Tag Archives: gateway

Gateway effects and snus taxes in Alberta

by Catherine M Nissen

[Editor’s Note: This is a guest post by CASAA Research Associate, Catherine Nissen. –CVP]

As most readers of this blog know, the gateway effect argument has been used aggressively by anti-THR advocates against smokeless tobacco and electronic cigarettes. They claim that using the low-risk alternatives will cause people to start smoking. Recently I have been working with Carl V Phillips on his paper about detecting gateway effects. He explains the logic of the claim and why it would be unlikely to occur in natural circumstances. But, as he explains, policy actions could manage to create gateway effects, either intentionally or inadvertently. Even then, he was able to offer only a few examples of where it might have happened. I am living in the middle of one of those examples, in western Canada.

As Carl has noted a few times (example), several nonsmoker experts on low-risk tobacco products have started using snus as adults because they learned about the minimal health risk and wanted to reap the benefits of the cognitive enhancement and risk reduction in neurodegenerative diseases that tobacco offers. While I may not be among the esteemed senior scientists he is referring to, and I admit I use snus a bit more for the pure pleasure of it rather than the cognitive enhancement, I am among those who took up snus use after learning about the low costs and substantial benefits. My grandmother suffers from Parkinson’s, and the risk reduction from it that tobacco offers is definitely among my motivations for continued use. I am also among the unfortunate few who have been pushed from low-risk product use into smoking some of the time. I am not sure whether this counts as a gateway case. It certainly is not an example of what the tobacco controllers have in mind when they make the gateway claim, since they are the ones responsible for it.

I have only smoked very occasionally throughout my life, yet I enjoy using snus (smokeless tobacco). I have a firmly established preference for nicotine, but I also have firmly established boundaries on how much I am willing to pay to enjoy it. I am a nonsmoker because the cost of smoking, health-wise, was always too much for me.

After Carl established the tobacco harm reduction research and education efforts at the University of Alberta School of Public Health in the 2000s (a group that would later include me, Karyn Heavner, and several others who have contributed to the field, along with Igor Burstyn sitting in), he, Paul Bergen, and some of Carl’s students launched the first concerted attempt to widely popularize the THR message. In response to this, the anti-tobacco people in Alberta shifted their effort away from trying to discourage smoking to trying to discourage THR. It worked. Today the taxes here on smokeless tobacco are exorbitant. I pay almost $25 for a tin of snus. A pack of cigarettes is about $12, less than half the cost. The price of a tin of snus in the U.S. or overseas is about $4. Under those economic circumstances, only people who are both wealthy enough and highly motivated would choose smokeless tobacco it in lieu of cigarettes. For a person of average means, this price difference is a strong incentive not to try THR, even if they are aware of its benefits.

I have a friend who was a very avid smoker, but armed with the knowledge of THR (simply because he knew me, and despite “public health” efforts to sow disinformation) and the desire to quit smoking, he switched successfully to snus. It wasn’t easy at first, but he became a regular user. As the prices kept rising, though, he moved back to cigarettes. The balance of cost and benefit in his case gave the edge to cigarettes. Eventually, however, he moved back to snus, despite the cost, because of his desire to be smoke-free. He is being punished for that choice, at a rate of about almost $5000 per year more than he would pay for smoking. The difference is because the government is charging him over $7000 per year in taxes on snus, a price he pays for not smoking.

It was much the same with me. I found myself strapped for cash and not willing to pay the cost of snus. My initial brief thoughts on buying cigarettes instead (as I talked about here) became much more prevalent. I caved to them and did buy cigarettes for a time. However, I found I could not smoke more than a pack a week because the health effects from them were so immediate and unpleasant. At the end of a week I would cough throughout my day and my taste and smell were affected. I ended up giving up on cigarettes and now just use snus infrequently. This lowers my welfare substantially from what it would be, and provides no benefit for me or anyone else.

