Wednesday, December 4, 2013
The headline on the Centers for Disease Control’s September 5 press release was dire: “E-cigarette use more than doubles among U.S. middle and high school students from 2011-2012” (here). The agency’s shocker generated reams of coverage (examples include USA Today, the Los Angeles Times, the Chicago Tribune and CBS News).
In an earlier blog post, I criticized the CDC’s media ploy for positioning e-cigarettes as a new childhood tobacco epidemic (here). Based on additional research, I have uncovered serious flaws in the agency’s analysis – errors and omissions that made the CDC’s message more appealing to the media, but less conscionable in terms of public health.
Analyzing the 2012 National Youth Tobacco Survey (NYTS), the dataset the CDC used to generate its report, I discovered the falsehood of this key statement in the agency’s press release: “Altogether, in 2012 more than 1.78 million middle and high school students nationwide had tried e-cigarettes.” This assertion was highlighted in most major media reports.
In fact, the NYTS did not collect information on the number of students who had used e-cigarettes in 2012. Instead, the survey asked if students HAD EVER TRIED e-cigarettes, “even just one time”; that number is 1.78 million. The only number in the survey that is applicable to 2012 is the 554,179 students who used an e-cigarette on “at least one day” in the past month. That is only 31% of the number wrongly reported by the CDC.
Another statement in the CDC release is seriously misleading: “The study also found that 76.3 percent of middle and high school students who used e-cigarettes within the past 30 days also smoked conventional cigarettes in the same period.” That statement implies that 24% of e-cigarette users were not smokers, and gives the distinct impression that e-cigarettes are emerging as a first-use tobacco product.
Not so fast. The NYTS also measured other forms of tobacco use, including smokeless tobacco, cigars, pipes, hookah, snus and dissolvable tobacco. In addition to the 76.3% of e-cig users who were concurrent cigarette smokers, another 12.9% were using other tobacco products. That means the percentage of e-cigarette users who weren’t using any other tobacco product was only 10.8%, a tiny fraction. Of this group, about half had “ever tried cigarette smoking, even one or two puffs”.
There is another feature of this and other federal surveys that you need to understand: the numbers that the CDC reports (e.g. 1.78 million) are not actual counts but are national estimates based on a complex sampling strategy. This is not necessarily a problem, but it provides needed context, especially when the number of survey respondents is small. For example, the total number of youths in this survey who used an e-cigarette in the past 30 days was 500, and the number of vapers who did not use any tobacco product nor had ever tried smoking was around 20.
The bottom line: Among all middle and high school e-cigarette users, only 10.8% were not concurrently using any other tobacco product, and half of those had tried to smoke in the past.
CDC director Tom Frieden may wish to use his position as a bully pulpit to oppose e-cigarette use, but abusing the facts is inexcusable.
In a future post I’ll discuss other key findings from the NYTS that were omitted by the CDC.
Wednesday, November 27, 2013
A November 12 e-cigarette summit at the Royal Society in London featured a range of views on European prospects for these new products (information here).
Tobacco harm reduction proponents included Clive Bates, Robert West, Jacques Le Houezec, Konstantinos Farsalinos, Jean Francois Etter and Antoine Flahault. One presenter summarized the Swedish experience with snus as population-level proof that safer smoke-free products save lives. He used my published study (abstract here) showing that there were 172,000 deaths from lung cancer – the sentinel disease of smoking – in the European Union in 2002. If all men in the EU had smoked like Swedes, there would have been only 80,000 lung cancer deaths.
A summit attendee asked if I could update that analysis with more recent data. In fact, the World Health Organization and the International Agency for Research on Cancer now have 2009 lung cancer mortality information for 27 of the 28 EU countries (Cyprus is the only exception). I have calculated the number of lung cancer deaths among men that would have occurred at Swedish smoking rates for all of these countries.
Sweden’s lung cancer rate is still the lowest in the EU by a long shot, at 68 deaths per 100,000 men age 45+ years. Finland’s is the next lowest at 102, which is interesting because snus is still used in some parts of that country, despite its prohibition. In contrast, Hungary and Poland have the highest rates, at 278 and 222 respectively.
