not understand the difference between liquids and solids.  This perhaps explains why he had to leave mechanical engineering (where not knowing the difference between liquids and solids can be rather disastrous) and go into anti-tobacco extremist activism (where it is not such a problem to not know… well, anything).

So, clear point to Burstyn there.

Circling back to his less substantive points, he leads with standard ANTZ drivel:

This paper uses  the same approach to risk assessment that I remember from risk assessments done of secondhand smoke years ago by tobacco industry apologists that concluded that secondhand tobacco smoke could not produce any adverse health effects.

What same approach to risk assessment?  Reviewing studies?  Calculating exposure levels?  Putting exposure levels in a useful perspective?  Basing conclusions on data rather than political goals?  Writing in English?

Of course this paper uses the same approach to risk assessment as other approaches to risk assessment.  Someone with a great deal of experience at doing such research (Burstyn) is going to use the accepted methods (though since he is one of the great epidemiologic thinkers of his generation, I am confident that he used the best of these, and did not blindly follow what is typical).  Someone who does not actually read much (Glantz) is going to notice that these look a lot like the only other risk assessments he has ever looked at.

Notice that Glantz’s statement is designed to make his typical sloppy reader believe that he said “there are elements of this analysis that are similar to Evil Evil Tobacco Company analyses of ETS and different from what is normally done in the analyses that are used to make exposure policy.”  But he does not say that, does he?  (The above quote is everything he says.)  He could have given even a single example of how Burstyn’s analysis had something in common with the studies he denigrates (though notice he does not actually find fault with them) and that differs from those used to make thousands of regulatory decisions about airborne exposures, but he did not.  Presumably he had nothing in mind beyond misleading innuendo.

This is such a stupid claim by Glantz that perhaps it would be too generous to award Burstyn a point for it, but Glantz definitely gets a -1 penalty for it.

Glantz follows that with:

The first problem with this study is that it compares levels of various toxins in e-cigs with threshold limit values (TLVs) which have been published by the American Council of Government Industrial Hygienists using that are generally viewed as not health protective.  In addition, as noted in the report, TLVs are for occupational exposures.  Occupational exposures are generally much higher than levels considered acceptable for ambient or population-level exposures. Occupational exposures also do not consider exposure to sensitive subgroups, such as people with medical conditions, children and infants, who might be exposed to secondhand ecigarette emissions.  Finally, even when setting allowable occupational exposures, regulatory agencies like OSHA often establish tighter standards than TLVs, and often those tighter levels have been criticized as not being health protective.

His basis for that claim about “not health protective”?  Burstyn explained and defended the choice of the TLVs; Glantz tries to trick his readers into believing that Burstyn just made a random choice without justification. Burstyn points out that occupational standards are actually rather conservative (i.e., highly protective) when we are talking about an intentionally-chosen exposure.  We all engage in countless activities that expose us to hazards that, if they were an involuntary hazard that was being forced upon workers in order to be able to keep their jobs, would not be allowed, or at least there would be mandatory mitigation measures imposed.

Glantz’s only basis for this attack appears to be quotes from Wikipedia — I did not notice before that this is what he links to (another LOL moment!).  The rest of that sentence is a close paraphrase of a sentence in the Wikipedia entry (and both the entry and Glantz assert the claim without support).  So Glantz is relying on an unsupported statement by an anonymous author (which might even be himself) of a single line of a general-knowledge encyclopedia.  (For those who may not know, Wikipedia is an excellent source for countless areas of inquiry, but every scientific expert knows that it fails miserably — for fairly obvious reasons — when dealing with controversies in science or science-based policy.)

But setting that aside, let us assume that Glantz genuinely believes there are better standards to compare an exposure to.  Fine.  That almost starts to look like a comment by someone who is actually seeking the truth.  Indeed, in private comments, several reviewers of the paper who are actual peer reviewers (i.e., expert enough to provide useful comments) have suggested that the next version make comparisons to some other standards too, which would show that the conclusions do not depend on the choice of standards (so long as Burstyn avoids absurd standards like an EPA standard for formaldehyde that apparently makes being in the same room as yourself an unacceptable hazard).

But Glantz’s statement only almost looks like that of someone interested in the truth.  Someone who was minimally attempting to seek the truth would have suggested a specific alternative comparison.  He makes a vague allusion to OSHA standards (again, apparently quoting from Wikipedia), but does not actually say “I think this would be better”.  Someone who was both seeking the truth and expert, and trying to be useful, would go so far as to pick one of those alternative standards and compare it to Burstyn’s numbers (a fairly simple exercise).  Even someone lacking the numeracy to be able to do that, but who was interested in the truth, could say something like “if he were to compare the levels to Standard X and still find that they were non-problematic, then I would believe him.”  But of course Glantz did not do any of that, because he already guesses that the answer will not support him, so he does not want to commit to ever believing any science.  He already plans to come up with some other rationalization for ignoring the truth when this one is shown to be wrong.