Still, I am luckier than many others. There are countless stories around here of people who prefer smokeless tobacco and have a history of using it instead of smoking sometimes, and being tempted to switch because of the absurd anti-THR price differential. Many of them are also victims of the disinformation about smokeless tobacco and so think there is little or no health difference between the products. For me, the punitive tax on snus made smoking a more attractive option in the short-term, but near-abstinence was more attractive because I understand the huge increase in risk with smoking and because I don’t gain as much from tobacco use as some others do. But others will just choose to smoke. I don’t personally know any smokeless tobacco users who switched to being exclusive smokers because of this tax, but I’m sure there are some because there are many smokeless tobacco users in the region.

So we have a demonstration of policy actions causing a gateway effect from smokeless products to cigarettes (for both a nonsmoker and an ex-smoker). For people uninformed about the health benefits of THR, high taxes on smokeless products (and lower taxes on the more harmful alternative) discourage it. People respond to price in the near term, especially when they are strapped for cash. This is a clear argument for making sure that THR products remain at lower prices than cigarettes, not higher.

As far as I can tell, my story is the only published testimonial of someone who was never a smoker (and clearly never would have become a smoker) who started using smokeless tobacco, and as a result of that became a smoker (though only temporarily). The proponents of the gateway claim never give any examples of people who seem to be gateway cases, which is one of the many reasons that their theory does not hold up to scientific scrutiny. I doubt that my story is what they have in mind, however, since anti-THR efforts were the ultimate cause of this. Without those “public health” policies, I would not have become a smoker.

I am sure a much more common story is like that of my friend who was encouraged to return to smoking even though he wanted to switch, which you might or might not call a gateway effect. This same effect seems to have happened with electronic cigarettes in Spain. It may be happening with electronic cigarettes elsewhere (the UK, California), because disinformation about their risk is tricking many people into believing they might as well smoke. It could certainly happen if all or most e-cigarettes are banned, as the U.S. FDA has proposed.

There is a high prevalence of “natural” smokeless tobacco use in Alberta, probably more than anywhere else outside of Scandinavia and a few rural subpopulations in the USA, because so many people work in jobs where smoking would be difficult. Most likely they don’t know they are engaging in THR (thanks to the disinformation campaigns that are ongoing here). Some may simply enjoy the fact that they are coughing less and experiencing other health benefits from reducing or quitting their smoking. In any case, giving these people a good reason to smoke instead is potentially creating a gateway effect to smoking, and yet it is created by the very people who claim to be worried about gateway effects.

 

Kandel, Kandel, and NEJM: flogging the gateway hypothesis to attack e-cigarettes

by Carl V Phillips

I expected to focus today’s post on all the stupid media reports on the publication that I wrote about yesterday via the CASAA press release. But a funny thing happened: almost nothing. Though this was the type of supposedly-authoritative sensationalism that the press usually eats up, there were remarkably few stories in the American press. So I decided to go old-school with the post instead, and focus on the lies and liars. Continue reading

CASAA response to new study that claims ecigs are a gateway to cocaine

by Carl V Phillips

I will write more about this later. I know it is a bit odd to lead with the response rather than the background analysis, but it has been a long day. By the time you read this, the first of the churnalism articles reporting the junk science claim referenced in the title should already be appearing, so you can see the details of what this press release was responding to. Here is what we sent out, copied below for your convenience.  Please send the above link to reporters and post in comments when you see the inevitable stories start appearing.

[Update: Rodu on this.]

——

CASAA: New claims that e-cigarettes are a gateway to cocaine use are junk science Continue reading

More nonsense about gateway effects – this time from ecig supporters

by Carl V Phillips

It seems that most every researcher or pundit making claims about gateway effects — that e-cigarette use causes some people to then become smokers — has no clue about what evidence would support or contradict such a claim.  It is a truly amazing and sad commentary on what passes for scientific thinking in this realm.

I have already explained at length how Glantz et al.’s claims about having found evidence of a gateway effect are fatally flawed.  But they are actually one step better than two recent claims by e-cigarette supporters that there is no gateway effect.  Glantz basically made a single observation about a statistical correlation that you would, indeed, expect to see if the gateway claim were true.  But you would also expect to see that correlation if either of two other things were true, one of which (confounding by common cause) certainly is true and the other of which (people are employing THR) is far more plausible and better supported than the gateway claim.  Basically the logic was this:  “If it is Monday at noon, there should be light coming in my window. There is light coming in my window. Therefore it is Monday at noon.”  There are obviously many more states of the world where the observation is true and the conclusion is not, so this is terrible reasoning.  I remember learning that in grade school; apparently Glantz, the faculty at UCSF, and the editors and reviewers of the junk journals he writes for missed that day of class in third grade and never took any science courses in college.

