Wednesday, October 11, 2017

“Deception or Evasion” by FDA CTP & National Cancer Institute Regarding Smokeless Tobacco?

“A majority of adults do not think smokeless tobacco is less harmful than cigarettes,” according to a study by the FDA Center for Tobacco Products and the Tobacco Control Research Branch of National Cancer Institute (abstract here). 

Sheri P. Feirman and colleagues analyzed responses to a question in the Health Information National Trends Survey (HINTS), 2012, 2014, and 2015: “Do you believe that some smokeless tobacco products, such as chewing tobacco and snuff, are less harmful than cigarettes?” 

Do You Believe that Some Smokeless Tobacco Products…Are Less Harmful Than Cigarettes?
Don’t Know17.1%15.9%22.2%

Simply put, only 9 to 12% of Americans correctly believe that smokeless tobacco is less harmful than cigarettes.

In a PubMed Commons commentary on this study, David Sweanor and I note:

“The article failed to specify that the correct answer [to the question] is:  ‘Yes, smokeless tobacco products are less harmful than cigarettes.’  The article instead focuses on the majority of participants who inaccurately answered ‘No’ or ‘Don’t Know,’ which demonstrates the misperception fostered by an effective ‘quarantine’ of truthful risk information by federal agencies (Kozlowski and Sweanor, 2016).

“Decades of epidemiologic studies have documented that the health risks of smokeless tobacco use are, at most, 2% those of smoking (Rodu and Godshall, 2006; Rodu, 2011; Fisher 2017; Royal College of Physicians, 2002; Lee and Hamling, 2009).  Unlike cigarettes, smokeless tobacco does not cause lung cancer, heart and circulatory diseases or emphysema.  The Royal College of Physicians concluded in 2002: ‘As a way of using nicotine, the consumption of non-combustible [smokeless] tobacco is on the order of 10–1,000 times less hazardous than smoking, depending on the product.’” (Royal College of Physicians, 2002)

”Low risks from smokeless tobacco use extend to mouth cancer.  A 2002 review documented that men in the U.S. who use moist snuff and chewing tobacco have minimal to no risk for mouth cancer (Rodu and Cole, 2002), and a recent federal study found no excess deaths from the disease among American men who use moist snuff or chewing tobacco (Wyss, 2016).

“As one of us recently wrote, ‘Deception or evasion about major differences in product risks is not supported by public health ethics, health communication or consumer practices.  Public health agencies have an obligation to correct the current dramatic level of consumer misinformation on relative risks that they have fostered.’ (Kozlowski and Sweanor, 2018).”

The FDA and NCI must be more forthcoming with the American public.

Wednesday, October 4, 2017

Mythic Tobacco Endgames

A new $1.2 million campaign to promote tobacco prohibition on college campuses was announced on September 19 (here). 

As I have noted, the federal government annually spends hundreds of millions of dollars in support of academic anti-tobacco research (here).  This time, the money is coming from pharmacy giant CVS’s Health Foundation as part of a five-year, $50 million campaign.  CVS collaborators include the misnamed Truth Initiative (see here and here) and the American Cancer Society, whose numerous prohibitionist exploits are reported in this blog (here, here, here, here, here, here, here, here, here, here).

Campaign awards to several Texas schools were reported in a Houston Chronicle article (here) that included illustrations offering and refuting four tobacco “myths”.  In this effort, the paper (or the campaign) repeated fantastical claims that are often made by prohibitionists.

Myth #1: “Almost no one smokes any more [sic].”  A myth, by definition, is a widely held view, so this attempt fails from the start. The latest data from the CDC, for 2016, shows 38 million smokers in the United States – a substantial and highly visible group of people, all in need of effective quit-smoking tools and support.

Myth #2: “e-Cigarettes, hookahs and cigars are safe alternatives.”  Again, few people hold this view (here).  Scientists, the industry and public health officials agree that no form of tobacco use is perfectly “safe.”  Eminent authorities like Britain’s Royal College of Physicians, however, have pronounced that vaping “is unlikely to exceed 5% of the harm from smoking tobacco.” (here)  Furthermore, FDA data shows that smoking one or two cigars a day have almost no health risks (here and here).

Myth #3: “Infrequent, social smoking is harmless.”  This is creating a myth when one doesn’t exist.

Myth #4: “Smoking outside eliminates secondhand smoke dangers.”  Myths convey false information.  This statement is entirely true.

Ironically, some viewers of the online Chronicle article are shown an advertisement for Nicorette gum, reproduced here.  While pharmaceutical nicotine has a known 93% quit-smoking failure rate (here), this ad touts one day of success – an extraordinarily low bar for cessation.