Notice also that he brings in the chiiiildren.  He implies that Burstyn’s analysis was about ambient and population exposures.  Is he lying to his useful idiots or just incapable of understanding the paper?  We cannot be sure.  But those of us who did understand the paper know that the numbers analyzed are for the exposure to the vaper herself, and that any second-hand exposure is noted to be orders of magnitude smaller still.  That is, the second-hand exposure is not merely well below the TLVs; it is orders of magnitude lower than the numbers that are already well below the TLVs.  Burstyn never tries to compare the exposure of bystanders to TLVs or any other standard because he reports that those exposures are so unimaginably low that it makes no sense.

Burstyn does not make the point that someone who has a medical condition that contraindicates e-cigarette use should not use them, but he does point out that it is a voluntary exposure and the rest obviously goes without saying.  And, of course, Glantz does not identify what conditions he might be talking about, he just vaguely waves his hands because he does not want to get pinned down so that he cannot change his story later.  (I will believe that he actually cares about second-hand exposure — rather than just using it as a rationalization for fighting THR — the day he recommends that smokeless tobacco should be endorsed over e-cigarette use, or even just over smoking.)

So, one point to Burstyn for explaining why occupational standards are actually conservative, a clear victory over Glantz just lifting some vague and unsubstantiated claims from Wikipedia.  One point to Burstyn for pointing out that the second-hand exposures are orders of magnitude less than the vapers’ exposures, a clear victory over Glantz trying to pretend this is not the case.  Because I cannot find anything else that could possibly earn Glantz a point, I am going to take pity and give him one for the very charitable interpretation of this passage as saying “you should probably include comparisons to other published exposure limits in order to make the accuracy of your conclusions more clear.”  However, I am going to penalize him a point for relying on Wikipedia for claims about a scientific controversy, just as I would penalize any undergraduate, let alone graduate student.

Finally, Glantz ends his missive with a random ad hominem attack on me.  This is especially pathetic because, obviously, I am not even an author of the study.  He attacks Burstyn because he mentions me in the acknowledgments.  It is like second-hand ad hominem (1000 times less harmful than the already inconsequential implications of an ad hominem attack).   The content of the attack is basically, “Phillips does not share my irrational hatred of tobacco products and tobacco companies.”  I will take that as a complement.  This is especially the case because I have repeatedly pointed out (and endorsed others pointing this out too; no links because there are too many to track down), based on actual analysis, not ad hominems, how Glantz is both scientifically clueless and dishonest.  And yet the best he can come up with about me, after all that, is that I do not share his irrational hatreds.

Another -1 for Glantz for exposing us to second-hand ad hominem, and even though I am not actually in the match, I am going to award myself a point for the fact that he cannot come up with even a single criticism of my analyses.

So the final score:  Burstyn gets a hat trick plus one, and Glantz nets negative one, which puts him behind me, even though I was not even on the pitch.  Come to think of it, it also puts him behind the 7 billion other people who have not entered the conversation at all.

A really good day for THR (navel gazing)

by Carl V. Phillips

I am assuming that there is no one reading this who did not already see yesterday’s post, so I will not even include a link.  The release of Igor Burstyn’s paper was huge for THR, making clear that the apparent risk from vaping is not only lower than the anti-THR liars are trying to portray it, but probably even lower than those of us who are interested in the truth and familiar with the science thought.

On the same day, we won a victory in the fight against inappropriate e-cigarette bans and learned of an amazing success story about THR in a clinical setting (I am seeking permission to report that story here).  Small scale in comparison to the study, I realize, but it makes for a good day.  And at the even smaller scale and purely personal level, first thing yesterday, before writing the blog post and the release of the study, I did what turned out to be great interview on talk radio.

It all added up to me thinking, “this is one of the best days in the history of THR”.  Not top five, but I found I had a hard time pushing it out of the top ten.  As you might expect, that got me thinking about what other days should appear on such a list.

The top few on the list definitely include the release of the seminal Rodu and Cole paper (Nature, 1994) that was the first major science and ethical statement in favor of THR, and when Judge Leon prevented the US FDA from banning e-cigarettes here in 2009.  I am also inclined (though obviously biased) to include up there the appearance of TobaccoHarmReduction.org, published by my research shop at University of Alberta in 2006 and updated for a few years after that; we got more press about that in Canada than “World No Tobacco Day” (the day we chose to release it) did, and the website is the source of a huge amount of the current popular wisdom about THR, even among many people who got here later and have never heard of it.  (Like the 1994 paper, it is still out there but quite dated now, and yet still is often read — though I would recommend against citing it for any purposes other than historical analysis.)  I am also inclined (and obviously biased) to include the creation of CASAA near the top.