But that is not the worst reasoning one could engage in.  At least observing the sun makes it a little more likely it is Monday at noon, since it allows you to rule out many times of the week, and therefore you have increased the probability that it is Monday at noon.  Of course, you have increased the probability that it is midafternoon on Wednesday just as much.  But the observations in this study, a survey of European e-cigarette users, do not even do that much.  That has not stopped e-cigarette touters from claiming that the study shows there is no gateway effect, a claim which has made the rounds in social media.

It is rather baffling.  The authors make no such suggestion in the article or their press release.  There is simply no support for the claim to be found there.  The interpretation seems to trace to this crap article in New Scientist, which makes the claim in the text, or this even worse one in International Business Times which put the claim in the headline.  Naturally, clueless people who know nothing about the topic believe whatever they read, but some people who are repeating this silly claim should know better.  (Here’s a useful little epistemic hint for future reference:  When a news story says a study was published in the non-existent Journal of Tobacco Studies, it is probably not a very good source of information.)

The “reasoning” seems to be that because only 1% of never-smokers in the survey had tried an e-cigarette, e-cigarettes must not be a gateway.  Huh?  By that logic, smoke-free tobacco products do not harm fetuses because less than 1% of pregnant women use them.  (Note: it remains unknown whether or not there is such harm.)  All the observation shows is that if there is a gateway effect, its possible absolute magnitude (so far) is capped by the fact that only a small portion of the at-risk[*] population has had the exposure.  It tells us nothing about whether there is any such effect.

[*Side note 1:  For those who may be confused due to the fact that this phrase is used incorrectly more often than correctly, “at risk” means “anyone who could become a case”.  So “at risk of being a gateway case” means “not a smoker” (notice that this means that ex-smokers are at risk of becoming gateway cases, not just never smokers, so leaving them out of the “reasoning” was another error).  Thus, Glantz is at risk of becoming a gateway case, whereas someone who quit smoking using e-cigarettes is not.  The common misuse of the term is incorrectly substituting it for the intended claim that someone is at high risk of becoming a case.]

[Side note 2: I feel a personal need to point out that part of the touting of the study by pro-e-cigarette pundits is that it came out of Harvard.  I beg to differ. The authors all have some affiliation with Harvard School of Public Health, not the real Harvard.  The faculty at HSPH were serious researchers 20 years ago, and there are still a few good people from past eras (though not in the anti-tobacco and other nanny-state units), but is now it is pretty much just a school of public health, with all that implies.  Or as I put it previously,

The study, from a research group calling itself “Harvard School of Public Health”, was widely cited in the popular press.  (Note that while this organization does not seem to be related to the prestigious research institution called “Harvard University”, the allegations in the literature that it is actually a lobbying front group for shadowy government agencies and industry have not been proven, and so cannot be considered a reason to doubt their research.

Resuming….

The other common error about what constitutes evidence of no gateway, most recently committed by Siegel, is suggesting that declining smoking rates, in the context of increasing e-cigarette usage, must mean there is no gateway.  It is a fundamentally different error, though the implications are similar.  The error is a simple misunderstanding of magnitudes, statistics, and the passage of time. Even though e-cigarette use is increasing, its absolute level is still very small among those at risk of becoming gateway cases.  If every single at-risk e-cigarette user is a gateway case, the impact would not be visible in population smoking statistics.  The total number of at-risk e-cigarette users constitutes a smaller portion of the population than the statistical error in smoking prevalence surveys, to say nothing of what it would take to sort it out of the real changes in smoking rates over time.  Moreover, since “destined to start smoking due to her e-cigarette use” is not the same as “has started smoking”, the gateway cases would mostly not even be observable yet.

