Wednesday, March 25, 2015

BBC Drops the Ball on Baseball & Smokeless Tobacco

It’s almost baseball season, which means it’s time for anti-tobacco extremists to start grabbing easy headlines.  One especially zealous state lawmaker wants to ban smokeless tobacco by players and fans in all California ballparks (here).  It’s all based on smoke and mirrors, as illustrated in a woefully inaccurate recent BBC story on smokeless tobacco and baseball.

The report includes an erroneous claim that baseball stars Tony Gwynn, Curt Schilling and Babe Ruth died from cancers caused by smokeless tobacco. 

Neither Gwynn’s nor Schilling’s cancer was related to smokeless products, as I have detailed before (here and here).   Reporter Nada Tawfik concedes that “doctors say a link between [Gwynn’s salivary] cancer and chewing tobacco cannot be proven.”  I have previously noted the absence of a scientific link between smokeless tobacco and this cancer type (here).  As for Schilling, he never said he had mouth cancer and not one of his doctors has supported his statement that smokeless tobacco caused his illness.

The BBC repeated the decades-old myth that Babe Ruth suffered from smokeless tobacco-induced mouth cancer.  In truth, Ruth had nasopharyngeal carcinoma, a rare disease caused by the Epstein-Barr virus.  Ruth was a prodigious consumer of cigars and alcohol, but neither are strongly associated with nasopharyngeal carcinoma (discussed here).  He also used smokeless tobacco, which has no link to this cancer type.

Included in the BBC story was a remarkable quote attributed to Dr. Jatin Shah, who runs the Head and Neck Service at New York’s Memorial Sloan Kettering Cancer Center.  Chewing tobacco, he is reported to have said, is “probably more harmful than smoking.”  I emailed Dr. Shah to ask if he had been misquoted.  He responded with a comment on South Asian products, but the BBC’s vast audience has been left with the grossly erroneous impression that American smokeless tobacco is more dangerous than cigarettes.

Thus are myths perpetuated and the public health undermined.     

Thursday, March 19, 2015

Do E-Cigarette Ads Promote Vaping?

The National Cancer Institute is wasting taxpayer dollars on slanted e-cigarette research that didn’t ask or answer an obvious and important question.

Consider the recent NCI-funded study by Drs. Erin Maloney and Joseph Cappella at the UPenn Annenberg School of Communication (abstract here). 

Maloney and Cappella recruited daily smokers, intermittent smokers and former smokers (there were no significant results in the middle group so I won’t discuss them).  They divided smokers into three subgroups: controls who didn’t see an ad, those who saw e-cig ads with vaping (called a cue) and those who viewed ads with no vaping.  Participants answered questions about their inclination to smoke a cigarette, to quit smoking or to continue to abstain.  Maloney and Cappella developed a scoring system to measure responses.  The results they pitched to the media are in the table.

All groups had lower urges to smoke after the experiment, but smokers who saw the cue had less of a lower urge, which was significant in the authors’ scoring.  Similarly, all former smokers had high scores for continuing to abstain, but those who saw the cue had a lower high score. 

E-Cigarette Ads and Urges in Daily Smokers and Former Smokers
Daily SmokersFormer Smokers
CueNo CueNo AdCueNo CueNo Ad
Urge to Smoke
Intention to:
*Significantly different than No Cue or No Ad.

The authors acknowledged that “effect sizes reported in this manuscript were not large.”  In fact, the differences are so small that they may not be meaningful for actual behavior.  Take 12.39 versus 13.14 in the table as an example.  The authors reported that higher numbers are better, and both numbers look “high” when compared with a previous study by Cappella that used the score (abstract here).  He showed former smokers anti-smoking ads in that study and got scores around 3.0 to 3.5.  This looks like e-cigarette ads are far better for former smokers than anti-smoking ads.    

There is a glaring defect in the report.  The researchers collected a lot of basic information (e.g., education, quitting history and time since last cigarette) that could affect how participants responded to questions, but the results weren't adjusted for these important characteristics.  It is possible that the cue, no-cue and no-ad groups had important differences in basic information that affected their scores.

The study’s biggest weakness is that no data was collected on urges and intentions to VAPE.  After all, that is the most important goal of e-cigarette ads, and it is an obvious outcome to measure. 

This study is a failure to communicate.

Thursday, March 12, 2015

Sloan Kettering Corrects E-Cigarette Study

Memorial Sloan Kettering Cancer Center researchers, led by first-author Sarah Borderud, claimed on September 22, 2014, that e-cigarettes did not help cancer patients quit smoking (media story here). They based that statement on a study they published online in Cancer, a journal of the American Cancer Society (abstract here).

The researchers had enrolled 1,074 cancer patients in a smoking cessation program.  They subsequently found that “E-cigarette users were as likely to be smoking at the time of follow-up as nonusers (odds ratio, 1.0; 95% confidence interval, 0.5-1.7).” 

Upon reading the study, I found a significant error: the main results table reported the exact opposite of the text.  On October 16, I submitted a letter to the Cancer editor, co-signed by my colleagues Nantaporn Plurphanswat and Carl Phillips, requesting a correction. 

Six weeks later, on November 25, a correction was published on the Cancer website.  It said: “The authors discovered some errors…in Table 2.”  The circumstances strongly suggest that the authors didn’t “discover” the errors, we did.  The journal office had our letter on October 16, six weeks before the correction appeared. 