At that point, I decided to crowdsource it.  Any thoughts from biases other than my own?  What are the best moments?  It definitely does not have to be an identifiable day, but I am looking for the relatively concrete and not just general phenomena (i.e., the gradual appearance of e-cigarettes on the market does not count, nor the gradual success of THR in Sweden).

It would be great to include the introduction of specific THR products into particular markets, which does tend to involve a clear moment in time, but sadly most of those efforts flopped (maybe Camel Snus?).  One or more of the moves by big companies into e-cigarettes might prove important, but it is hard to tell now, and for similar reasons hard to be sure something like the founding of NJOY should make the list; in such cases, it is tough to say that something really made the world different, rather than merely being a matter of who edged out competitors that would have been almost exactly the same.

No political victory compares to 2009, but what are the candidates for the list? Defeating the proposed New York ban?  The original MHRA decision to allow THR to be an “indication” for use of a product would surly be high on the list, but for what has come later that seems to make that part of a larger picture that does more harm than good — so include it?  The granting to Sweden of an exception to the anti-health EU snus ban comes to mind, but since Sweden would presumably not have joined the EU without it, it does not seem to count.

What other research publications?  It is really hard to identify many individual publications that had much of an impact.  Rodu’s book from the 1990s or others by him?  There are a few candidates about smokeless tobacco.  The nascent research on e-cigarettes does not seem to offer candidates — there are good and useful studies, but no game changers other than yesterday’s.  I am partial to a few of my other publications, but I can’t say they made much of a splash at the time; my 2006 calculation about comparative risks is quoted constantly without people knowing they are doing so (“99% less harmful”), but it is hard to identify any “moment” for that one

Prominent policy opinion statements?  The first Royal College of Physicians report on the topic is a clear candidate.  (But please do not suggestion Clearing the Smoke — bleah!)  Was there an identifiable moment for Bates launching his backing of THR (I honestly forget — getting old)?  I can’t think of any clear “moment” for Godshall or Stimson, but maybe there was one.  (All three of you read this, so I demand answers!! ;-)  IHRA embraced THR for about five minutes, but we subsequently lost that fight, so no credit there.

So that is my brainstorm.  Should be enough to get some thoughts flowing.  Your turn.

Breaking News: New study shows no risk from e-cigarette contaminants

by Carl V Phillips

[UPDATE 4, 11 Jun 15: A correction to one of the results in the study has been posted to this blog by the author. As of yet, the journal has not posted the correction as requested.]

[UPDATE  3: The published version of the paper, at BMC Public Health, is now here.]

[UPDATE:  Here is CASAA’s press release about this.]
[UPDATE 2: Here is the post of the press release at CASAA’s main blog (same content as above link, but with a link to here for discussion — so a better choice if you want to share the press release).]

CASAA is delighted to announce that the first research study funded by the CASAA Research Fund (thanks to all of you who donated to that!) has been released.  The study, by Prof. Igor Burstyn, Drexel University School of Public Health, is available at the Drexel website, here (pdf).  Burstyn reviewed all of the available chemistry on e-cigarette vapor and liquid and found that the levels reported — even in those studies that were hyped as showing there is a danger — are well below the level that is of concern.

And that assessment applies to the vaper himself.  The exposure to bystanders is orders of magnitude less and of no concern at all.

The paper is technical, of course, but I believe it does a great job of communicating for readers at many levels.  It puts the results in very clear and useful terms — exactly what policy makers need for making decisions.

For the first time, we have a definitive study that can be used to respond to claims that contaminants in e-cigarettes are dangerous and that there is a hazard to bystanders that calls for usage restrictions.  Existing individual chemistry studies have been difficult for anyone other than an expert to understand (which is why we gave a grant to an expert to understand them!), and a naive interpretation of individual studies (just reading what the authors editorialized about their results) gave the impression of “dueling studies”, with some showing a problem and some not.  While many THR advocates made an effort to make sense of and use the existing literature, it was almost impossible to do so effectively.  Burstyn’s analysis solves that problem and shows there is no duel:  All of the studies, including the “bad” ones, show that there is no worry.

I cannot overstate it:  This is a game-changer for anyone trying to respond to misinformation about the hazards of e-cigarettes.  Before we had an apparently contradictory mess on this topic.  Now we have clarity.

I have to say that I am genuinely surprised that the results are quite so definitive, and I assume that will be true of anyone else of was seriously trying to assess the risks, rather than just cheerleading.  We were all confident that the risks were minimal, but we could not previously reach a (good news) conclusion as strong as the one in the paper.