On top of that, e-cigarettes are causing some people to quit smoking.  So even if we had a perfect measure of smoking prevalence, and the only thing changing it over time was the effects of e-cigarettes, we would still see a decline in smoking rates even if there were a gateway effect (unless, of course, it were already so big in absolute magnitude that it exceeded the THR effect).  Thus, the “reasoning” here is an epic fail for at least three different reasons.

The reason that the implications of the two different errors described above are similar is that their proponents are really saying “the impact of the gateway effect is apparently small so far, so don’t worry about it.”  This is not a very effective argument.  There are very good reasons to believe there is not and never will be a gateway effect, or at least extremely little of it, but neither of the above are among them.  Effectively, those erroneous arguments invite the (valid) retort, “sure, we are not seeing it yet, but the way things are going, it will show up, and so we need to stop e-cigarettes before it does.”

The conclusion that there is no reason to expect a gateway effect is correct.  But making bad arguments in favor of a valid conclusion almost always sets up your opponent with a good argument in response, and that is certainly the case here. Moreover, if we are going to start trafficking in bad arguments, we are going to encourage and validate lying.  The other side will inevitably win the argument under those rules of engagement, because they are waaaay better at it.

Hitchman, McNeill, Brose (2014) Addiction paper on ecigs

by Carl V Phillips

This recent paper in Addiction by Hitchman, McNeill, and Brose, is a commentary calling for an “accurate and evidence-based debate” about e-cigarettes.  I will admit that my favorite part of it is this reference:

14. Phillips C. V. Anti-THR lies and related topics [internet] 2014. Available at: https://antithrlies.com/2014/03/07/stanton-glantz-is-such-a-liar-that-even-the-acs-balks/ (accessed 11 March 2014) (Archived at http://www.webcitation.org/6OJPSzZLh on 24 March 2014).

I find it quite an entertaining citation, and for that I want to offer an apology to the authors.  That post was properly cited because it was (in my possibly biased opinion) the best debunking of the spurious gateway claims that was published at the time of their writing.  However, citing the title I published the analysis under must have given the authors pause.  Fortunately they went ahead and did it anyway. Continue reading

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

by Carl V Phillips

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

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

draft Regulatory Science White Paper #2: The “gateway effect”

by Carl V Phillips

You will recall that a month ago, we posted our first draft white paper, on e-cigarette use by children.  We received, in various forms, the very useful suggest that our original title for the series (position papers or position statements) was misleading and did not do them justice.  Thus, we have renamed the series “Regulatory Science” and just call them white papers.

The term “regulatory science” is a thing right now, and is the language being used by the FDA and others.  It is not clear exactly what it means (and, indeed, it is my personal feeling that almost anytime someone precedes “science” with an adjective like that — pretty much any adjective that does not demarcate a specific area of science like “biological” — the adjective might as well be “junk”). We have chosen to interpret the term as something like: “scientific analysis that is specifically geared toward translating the scientific knowledge base into decision-relevant information”.   That is basically what I taught as a professor, and that turns out to be almost completely absent (perhaps completely now that I am retired from academia ;-) from public health sciences programs.

Anyway, the first white paper has now been reviewed — by you and recruited peer reviewers — and will be finalized and posted soon.  The second and third are done.  The second follows this paragraph.  As before, we are interested in any comments from anyone — peer review type comments especially, but we will certainly consider anything else that might strike you also.  CASAA members are invited to weigh in on the “our position” bit, since you are part of “our” (want to comment on that and are not a member? join – it’s free!).

Consumer Advocates for Smoke-free Alternatives Association

DRAFT Regulatory Science Series #2:  The “gateway effect”

draft – not yet peer reviewed

 Soundbite version

Those who oppose the promotion of tobacco harm reduction frequently claim that low-risk tobacco products will cause people to start smoking, the so-called “gateway effect.”  This claim has been heavily employed in anti-e-cigarette disinformation campaigns.  However, there is absolutely no evidence that such causation occurs.  Data that is cited in support of gateway claims about smokeless tobacco merely demonstrates the obvious point: people who use one tobacco product are more likely to use other tobacco products than those who avoid tobacco entirely.  Moreover, a moment’s thought reveals that such an effect is unlikely:  Why would someone who chose abstinence over smoking, upon discovering that they prefer a third alternative to either of those, be caused to make a change to their least-preferred option, smoking?  Asking that question, rather than making affirmative arguments, is probably the best response to anyone who is claiming that there is a gateway effect.

