Wednesday, April 23, 2014

Federal E-Cigarette Data AWOL

Americans are familiar with the census, taken every 10 years by the U.S. Census Bureau, but few are aware that the Bureau regularly collects information on a range of demographic, social and economic characteristics through Current Population Survey (CPS) supplements, which are sponsored by various government agencies.

The National Cancer Institute regularly sponsors the CPS Tobacco Use Supplement (TUS), which was conducted most recently in May and August 2010, and January 2011 (information here).  These datasets and accompanying technical documentation are available for download and analysis by tobacco researchers (here). 

Surprisingly, another TUS, conducted in May 2011 and described in a technical document as a follow-up survey that includes information on e-cigarettes (here), has never been released.  This conflicts with Census Bureau guidance that supplements “are available anywhere from 6 to 18 months after data collection.” (here) 

The 36-month-and-counting delay is troubling. 

High ranking government officials have been campaigning against e-cigarettes for some time, creating demand for FDA regulation.  The NCI, sponsor of this TUS, has been a powerful opponent of anything related to tobacco harm reduction.  Is it possible that NCI officials are not releasing e-cigarette data until FDA regulations are issued?

The NCI has suppressed positive positive data in the past.  An NCI-sponsored supplement to the 2000 National Health Interview Survey asked current and former smokers the method they had used to try to quit smoking.  One response was “switch to smokeless tobacco.”  Carl Phillips and I published an analysis of this survey, noting that it provided the first population-level evidence that American men have quit smoking by switching to smokeless tobacco (here).

Five years later, despite the fact that tobacco harm reduction had gained increased visibility and more American smokers were likely making the switch, the NCI struck the switch-to-smokeless query from the survey, denying the public information about this cessation option.     

Public health requires public access to taxpayer-funded survey data.  NCI should be an ally in this regard, not an obstacle.

Thursday, April 17, 2014

UCSF Redefines Youth Smoking; Journal’s Peer-Review Fails

The National Youth Tobacco Survey (NYTS) has been abused on an unprecedented scale by anti-tobacco forces.  First the Centers for Disease Control and Prevention released cherry-picked data, fabricating an epidemic of childhood e-cigarette use (discussed here and here).  Then the New England Journal of Medicine refused to correct an inaccurate and misleading portrayal of e-cigarette and cigarette usage (link here). 

Now we have the work of the University of California San Francisco’s Lauren Dutra and Stanton Glantz, who a use a dizzying array of statistical analyses of the NYTS to argue that e-cigarettes are a gateway to cigarettes for youth (discussed here).  The Dutra-Glantz study has been criticized by tobacco research and policy experts Clive Bates (here), Michael Siegel (here) and Carl Phillips (here).  The fabrication was called out by the American Cancer Society and the American Legacy Foundation (here).

After additional analysis, I have discovered major flaws in the Dutra-Glantz study that further undermine its credibility. 

First, it is difficult to accept their finding on smoking and e-cigarette use when, by all conventional standards, Dutra and Glantz have grossly underestimated youth smokers. They reported that current smoking prevalence was 5.0% in 2011, and 4.0% in 2012.  This is less than half the prevalence reported by the CDC and other authorities (see chart).  How could this have happened?

It turns out that Dutra and Glantz invented a new definition of current smoking for youth: one who has smoked 100 cigarettes in her lifetime AND smoked on at least one day in the past 30. The standard definition for a youth smoker used by the CDC and all other authorities is anyone who smoked a cigarette on at least one of the past 30 days.  Dutra and Glantz’s definition of current smoking for youth is also completely different from the definition they use for e-cigarette use (one day in the past 30).

Dr. Glantz knows the standard definition for current youth smoking, because he used it last year in his report on e-cigarette use among Korean youth (abstract here).

Valuable information in the NYTS surveys was obscured or ignored by Dutra-Glantz.  While providing incomprehensible tables of odds ratios to inappropriately link e-cigarettes use and smoking, they omitted basic information related to e-cigarette use.

The CDC data show that about 76% of current e-cigarette users are also current smokers, but the surveys contained additional information that helps interpret this e-cigarette and cigarette link.  The surveys provide insightful data on students’ use of other combusted products (pipes, cigars and hookah).  The following table places current e-cigarette users in four categories: (1) those who smoked only cigarettes, (2) those who smoked cigarettes and one of the other products, (3) those who smoked only the other products, and (4) or those who didn’t smoke.

Percentage of Current E-cigarette Users Also Currently Using Other Tobacco Products in the 2012 NYTS
Cigarettes Only21
Cigarettes and Pipes, Cigars or Hookah55
Pipes, Cigars or Hookah Only10
No Other Products13

It is clear that the majority of e-cigarette users were users of multiple products.  This is not surprising, as some youth tend to be risk-takers and experimenters.  The table also shows that only a tiny number of students (13%) used e-cigarettes but no other smoked product in the past 30 days. 