Wednesday, September 27, 2017

2016 CDC Data Shows E-Cigarette Use Declines Again

Some 7.8 million American adults used e-cigarettes in 2016, according to data from the 2016 National Health Interview Survey, the source for CDC national smoking estimates.  That is about half a million fewer than a year earlier, and 1.1 million fewer than in 2014, the first year NHIS surveyed for vaping.  As the CDC reported a month ago (here), the 2016 data indicates 3.2% adult prevalence – 3.9% (about 4.5 million) for men, and 2.6%, (about 3.3 million) for women.  

The 2.62 million former smokers who are current vapers comprised an increasing percentage of all vapers, from 22% in 2014, to almost 34% in 2016.  This is more evidence that smokers are using e-cigarettes to quit their habit.  As the following chart shows, 87% of former smokers currently using e-cigarettes quit in the last 5 years, suggesting that e-cigarettes played a significant role.  Meanwhile, 13% of former-smoker current-vapers quit over 6 years ago.  The CDC admits that relapse among former smokers is common (here), so health advocates should applaud these former-smokers’ choice of e-cigarettes over far more dangerous cigarettes.

As noted previously (here), the 2.6 million former smokers represent more than mere anecdotal evidence; their documented experience ought to carry substantial weight with government policymakers. 

In view of the important positive health implications of switching to smoke-free products, the number of former smokers ought to be growing faster.  Unfortunately, the sustained war on all smoke-free products is likely suppressing broader transition away from cigarettes.

Addendum, September 29:  Bill Godshall asked me to take a closer look at every-day and some-day e-cigarette use in the NHIS surveys.  Here are the results:

Number (in millions) and Prevalence (%) of Every-Day and Some-Day E-Cigarette Use in the U.S., 2014 to 2016


20142.71 (1.1%)6.20 (2.6%)8.91 (3.7%)
20152.94 (1.2%)5.40 (2.2%)8.34 (3.4%)
20163.03 (1.2%)4.77 (2.0%)7.80 (3.2%)
 The number of every-day e-cig users increased by 12% between 2014 and 2016.  In 2014, the proportions of current, former and never smokers were 50% / 46% / 4%.  By 2016 the proportions were 32% / 58% / 10%, indicating that more every-day e-cig users were former smokers.  The number of some-day e-cigarette users dropped 23% from 2014 to 2016.  The proportions of current, former and never smokers in 2014 were 80% / 12% / 8%.  By 2016 the proportions were 68% / 18% / 14%. 

Monday, September 18, 2017

Antidote to NEJM Formaldehype Arrives at Last

In January 2015, R. Paul Jensen and colleagues created global headlines with a defective e-cigarette experiment (here).  They claimed in the New England Journal of Medicine that vapor contains “hidden” formaldehyde at far higher levels than cigarettes (here).  Their measurements required overheating or “dry-puffing” e-cigarette liquid, a process that produces such harsh (not hidden) oral sensations that the vapor is intolerable to normal consumers. 

As Churchill said, “A lie gets halfway around the world before the truth has a chance to get its pants on.”  The Jensen mischaracterization caused considerable damage, as it encouraged smokers to believe that vaping is more dangerous than smoking. 

Last week, the formaldehyde fallacy was laid bare.  Dr. Konstantinos Farsalinos and colleagues reproduced the Jensen experiment and found that “The high levels of formaldehyde emissions that were reported in [the Jensen] study were caused by unrealistic use conditions that create the unpleasant taste of dry puffs to e-cigarette users and are thus avoided.” Their work appears in Food and Chemical Toxicology (abstract here). 

Farsalinos’ group painstakingly reproduced the earlier experiment, using the same now-outdated vaping equipment that was prone to dry puffs.  First, they had experienced vapers identify at what settings the “burning” taste of a dry puff was detected: 4.2 volts, 8.0 watts.  They then used Jensen’s methods to measure formaldehyde at various voltage-power settings, seen in the chart (above) adapted from their publication.

Vapers detected dry puffs when the formaldehyde level was 100 micrograms (per 10 puffs).  Given that a microgram is one-millionth of a gram, Jensen’s formaldehyde level wasn’t hidden at all; at 380 micrograms, it was much higher than vapers could tolerate.  At lower, normal vaping power, formaldehyde was only 20 micrograms, or two-thirds that of cigarettes.

Farsalinos cautions the scientific community: “blindly testing e-cigarettes in the laboratory setting without evaluating realistic use is a serious omission that can result in misleading conclusions about the risk to consumers compared to smoking;” and such conclusions can wrongly imply “that there is little to be gained by switching to e-cigarettes.”

In response to the Jensen article in 2015, Clive Bates and Konstantinos Farsalinos published a letter in Addiction calling for its retraction (here); the demand was ignored.  The current publication is a much-needed antidote to Jensen’s seriously flawed and misleading findings.