 Finally, even if someone speculates that there are some gateway cases, these are still clearly dwarfed by the number of would-be smokers who choose a low-risk alternative instead.  Thus the low-risk products still provide large net population health benefits.

 Introduction

A typical fallback position for those who want to condemn a drug or behavior, but cannot credibly argue that it is harmful in itself, is to claim that it is a “gateway” to genuinely harmful behaviors.  In the case of tobacco harm reduction (THR) products, the claim is that they cause some people to smoke.  In the early 2000s, anti-THR activists frequently claimed that smokeless tobacco (ST) was a gateway to smoking, though they seem to have largely dropped the argument because it proved much more effective to just mislead people into believing that ST causes substantial risk in itself.  But the rhetoric has recently been revived as an attack on e-cigarettes because attempts to convince the public they are high-risk are falling flat.

A simple analysis reveals that the gateway claim is fatally flawed.  It must be realized that the gateway claim is that the THR product is causing smoking – that is, smoking would not have occurred if the other product did not exist or were not tried by the user.  Mere precedence – e.g., someone puffing an e-cigarette before they ever tried a cigarette and later becoming a smoker – does not suggest there is causation; the smoking habit probably would have happened had the other product not existed.  When the gateway claim is used in anti-THR rhetoric, there is (presumably intentional) conflation of causation and mere precedence, but the implication is always about causation, and thus “gateway” should be interpreted in terms of causation.

While it is theoretically possible for low-risk tobacco product use to cause smoking, there is no empirical evidence that it ever occurs, and indeed anyone who thinks through the scientific analysis will realize that it is vanishingly unlikely.

Empirical evidence

Simply put, there is no empirical evidence of a gateway from low-risk products to smoking.  What was cited as a evidence of this for ST merely showed that people who were inclined to use tobacco liked to use tobacco.  That is, the conclusions were based entirely on the (clearly true and unsurprising) observation that people who used one tobacco product were more likely to become users of another tobacco product than were lifelong never-users (example).  So, in particular, users of ST were more likely to become smokers than were never-users of tobacco.  But this told us nothing about whether they would have been smokers had they never used ST.

In theory, evidence like this could show whether there is a gateway effect by controlling for propensity to smoke.  That is, if many former ST users became smokers even though they were not the type of people who normally become smokers, this would suggest a gateway effect (and if it did not occur, it would be empirical evidence that there was no such measurable effect).  None of the researchers or activists making gateway claims seemed to have even seriously attempted this, nor even to have understood that it was necessary.  One response reanalyzed the data from one of the naive pro-gateway claims that merely observed that those who used one tobacco product were more likely to use another; using with controls for propensity, it showed that most of the claimed association disappeared.  Another study used propensity based matching and did not detect a causal relationship between ST use and later smoking.  However, it is difficult to imagine creating a sufficiently accurate “propensity to smoke” score that could detect the signal amidst the noise of the obvious correlation between liking one tobacco product and liking the other, and the modeling would offer the analyst so many degrees of freedom that it would be easy to bias the results for political purposes.  Thus, there is basically no possibility that this line of research can distinguish between zero gateway effect and a small gateway effect, though it can clearly rule out a large effect.

(Aside: The mere fact that switching from ST to smoking was about as common as the other way around in historical U.S. data is disturbing from a public health perspective, even though it does not support the gateway claim.  This pattern is easily explained by the fact that most Americans were (and largely still are) victims of the anti-THR disinformation campaign that convinced them that smokeless is just as high risk as smoking, so they might as well smoke.  The good news is that willingness to switch products means that THR is likely once someone fully understands and internalizes the truth.)

There have been several studies that provide affirmative observations that are generally contrary to gateway claims about ST.  They found that few cases of ST use were even candidates for the gateway claim, that people who initiated tobacco use with ST were less likely to smoke than those who initiated with cigarettes, and that in Sweden (a population where ST use is common) there was far more switching from smoking to ST than the other way around.