For perspective, two non-EU countries are worth mentioning. The lung cancer mortality rate in Norway, where snus has contributed to reduced smoking (discussed here and here) was 121, which would have been fourth in the EU. The rate in the U.S., where tobacco harm reduction has been trashed by prohibitionists, was 138, which would have placed it tenth, behind Sweden.
In the EU, the 2009 Swedish lung cancer rate was 12% lower than in 2002. This is consistent with declines in most countries’ rates, ranging from -3% in Hungary (from 287 in 2002 to 278 in 2009) to -20% in Estonia (from 227 to 181) and Malta (from 158 to 126).
While the declines may appear modest or even impressive, the lung cancer death toll among European men of 183,423 is intolerable. The EU continues to ban snus everywhere except Sweden. The price for this appalling policy: 99,086 avoidable lung cancer deaths per year, plus more from other smoking-related diseases.
Considering that 91% of lung cancer deaths are attributed to smoking, and lung cancer accounts for only 31% of all smoking-attributable deaths among men in the EU, the toll from smoking among men in these EU countries is 538,435.
At the Swedish rate, the toll would be 247,570. That makes the net cost of the EU snus ban 290,865 deaths (assuming that all EU male smokers would adopt snus as successfully as Swedish males).
Recently the European Parliament voted on a new tobacco directive; the results make smokers both losers and winners. Parliament continued the snus ban but struck down a provision that would have suppressed e-cigarette access. As Clive Bates noted (here), “…the snus ban tells us that evidence, analysis and even concern for human life are not always that influential in way the EU makes policy.”
The EU snus ban is indefensible and immoral.
|Lung Cancer Mortality Rates*, Numbers of Deaths, and Numbers Expected at Swedish Rates Among Men 45+ Years in 27 European Countries, 2009|
|Country||Rate*||Deaths||Deaths at Swedish Rate|
Note: Croatia was not an EU member in 2009.
Thursday, November 21, 2013
Australia is the darling of anti-tobacco extremists. They tout that country as the model for draconian cigarette regulation and taxation. Australia imposed mandatory plain packaging last December, and exorbitant excise taxes have raised the price of a pack of cigarettes to 16 Australian dollars (AUD).
A new report (here) from KPMG tracks the effect of these policies on smoking prevalence and consumption. The unintended consequences remind one of America’s Prohibition Era fiasco.
KPMG compares Australia’s exorbitant per-pack prices with those of other countries in the region (all in AUD), including Cambodia (1.12), Vietnam (1.08), Indonesia (1.43), Thailand (3.07) and Papua New Guinea (5.37). It comes as no surprise that these differences have created a huge illicit market in Australia, accounting for about 13% of all cigarette consumption.
The Aussie black market offers smokers an array of smuggled products. Counterfeit cigarettes are inferior products manufactured offshore and packaged to resemble popular brands. KPMG also identifies a type of contraband cigarette called “illicit white” which is produced specifically for smuggling. One such brand, Manchester, is so popular that it has a market share of 1.3%. In 2012, Manchester was only found in Sydney and Melbourne; this year it was available in 13 of the 16 cities surveyed by KPMG.
I discussed earlier this year how prohibitive policies and prices in New York (population 20 million) have cost the state a quarter billion dollars that wound up in criminal hands (here). In Australia (population 23 million), the toll is larger: KPMG estimates that the government has lost $1 billion in excise taxes to the black market.
In their popular book Freakonomics Steven Levitt and Stephen Dubner argue that “Morality…represents the way that people would like the world to work – whereas economics represents how it actually does work.” (emphasis in original)
Australia’s treatment of smoking as a moral issue has resulted in Prohibition-Era tobacco policies and real-world economic consequences.
Wednesday, November 13, 2013
I documented in 2010 that three FDA appointees repeatedly conflated “tobacco” and “smoking” in a high-profile New England Journal of Medicine article (here). Three years later, federal officials are still distorting the truth.
Mitch Zeller, director of the FDA Center for Tobacco Products, supplied these appalling comments in a November 6 Robert Wood Johnson Foundation interview:
“It’s really stunning that in 2013 – with everything that we know about the harms associated with TOBACCO use – that it remains the leading cause of preventable death and disease both in this country and globally.” (emphasis added)
Stunning, indeed, but the fact is that smoking is the killer, not tobacco. Zeller knows the truth. He has spent over 30 years working on tobacco issues, as associate commissioner and director of FDA’s first Office of Tobacco Programs, at the American Legacy Foundation, and as a vice president at the influential consulting group Pinney and Associates.
