CDC Sees E-Cigarette Use at Marked Increase and Leveling Off – Tortured Logic

The CDC has released another “more of the same” report on e-cigarette awareness and use.  The lead author is Dr. Brian King; the report appears in Nicotine & Tobacco Research (abstract here). 

While the manuscript refers at least 15 times to an “increase” in U.S. e-cigarette use from 2010 to 2013, Dr. King informed the media that e-cigarette use is leveling off (example here).  Ironically, Dr. King characterized the plateau in use of a vastly safer cigarette substitute as “a positive note.”  

On what did Dr. King base his “leveling” remark?  His conclusion was cherry-picked from two out of about a hundred percentage figures in Table 2 (in yellow in the screenshot on the left; you'll need some magnification).  Those percentages were not even mentioned in the results, but Dr. King considered them important enough to highlight for the media. 

This is a perfect example of the CDC producing data claiming one thing – a “considerable,” “marked,” “rapid,” “doubling” increase in e-cigarette use – then pitching it to the media as something else – a “leveling,” which is “positive.”  The agency’s purpose is to disparage a vastly safer cigarette alternative.  

The report contains other examples of distorted logic.  A reasonable observation – “The marked increase [in use] among former smokers could be attributable to the use of e-cigarettes for cessation.” – is supported by the fact that ever e-cig use among former smokers increased to 10% in 2013.  But King and his coauthors perversely observe that “…the increase could be attributable to new initiation of e-cigarettes among individuals who had successfully quit without previous use of the product, highlighting concerns over the potential for these products to promote relapse to combustible tobacco use.”

In other words, the CDC thinks that e-cigs are a gateway to smoking because they might be corrupting former smokers who had previously been abstinent.  As Lewis Carroll wrote, “It sounds uncommon nonsense.”

The Swedish Snus Experience Isn’t Finnished

Despite the wealth of evidence demonstrating that snus has helped thousands of Swedish men and women avoid the ravages of smoking, the European Union continues to enforce an irrational ban on snus beyond Sweden’s border. 

I have documented that smoking deaths in Sweden are significantly lower than in all other EU countries (here and here).  A new study clearly demonstrates the differences in smoking rates when snus is available and when it is banned (abstract here).

Snus has been popular in Sweden for 200 years, but it was also used in neighboring Norway and Finland.  In 1995, Sweden and Finland joined the EU.  Sweden applied for and received a waiver on the EU’s existing snus prohibition, thereby allowing Swedes to continue producing and selling within the country.  In contrast, Finland accepted the ban, denying its snus consumers a legal source.  Norway never joined the EU, so snus remained available.

Dr. Jennifer Maki, an economist with the Center for Healthcare Economics and Policy, compared the smoking rates in these three countries before and after 1995.  Maki's figure above shows the rates among men in Sweden and Finland.  Clearly, a decline in smoking levels off in Finland after 1995, while the decline in Sweden continues, despite the fact that it was far lower over the entire period.  As Maki writes, “…in the post-ban period, smoking increased in Finland by 3.47 percentage points relative to Sweden…this estimate can be interpreted as an increase in the smoking rate [in Finland], relative to what it would have been, in the absence of the ban.”

The comparison of Finland and Norway, seen in Maki's chart on the left, also shows the effects of snus use on smoking.  According to Maki, “the smoking rate [decline] in Norway is similar to that in Finland prior to 1995, after which point the rates diverge. Using Norway in place of Sweden as a control produces a result similar to, but not as drastic as, [the Swedish comparison].”

Maki’s conclusions illustrate the impact of snus in Sweden, the impact of the snus ban in Finland, and the utter failure of EU policy:

“The smoking rate among Swedish males is remarkable [sic] low, and continues to decline; given Sweden’s low smoking rate pre-1995, the ability to achieve further reductions post-1995 is notable… The findings presented in this paper provide support for the viability of a harm reduction approach to smoking cessation and suggest that the Swedish Experience could be replicated elsewhere… It may have been underway in Finland prior to the implementation of the ban.  These results are not only meaningful within Finland, but may be applicable to the entire EU.”

Note: I am especially proud of Jennifer’s contribution.  She contacted me when she was a doctoral student at North Carolina State University; I provided materials on tobacco harm reduction, reviewed and critiqued early versions of her thesis and helped her search for Swedish and Finnish datasets.  Her mentor, Professor Barry Goodwin, sponsored my guest lecture at NC State, and I hosted a visit by Jennifer to the University of Louisville so that she could present her work.   

Oral Cancer Scaremongering by Public Health Officials

A range of public health leaders, who should know better, have rushed to repeat and, with their stature, endorse the apparently unfounded claim by baseball great Curt Schilling that his mouth cancer was caused by smokeless tobacco.

Claims about cancer causation can significantly influence national health policy; when made by recognized authorities, they should be based on scientific and medical facts.

While I fully sympathize with Mr. Schilling, his claim of causation has no on-the-record support from his medical team. That has not stopped the anti-tobacco establishment from rushing to the media.

In remarks trashing smokeless tobacco, Schilling’s oncologist, Dr. Robert Haddad of the Dana-Farber Cancer Institute, made no comments specifically connecting his patient’s cancer to use of smokeless products.

Regardless, in short order, the FDA Center for Tobacco Products repeated Schilling’s causation claim on Twitter (here), and the presidents of the Massachusetts Medical and Dental Societies (here) and the director of the Arizona Department of Health Services (here) gave it further credence.

I don’t question Schilling’s belief that smokeless tobacco caused his cancer.  However, before endorsing his statements, public health officials should address several points:

1.  Where, specifically, was the “mouth cancer”?  According to this National Cancer Institute monograph (here), almost all cases of mouth cancer attributable to smokeless tobacco occur in the location where it is used.  That is also my experience in 30 years as an oral pathologist.  In addition, the cases of mouth cancer that I have seen are almost always in users of dry powdered snuff, and they occur in the gum-cheek area.  Schilling hasn’t disclosed the location of his cancer, which he blames on moist snuff.  Users of that product are not protected from mouth cancer, but epidemiologic studies show that they are not at higher risk than nonusers.

2.  Other risk behaviors.  It can be uncomfortable, but doctors need to know about all risk factors for oral cancer. Those at higher risk are individuals who smoke and drink, a combination that tends to be associated with cancers in the throat as well as the mouth.  Human papillomavirus infection is an emerging risk factor, especially for throat cancer.  Schilling disclosed that his cancer was discovered as a “lump” in his neck; this presentation is more common with a throat cancer than a mouth cancer.  Schilling hasn’t disclosed information on his other risk factors.

It is inappropriate for the FDA, presidents of medical societies and other public health authorities to blindly endorse unvalidated medical claims.  Hundreds of thousands of former smokers in the U.S. use smokeless tobacco.  Dreading the prospect of getting mouth cancer, they might be motivated by these authorities’ pronouncements to start smoking again, not knowing that the latter significantly increases their mouth, throat and lung cancer risks.  Public health advocates should stick to the facts, not engage in scaremongering.