The evidence from Sweden shows that if there is a gateway effect, it is utterly dwarfed by the THR effect (that is, even if the gateway affects a few people, far more would-be smokers choose ST, so the net effects are overwhelmingly positive).  Sweden has a high and long-standing use of THR products (in particular, snus) and has by far the lowest smoking prevalence of any country where smoking was ever popular.  Moreover, the comparison of men (whose use of snus is more prevalent and occurred earlier in time) and women shows an inverse association: male smoking rates dropped markedly as they took up snus while female smoking rates only followed the steady downward trend observed elsewhere (see, e.g., reference).  If snus were causing many users to smoke, this would not be the case.  (No analogous observation is possible about e-cigarettes because they are not sufficiently popular in any population that a gateway effect would impact population statistics.)

Neither the above-cited studies, nor the Swedish data, nor any conceivable data can rule out that there are some gateway cases.  A few cases would simply not be detectable, and thus cannot be ruled out.  But they do show that there are either few or none.

In the current discussion of e-cigarettes, there are not even any observations about people trying e-cigarettes first and becoming smokers, let alone support for the claim that it is a gateway.  The claims about e-cigarettes are just made up from whole cloth (example).

There are no apparent studies of possible gateway effects at the individual level (for example, testimonials of smokers who report that they eschewed smoking until they became a user of a low-risk alternative and then found themselves drawn to smoking).

Scientific analysis

The empirical evidence fails to demonstrate any gateway effect and shows that it is small if it exists.  The argument that it is non-existent, or close do that, can be found in the logic.  It is absurd to even think that low-risk tobacco/nicotine products would cause smoking.  Consider the combination of traits and choices that would have to be true of someone for someone to be a “gateway” case:

1) He would not smoke if not exposed to the low-risk alternative (otherwise smoking would have occurred anyway, so the other exposure is not causing it).  That is, abstinence is preferred to smoking, perhaps because of the health risks or perhaps just a lack of taste for tobacco use.

2) He chooses to use the low-risk product.  That is, the low-risk product is preferred to abstinence, so he has a preference for tobacco use so long as the risk is low.

3) Having adopted the low-risk product, he then prefers smoking and switches to it.

 A moment’s thought reveals how absurd that combination is.  The low-risk product is preferred to abstinence which is preferred to smoking.  But using the low-risk product does not cause the user to decide he does not like it (and go back to abstinence) or to become a dedicated user of that product.  For some mysterious reason, it somehow causes him to switch to his least-preferred alternative.  Why would this be?  His preference pattern probably reflects the fact that he is concerned about the health effects, even though he likes to use tobacco/nicotine (though it might just be that he just does not like smoke).  Why, exactly, would using the low-risk product cause him to forget about this?

The reason the absurdity of the claim is not immediately obvious to all observers is that tobacco control has convinced many people of their “demonic possession” theory of tobacco use.  That is, contrary to ample evidence, and in contrast with all other consumer choices, they imply that people do not choose to use tobacco or choose among tobacco products because of preferences.  It just sort of happens.  Since people’s actions, according to this story, have nothing to do with preferences or volitions, they must be controlled by demons.  Since demons can behave in completely arbitrary ways, any behavior pattern is thus possible, even when it is clearly absurd if based on an analysis of preferences.

Of course, it might be that someone could craft a non-absurd story of how the gateway works.  But to our knowledge, none of those who assert there is such an effect have ever done so.  We suspect such a story would involve an appeal to a some concept of addiction, but invoking that concept would not explain why an increasing desire for the low-risk product would result in it having less appeal than the previously dispreferred product; some plausible reason for that would be necessary.

The failure of THR opponents to try to produce a mechanism for the gateway effect may be because one part of any plausible explanation does not work in their favor.  When people do not know that smoke-free products pose orders-of-magnitude lower risk than smoking, the barrier for switching in the unhealthy direction is much lower. The aforementioned studies about ST use and smoking in the USA, a population that mistakenly believed the two products posed similar risks, show a similar pattern of switching in both directions.  While it is still the case that most or even all would have still smoked in the absence of ST, some of the switching in the unhealthful direction might have been causal.  Ignorance of the comparative risk alone still does not explain why someone who would have never smoked would be caused to smoke, but it frees that story from one enormous hurdle:  The user is still switching to what was once his least-preferred option, but he does not know that this entails an enormous increase in health risks because he has been tricked into believing that, from the health perspective, he might as well smoke.