Zeller, in the same interview, did acknowledge the continuum of risk: “there are different nicotine containing and nicotine delivering products that pose different levels of risk to the individual. Right now the overwhelming majority of people seeking nicotine are getting it from the deadliest and most toxic delivery system, and that’s the conventional cigarette.” Having recognized this, FDA officials should stop using TOBACCO as a synonym for smoking.
CDC Director Dr. Tom Frieden also suffers from the fact-vs.-propaganda flu when it comes to tobacco and smoking. In a recent interview with USA Today, he said:
“We work 24/7 protecting Americans from threats, whether these threats are from this country or anywhere in the world, whether they are natural or man-made, whether they are infectious or chronic. Overall, if you look at what’s making Americans sick and killing us, TOBACCO remains, unfortunately, the leading cause of preventable death, more than 440,000 people a year, more than 1,000 a day, every single day, are killed by TOBACCO.”
The CDC routinely publishes the exact number of deaths from smoking: it’s currently 392,681 among smokers and 49,400 from secondhand smoke. But that’s not the number of deaths from TOBACCO. In truth, the number of deaths attributable to smokeless tobacco is so low that the CDC and the American Cancer Society have never reported it, even though they have the information (here).
Americans expect their government to protect them from threats; among the most insidious and destructive is intentionally misleading public health statements from federal officials.
Wednesday, November 6, 2013
E-cigarettes are gaining traction as legitimate harm reduction alternatives for cigarette smokers, but one nagging question persists: Should vaping be permitted in interior public spaces?
With few exceptions, indoor smoking bans, which protect nonsmokers from exposure to thousands of airborne toxins, are now the standard. Tobacco prohibitionists would extend these measures to cover e-cigarette vapor. E-cigarette enthusiasts insist they should be able to vape wherever they like, since their products’ vapor is harmless. I’ll suggest a compromise that will please no one in these polarized factions.
E-cig fans point to scientific evidence that suggests that e-cigarette vapor confers extremely low health risks. The FDA reports that adverse events related to e-cigarettes are virtually nonexistent (here), and it is unlikely that inhaling a mist of water, propylene glycol or glycerin, nicotine and flavors – even for an extended period – will lead to any medical illness.
Consumer Advocates for Smoke-Free Alternatives funded a study of e-cigarette aerosols by Igor Burstyn at Drexel University’s Department of Environmental and Occupational Health. He concluded that “there is no evidence that vaping produces inhalable exposures to contaminants of the aerosol that would warrant health concerns by the standards that are used to ensure safety of workplaces…the aerosol generated during vaping as a whole (contaminants plus declared ingredients), if it were an emission from industrial process, creates personal exposures that would justify surveillance of health among exposed persons in conjunction with investigation of means to keep health effects as low as reasonably achievable. Exposures of bystanders are likely to be orders of magnitude less, and thus pose no apparent concern.” Professor Burstyn’s report on his thorough investigation has not yet been published in a peer-reviewed forum.
The problem is that, however innocuous e-cigarette aerosols are, a bystander exposure level that is “orders of magnitude” lower than for vapers is still not zero. Modern indoor environments are remarkably free of obvious airborne contaminants, such as smoke or noxious odors. As a society, we frown upon indoor emissions of all types. Interestingly, unobserved e-cig use is effectively undetectable, as resulting vapors dissipate almost instantly. Vapers often suggest that indoor e-cig bans will force them outside, where they may return to deadly cigarettes; the reality is they can stay indoors and continue vaping, so long as they are discreet – no one will know.
Still, it is unreasonable for vapers to expect that they will be given a free pass to use e-cigarettes in every interior public space. The fact that e-cigarette aerosols are low-exposure and low-risk for bystanders does not make a compelling case to allow them.
Vapers should realize that the vast majority of Americans do not use any form of tobacco, are ill-informed at best about e-cigarettes, and are uncomfortable with others exhaling clouds of an unknown substance.