The list of key conclusions in the paper:

  • Even when compared to workplace standards for involuntary exposures, and using several conservative (erring on the side of caution) assumptions, the exposures from using e-cigarettes fall well below the threshold for concern for compounds with known toxicity. That is, even ignoring the benefits of e-cigarette use and the fact that the exposure is actively chosen, and even comparing to the levels that are considered unacceptable to people who are not benefiting from the exposure and do not want it, the exposures would not generate concern or call for remedial action.
  • Expressed concerns about nicotine only apply to vapers who do not wish to consume it; a voluntary (indeed, intentional) exposure is very different from a contaminant.
  • There is no serious concern about the contaminants such as volatile organic compounds (formaldehyde, acrolein, etc.) in the liquid or produced by heating.  While these contaminants are present, they have been detected at problematic levels only in a few studies that apparently were based on unrealistic levels of heating.
  • The frequently stated concern about contamination of the liquid by a nontrivial quantity of ethylene glycol or diethylene glycol remains based on a single sample of an early technology product (and even this did not rise to the level of health concern) and has not been replicated.
  • Tobacco-specific nitrosamines (TSNA) are present in trace quantities and pose no more (likely much less) threat to health than TSNAs from modern smokeless tobacco products, which cause no measurable risk for cancer.
  • Contamination by metals is shown to be at similarly trivial levels that pose no health risk, and the alarmist claims about such contamination are based on unrealistic assumptions about the molecular form of these elements.
  • The existing literature tends to overestimate the exposures and exaggerate their implications.  This is partially due to rhetoric, but also results from technical features.  The most important is confusion of the concentration in aerosol, which on its own tells us little about risk to heath, with the relevant and much smaller total exposure to compounds in the aerosol averaged across all air inhaled in the course of a day.  There is also clear bias in previous reports in favor of isolated instances of highest level of chemical detected across multiple studies, such that average exposure that can be calculated are higher than true value because they are “missing” all true zeros.
  • Routine monitoring of liquid chemistry is easier and cheaper than assessment of aerosols.  Combined with an understanding of how the chemistry of the liquid affects the chemistry of the aerosol and insights into behavior of vapers, this can serve as a useful tool to ensure the safety of e-cigarettes.
  • The only unintentional exposures (i.e., not the nicotine) that seem to rise to the level that they are worth further research are the carrier chemicals themselves, propylene glycol and glycerin.  This exposure is not known to cause health problems, but the magnitude of the exposure is novel and thus is at the levels for concern based on the lack of reassuring data.

It is worth expanding on the observation about propylene glycol and glycerin a bit:  While there is no affirmative reason to believe that the level of exposure experienced by vapers is hazardous, we have never before had a situation where millions of people had such a high level of exposure.  Thus it is worth gathering data on what happens, just to make sure there is no small subtle effect.  This contrasts with the levels of the much-hyped contaminants, which pose no concern at all.  It is also important to remember that this refers to the vaper herself; there is no such caution for bystanders, who have far far lower levels of exposure.

This paper should immediately become a central point in all political advocacy to stop anti-e-cigarette regulations, as well as trying to encourage smokers to adopt THR.  The key talking point that should be used is this (my words, not Burstyn’s):

The only expert review of all of the studies found that there was no risk from the chemicals to vapers, let alone bystanders.  This took into consideration the studies that you are referring to [note: assuming this is being used as a rebuttal to some claim of chemical hazards].  Indeed, even the results of the studies that have been used to generate alarm represented levels of chemicals that were too low to be of concern.

For those of you who have any comments for the author, particularly peer review (or even non-peer review) comments for improving on the working paper before it is submitted to a journal[*], please use the comments section of this post.  The author has agreed to monitor one page (this one), but will probably not see it if you post a comment at another blog, on ECF, etc.

[*Footnote: To head off a concern I have heard a few times, no, there is not a problem with the author releasing a working paper before submitting to a journal.  A handful of medical and general-science journals — those that are trying to sell copies as if they were a glossy magazine — like to have “exclusives” of previously secret studies (which, by the way, is why they publish far more papers that are shown to be wrong than do more serious journals).  Serious science journals generally prefer that the paper is circulated and commented on before they are asked to deal with it.  Indeed, in several of the more serious sciences (public health will catch up in a few decades — perhaps), working paper versions are considered the key source of scientific communication, and the eventual appearance in a journal is more of an afterthought and happens long after everyone has already read the paper.  Real peer review is what starts now (here) when every interested expert can read and comment, rather than at a journal where a couple of people with their limited knowledge are the only ones reviewing it.

[Of course, that knowledge does not help you if you are dealing with people who do not understand how science works and are not likely to listen long enough to learn.  There will be retorts of “that is not a peer-reviewed publication” (which is actually not true — it was reviewed before the author released it).  Your best talking point in response to that is something like, “So are you saying that in a few months, when the paper appears in a journal, you will agree that it is all correct and change your position?”  If you are responding to someone who claims to be an expert, you can add “So, why don’t you just review it like other expert readers have done, or are you admitting that you are not expert enough to do so?”

[UPDATE 3 vers.2: Later posts here that relate to this study can be found at this tag.]