In short, if there are gateway cases, much of the explanation for them is the mistaken belief that the low-risk alternative is actually high risk.  The fact that the same activists who purport to worry about a gateway effect also spread such disinformation suggests that they are not genuinely worried about the gateway effect.  It is also worth noting that the claims refer only to non-pharmaceutical tobacco/nicotine products, though it is equally plausible (which is to say, equally implausible) that nicotine gums, lozenges, and patches could be a gateway to smoking.  Yet those who claim to fear the gateway effect usually support aggressive touting of these products.

It follows from this that accurate communication about low-risk alternatives cannot create a gateway effect.  Even if availability of those product could create some gateway effect (contrary to both the empirical evidence and logic that suggests otherwise), accurate communication about the risks would tend to reduce this.  Thus, it is nonsense to even suggest that informing people about the low risk of available products could cause a gateway effect.

Our position

If anyone who would not have otherwise smoked is caused to smoke, that is unfortunate.  If THR were causing this to happen to a substantial degree, it might be a cause for concern even though the net population effects would still be beneficial.  Ethically, it is debatable whether population benefits always trump uncompensated individual costs.  But given that it is difficult to imagine why it would happen at all, and there is nothing to suggest it is happening to a measurable degree, this abstract debate is moot.

It is clear from their other behaviors that those who make claims about a gateway effect are not genuinely concerned, but are merely following a pattern of making every anti-THR claim they can think of.  Their willingness to mislead about comparative risks, and to express no concern about NRT availability and marketing, make clear that they do not really believe what they are saying.

If there is any gateway effect, the best way to reduce it is to clearly communicate to low-risk product users how much higher risk smoking is.  There is no plausible way such communication could increase the effect.

Based on everything we know, this is simply a non-issue.  Unless those who claim to worry about it are able to produce some argument or evidence, rather than just making vague assertions, there is nothing more that can be said about it.

CDC lies about kids using e-cigarettes

by Carl V Phillips

In a story that is practically a carbon copy of the lies from the Florida Department of Health that I discussed a few days ago, the CDC is lying to the public about statistics on school-aged e-cigarette use.  But this time, the lies are officially coming from our nation’s government, not some second-rate local department.  (Note, by calling them “second-rate” I am giving Florida the benefit of the doubt: in my experience, state health departments start at second-rate and go down from there.)

The CDC results were published in the agency’s newsletter/blog, Morbidity and Mortality Weekly Report and the lies were blasted out to the public via this press release.  Any American who is still shocked to find that their government is lying to them is an idiot (I doubt I will insult even a single one of my readers by saying that), and yet many reporters tend to blindly transcribe what CDC says rather than, say, bothering to read beyond the headline to see that it is clear based on only what CDC themselves reported in their press release that the claims are lies.

The headline of the press release manages to fit in one lie and two misleading claims, “E-cigarette use more than doubles among U.S. middle and high school students from 2011-2012”.  The biggest lie is that they report nothing about use.  All the reported statistics are about about trying the products, perhaps only once, which is obviously not the same thing (and CDC knows this).  Some statistics reported are for “ever having tried” and the others are “tried at least once in the last 30 days”.  They misidentify anyone who has tried in the last month as a current user, which is a rather blatant lie.  (Of course, some of those who tried recently may well actually be users, but there is nothing in the report that lets us conclude that even one single student is actually an e-cigarette user.)

The second sneaky lie was listing “middle school” ahead of “high school” even though the results for the former are trivial.  But it is scarier to imply that this is mostly about 12-year-olds and not 18-year-old high school students, isn’t it?