Our letter, published online on March 4 (here), described other problems with the study; one is particularly important.  Borderud et al. claimed: “Using an intention-to-treat analysis, E-cigarette users were twice as likely to be smoking at the time of follow-up as nonusers (odds ratio, 2.0; 95% confidence interval, 1.2-3.3).”  In other words, e-cigarettes were harmful.

They reached this striking result by assuming that anyone lost during follow-up had continued to smoke.  We pointed out that “Smokers who were E-cigarette users were twice as likely to be lost to follow-up as the other smokers (66% vs 32%)… The conclusion that E-cigarette users were twice as likely to be smoking is purely an artifact of the assumption. An equally plausible counter-assumption is that dropouts left the program because they had quit smoking...”  They didn’t consider this possibility, but they should have. 

Carl Phillips’ goes into more detail about the technical irregularities here.

Thursday, March 5, 2015

Conflicts of Interest Exposed, FDA Reorganizes Tobacco Advisory Panel

A range of obvious conflicts of interest has led to the replacement of several FDA Tobacco Products Scientific Advisory Committee (TPSAC) members.

Federal judge Richard Leon ruled last July that “The presence of conflicted members on [TPSAC] irrevocably tainted its very composition and its work product” and “the Committee’s findings and recommendations…are, at a minimum, suspect, and, at worst, untrustworthy.” (here).

Today, Mitch Zeller, director of the FDA Center for Tobacco Products, announced (here) that, “As a result of the expanded [conflict of interest] criteria outlined in Judge Leon’s ruling, each voting TPSAC member was rescreened and four members – Chairman Jonathan Samet, Claudia Barone, Joanna Cohen, and Suchitra Krishnan-Sarin – have resigned or their terms on TPSAC have been terminated.”  Pebbles Fagan, Gary A. Giovino and Thomas E. Novotny are new committee members; the chair remains vacant.

Judge Leon ruled that Samet was conflicted because he “received grant support from [pharma giant] GlaxoSmithKline at least six times, including in 2010.  He also led the Institute for Global Tobacco Control, funded by GSK and Pfizer.  Dr. Samet also testified for lawyers suing tobacco-product manufacturers…he was designated to testify in two pending tobacco cases.”  I have noted that Claudia Barone also had a conflict of interest because of a Pfizer grant in 2013 that preceded her 2014 TPSAC appointment (here).

I have reported that Dr. Samet and Krishnan-Sarin also had conflicts due to their having received substantial grants from the anti-tobacco NIH ($8 million in 2014 for Dr. Samet, $5.8 million for Krishnan-Sarin).  Current TPSAC members with major NIH funding include Kurt Ribisl ($9.2 million in 2014), Thomas Eissenberg ($3.9 million), Richard O’Connor ($0.5 million) and Warren Bickel ($0.4 million)(here).

Experts can be influenced by substantial financial support from organizations committed to a tobacco-free society, a euphemism for the obliteration of the tobacco industry (an objective that is at odds with the principle of regulation).  To avoid even the appearance of impropriety, those who are funded by the American Cancer Society, the American Heart Association, the American Lung Association, the National Institutes of Health, the Centers for Disease Control and Prevention, or the Robert Wood Johnson Foundation should be ineligible for TPSAC membership.

Wednesday, March 4, 2015

Smoking Cessation: Minimal Impact on Weight

The association of tobacco use and body weight has long been a matter of concern.  In 2004, I collaborated with Swedish investigators to publish the first research on whether switching from cigarettes to smokeless tobacco blunts some of the weight gain normally seen with quitting via abstinence (abstract here, blog post here). 

We found that Swedish snus users and smokers who switched to snus gained no more weight than nonusers (average gain of around 7 pounds over 9 years).  In contrast, the big gainers in our study were smokers and snus users who completely abstained from nicotine and tobacco.

Numerous studies have documented that smokers weigh less than nonsmokers, and smokers who quit add pounds.  Since the 1970s, there are fewer smokers and more former smokers in the U.S.  For example, in 2010, only 19% of the adult population were current smokers (44 million), while 22% (49 million) were former smokers.  Did changes in population smoking contribute significantly to changes in population overweight and obesity?  The answer is no.

My University of Louisville colleague, research economist Nantaporn Plurphanswat, and I explore this question in a research article published in BMC Obesity (available here).  We used data from the National Health and Nutrition Examination Surveys (NHANES) for the years 1999 through 2012. 

Our analysis used body mass index (BMI), a measure of weight that accounts for height.  Conventional BMI categories are underweight (BMI < 18.5), normal weight (18.5 to less than 25), overweight (25 to less than 30) and obese (30+).

Consistent with previous studies, we found that smoking was associated with lower BMI among both men and women.  In addition, being a smoker increased the probability of being normal weight by 12% and reduced the probability of being obese by 13% among men; the magnitudes for women were smaller, +7%  for normal weight and -8% for obesity.

We noted that women with higher education had significantly lower BMI than those with less education; this relationship was not seen among men.  Marriage was associated with higher BMI among men, but lower BMI among women.

In a positive finding for men, we found no difference between never smokers and former smokers in terms of being in particular BMI categories.  However, women were shown to be more prone to weight gain.  Women who were former smokers had lower probability of underweight (0.2%), normal weight (2.3%), and overweight (0.4%), but had higher probability of obesity (2.9%). 

No one should be dissuaded from quitting cigarettes, especially when there are many smoke-free options like snus and e-cigarettes that might obviate any weight gain.