That the significantly-flawed Dutra-Glantz study was published in the Journal of the American Medical Association Pediatrics is an indictment of the medical publishing industry’s peer review process.  Unfortunately, journals generally under-scrutinize anti-tobacco submissions.  After publication, journals tend to reject corrections, absent a glaring key error.  But even that situation does not guarantee correction, as the New England Journal story shows (here).

Friday, April 11, 2014

Swedish Tax Proposal Threatens Successful Tobacco Harm Reduction

Sweden, which represents the world’s best example of the population effect of tobacco harm reduction, is considering increasing its snus tax by 22%, according to the Swedish national newspaper Aftonbladet.  An April 2 article claims “it would be the first time ever that a can of snus would cost more than a pack of cigarettes.”  Swedes are reportedly outraged by the proposal.  Public health experts should be outraged as well, given such a tax hike’s threat to the developed world’s lowest smoking and lung cancer rates.

As expected, the Karolinska Institute’s tobacco expert Hans Giljam expressed support for a higher snus tax.  However, even he admitted, “There is a risk that many will quit snus and move to cigarettes.  And if many start smoking instead of using snus, we will get sicker. That is a certainty.”

That is unquestionably the strangest endorsement of tobacco harm reduction ever heard.  Giljam couched his comment in dire, unfounded or exaggerated warnings about links between snus and a host of diseases, but he waffled on how much snus use triggers health effects.  “It takes decades of study to reach such conclusions.  It is one of the pedagogic problems we face; we don’t really know what the health effects of long-term snus usage are.”

In fact, decades of study have defined the long-term health effects snus use – nearly zero.  And even Giljam acknowledges that smoking is at least ten times more dangerous than using snus.  His support for equalizing taxes on snus and cigarettes is unfathomable.

This article is available only in Swedish (here), so the English translation I have could account for Giljam’s bizarre logic.  But I sincerely doubt it.  Like anti-tobacco extremists everywhere, those in Sweden not only completely ignore the phenomenal Swedish tobacco experience, they enthusiastically endorse policies that would destroy it. 

Wednesday, April 9, 2014

NEJM Fails to Correct Data on Children’s E-Cigarette Use

The New England Journal of Medicine and authors of a commentary on e-cigarette use (here) have ignored our call for correction of a substantial error regarding e-cigarette use among American schoolchildren in 2011 and 2012.  Authors Amy L. Fairchild, Ronald Bayer and James Colgrove of Columbia University double-counted some users in a figure they used to illustrate data from the National Youth Tobacco Survey (NYTS)(seen at left).

The commentary, published December 18, addressed the legitimate question, What is the appropriate public health goal: eradication of smoking or elimination of all tobacco products?

Clive Bates first raised the critical data error in a group email discussion; I responded because I had used the figure’s source data for blog posts earlier in December (here and here). 

Clive and I, along with my University of Louisville colleague Nantaporn Plurphanswat, submitted a letter to the NEJM editor on December 22.  We explained, “the [Fairchild] figure inaccurately represents data from the National Youth Tobacco Survey on use of cigarettes and e-cigarettes by U.S. students in 2011 and 2012 in a report from the Centers for Disease Control and Prevention (2). For example, the figure shows that 16.8% of high school students used either product in 2012. However, the correct percentage is 14.6% because of dual use, which was reported in another CDC publication (3). We submit a revised figure that accurately represents the information in both CDC reports.” (at left)

On February 19 Editor Debra Malina informed us that our letter and corrected figure would not be published. 

We subsequently sent an email request to Dr. Fairchild.  We advised that her figure was constructed incorrectly, noting, “it does not properly account for e-cigarette users who also smoke, and these are the majority.  Given this misconstruction, the chart should not be reproduced in its current form.  We have taken this up with the NEJM, but they do not wish to publish an alternative from us.  That being the case, the responsibility for amending the chart rests with you as lead author.   We urge you to submit a revised figure along the lines we included in our communication with the editor.  We attach our letter and revised chart and would be happy to discuss the underlying data (also available in the referenced CDC publications) that we used to create it.” Dr. Fairchild ignored that missive, and a March 3 follow-up email.

The NYTS survey has been subject to repeated and egregious abuse by anti-tobacco forces, all to serve the specious claim that e-cigarettes are a gateway to cigarette smoking. 

Tom Frieden, director of the Centers for Disease Control and Prevention, Dr. Tim McAfee, director of the CDC Office of Smoking and Health, and FDA Tobacco Center director Mitch Zeller started the gateway fallacy with reports and press releases, a tactic that I labeled “irresponsible theatrics” (here  ).  I also detailed how the CDC abused the data (here and here).

The inaccurate information in the NEJM is a dangerous error that can undeservedly gain traction through repetition.  This happened in 1981, when National Cancer Institute epidemiologist Dr. Deborah Winn misstated oral cancer risks related to smokeless tobacco (here and here).  Her erroneous data became gospel for anti-tobacco forces, despite her subsequent acknowledgement of the misstatement.

The NEJM is doing public health and science a disservice by refusing to correct the error.