The third lie in the headline requires a bit of numeracy and data that is right there in the press release.  (This opens the question of whether our nation’s government’s top health officials are themselves innumerate.)  The number that more than doubled is for “ever tried”.  When your study population is 3/4 the same people from one observation to the next (as it the case with students who are in high school in 2012 compared to those in 2011), and the phenomenon you are studying is new enough that most of the trying is recent (as with e-cigarettes or whatever the latest offering McDonalds or Pepsico has added to their menu), then of course you are going to see a sharp increase in the number who have ever tried it.  It is almost impossible to see a decrease, and moreover, if the exact same number tried for the first time each year, that would come close to doubling the number who had ever tried.

You are with me there, right?  An 11th grader, in 2011, who tried an e-cigarette in 10th grade is still part of the “ever tried” group when he is in 12th grade in 2012.  If one of his classmates tried one for the first time in 11th grade, he joins his friend in the “ever tried” group in 2012.  Though the rate of trying was the same for this two-person population each year, the “ever tried” statistic DOUBLED!!!!  Scream it from the rooftops!

Did I mention that CDC are lying to people?

CDC apparently did not actually measure e-cigarette use.  They could have, of course.  Presumably they knew that the results would contradict the alarmist prohibitionist message they wanted to deliver, and so avoided the truth intentionally.  Actual use is clearly trivial.  If you actually wade though their breathless rhetoric to find information, you learn that 2.8% of high school students reporting trying an e-cigarette in the last month.  How many are actually using them?  If it is even as high as 1/10th of that, we are talking 0.3%.  But, hey, if you report something like that people will not be worried.  And worrying people is the goal.  So stick with “doubled!!!!!”.

Identifying the other important lies requires a bit of knowledge rather just the level of math that we can hope every subject of the studies learned many years ago.  (Am I being too optimistic about the quality of our schools?  Perhaps.  But that is off-topic.)  It turns out that almost all the e-cigarette triers had also tried cigarettes and indeed that almost 80% of them were “current smokers” (which, given CDC’s misuse of terms may be an overstatement of how much they actually smoke, though we do know that — unlike with e-cigarette trying (“hey, what is that? can I try a puff?”) — a large portion of those who puff a cigarette in a month are genuinely current smokers).  So this means that it is quite conceivable that most of those kids who tried an e-cigarette were pursuing THR!  That is, they consider themselves to be hooked on smoking and are seeking a low-risk alternative.  But we can’t have that, can we?

A comparatively minor point in the context of their more blatant lies, but still quite poisonous, is CDC converting their statistics (via the estimated size of the cohort they are studying) to “1.78 million” total students having tried e-cigarettes.  This level of precision implies that they have their result estimated so precisely that they know it to 1 part in 1000.  But their trying statistics, even if about as right as they could possibly be have precision in the range of maybe +/-20% at best.  (That is the best case scenario — when someone is lying about their statistics, always be concerned that they are lying about the data quality too.)  If they had said “almost 2 million” that would be reasonable, but even rounding to 1.8 million would imply more precision than they actually have, let alone 1.78.

Another comparatively minor but not trivial point is that quite a few high school students are of legal age to use tobacco products, and so it would be useful to break out the statistics for under-18 (which, of course, would be lower than those that include the 18- and even 19-year-olds).

It is also worth noting something that we know but apparently CDC does not:  Not all e-cigarettes even have nicotine in them.  How many of the kids tried e-cigarettes with nicotine?  No one knows.

Of course, the biggest lie is the “gateway” lie.  You know that when prohibitionists start making claims about a gateway that they have given up on pretending that a behavior is a problem in itself.  So they have to make up some reason for prohibiting it, so they claim that it leads to something that is a problem.  There is never any evidence to support those claims, about anything, as far as I have ever observed.  That is certainly the case here.  And yet the CDC makes claims that their data show that we should be worried about gateway effects even though there is no actual hint of that.

You can tell someone is starting with a conclusion and fishing for claims to support it when they contradict themselves over it within a few thousand words.  They claim both that the statistics showing almost all e-cigarette triers are smokers (or have tried cigarettes) suggests that there is a worry of a gateway and also that the statistics showing that a few (1/5th) of the (very few) younger kids who tried e-cigarettes had not tried cigarettes means that there might be a gateway.  So, guys, what would the evidence need to show to refute the claim there is a gateway?  The answer, of course, is that whatever the evidence shows, it supports the claim — this is religion, not science.