Tuesday, February 26, 2019

The American Cancer Society: For and Against Tobacco 21


My op-ed about Virginia’s adoption of Tobacco 21 was published in the Richmond Times-Dispatch (available at Richmond.com here and below).  As I have documented before (here), the American Cancer Society is out of touch with American smokers and their need for reasonable and rational ways to quit.  Further evidence is seen in the Society’s U-turn from supporting to opposing Tobacco 21 in Virginia (below) and Utah (here).  The Society complained in both states that “the devil’s in the details,” but there are no details: states simply want to move the legal age for tobacco sales from 18 to 21.  The Society should advocate for the health, and respect the rights, of American teens and smokers.
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Virginia has raised the minimum age for buying all nicotine products, including e-cigarettes, from 18 to 21. The bill had widespread support from state medical societies and Gov. Ralph Northam, a pediatric neurologist; and it is part of a national trend in which states are responding to the growing number of adolescents choosing to vape. But some in the public health community tried to make the perfect the enemy of the good by standing in the way of a sensible regulation that has the potential to curtail teen nicotine use, without making it harder for adult smokers to access healthier alternatives.

It’s true there has been an increase in teen vaping — a problem exacerbated, in part, by older students legally buying tobacco products and selling them to their younger classmates. Raising the age from 18 to 21 will delegitimize tobacco sales to 18-year-olds and potentially disrupt high school “black markets.” Eighteen-year-olds make up 14 percent of all American high school students, but they account for one-quarter of high school smokers and smoker-vapers. Legal buyers — not manufacturers and retailers — are the primary source for tobacco products used by underage high schoolers. So Virginia’s Tobacco 21 law could make a big impact in limiting access to youth.

The problem comes from the growing contingent of “anti-tobacco” activists who won’t be happy until there is simply no tobacco — or nicotine — for sale at all. Specifically, the American Cancer Society needs to start acknowledging scientific facts and abandon its “tobacco-prohibition” stance. The society opposed the sensible Tobacco 21 bill in the Virginia legislature, despite the fact that the ACS’s lobbying arm, the Cancer Action Network (CAN), endorses Tobacco 21 at the national level. CAN spokesman Brian Donohue insists, “the devil is in the details.”


Similarly, the American Heart Association also supports Tobacco 21 in theory, but has been critical of the Virginia legislation. AHA spokesperson Ashley Bell said — somewhat incoherently — that youth access laws “may not be strong enough to support the current age … are not strong enough to support the enforcement of raising the age.” ACS-CAN’s Donohue added that Tobacco 21 “is a great goal, but it’s backwards.”


The only thing backwards is the public health community’s flip-flopping on support for Tobacco 21. ACS-CAN is critical of the bill’s focus on youth — rather than retailers — and is insisting additional changes ought to be made such as the elimination of fines for teen buyers (currently $100 for the first violation, $250 after that), and increased fines for retailers (currently set at $500 for the first violation and up to $2,500 subsequently). But the reality is, they don’t intend to settle halfway because they want the complete elimination of nicotine and tobacco products.


Efforts to stem the use of tobacco and vaping products through Tobacco 21 laws — like the one signed into law in Virginia — are growing. Hawaii, California, New Jersey, Oregon, Maine, and Massachusetts have already raised the purchase age to 21, and Alabama, Alaska, and Utah bumped it to 19. The leadership at organizations like ACS-CAN and the AHA know that the FDA punishes retailers who sell tobacco to anyone under 18. E-cigarette companies have implemented stringent age verification systems online to support these measures.


No tobacco product is perfectly safe, but vaping is considered 95 percent safer than smoking. E-cigarettes not only provide a safer alternative for adult smokers; but, as the New England Journal of Medicine just confirmed, they are used more often by smokers, and they are more effective than medicinal nicotine in helping smokers quit.


Each year more than 16 million Americans live with, and almost half a million die from, smoking-attributable illnesses; the total economic cost is more than $300 billion. We can’t afford to let politics interfere with sensible policies.


Kudos to Governor Northam for ignoring tobacco policy u-turners in order to remove legal tobacco consumers from Virginia high schools.




Thursday, February 21, 2019

Teen Smoking-to-Vaping Is More Frequent Than Vaping-to-Smoking, Says Data in New Study


FDA Commissioner Gottlieb on February 10 tweeted, “Now, a new study, published in the Journal of the American Medical Association (JAMA), further demonstrates what we’ve seen from other data: Teens who vape are more likely to start smoking cigarettes.” (Tweet here)  The study (here), by Kaitlyn Berry at Boston University and colleagues there and at the Universities of Louisville and Southern California, appeared in JAMA Network Open.

Berry et al. examined the FDA Population Assessment of Tobacco and Health (PATH) survey involving youth, which started in 2013-14 and had two follow-ups, one and two years later.  The researchers identified 6,123 youths age 12-15 years who had not used a tobacco product at enrollment.  Some of the participants first tried a tobacco product over the next two years.  Berry et al. assessed whether first use of a particular product resulted in youth ever or current (past 30 days) cigarette smoking.  They concluded that “e-cigarette use is associated with increased risk for cigarette initiation and use.”

Taking a closer look at the study, New York University professors David Abrams and Ray Niaura and I produced a comment, which has been published in the journal, making the following important observations.

While Berry et al., and Commissioner Gottlieb, emphasized the 4.0% probability of current smoking among e-cigarette first users, we found a reverse result buried in a supplemental table: The probability of current e-cigarette use at follow up among cigarette first users was 8.3%.  This means that twice as many first-smoking teens currently used e-cigarettes at follow-up than first-vaping teens who currently used cigarettes. 

We also noted that 527 teens first used e-cigarettes during follow-up, 202 used cigarettes first, and 306 used other products.  The table shows that out of 130 current smokers at follow-up, the relative impact is 25% for first e-cigarette use and 75% for all others.

First Use of Tobacco Products By Teens in the PATH Survey and Current Smoking at Follow-up


First Product Used (n)Percentage Currently Smoking at Follow-up (n)


E-cigarette (527)5.9% (31)
Other Tobacco (306)8.2% (25)
Cigarette* (202)
None* (5,088)1.4% (74)
All (6,123)2.1% (130)


*First cigarette users were combined with nonusers by Berry et al.

This is entirely relevant to the FDA public health standard.  The absolute population impact (API) can be calculated using the full denominator of 6,123 teens. This reveals that e-cigarette first use resulted in 31/6,123 or about 0.5% API, contrasted with 25+74 = 99 /6123 or 1.6 % for teens without any first e-cigarette use.  In short, the API for teens without e-cigarette first use was triple that for teens with first e-cigarette use.

Drs. Abrams, Niaura and I concluded:

“Even with this small impact [0.5% API], e-cigarette first use cannot be causally linked to current smoking two years later, because plausible shared liability factors have not been ruled out. As a result of the issues we raise, scientists, journalists, regulators, policymakers and the public may be misled into thinking that e-cigarette first use is a unidirectional gateway into smoking. When information about API and the opposite gateway to smoking cessation are included, a much more complete picture emerges.”

We look forward to a response from Ms. Berry and her colleagues.

Tuesday, February 19, 2019

Twitter Caught Up In This Year’s Annual Through With Chew Misinformation Orgy


Smokeless tobacco users are in for harassment this week, the 30th iteration of the annual Through With Chew orgy of smokeless tobacco misinformation.  Dippers and chewers will be demonized and the real science about the relative safety of their favored products will be twisted into fear-inspiring untruths.

Consider this Tweet, for example, from the U.S. Department of Defense @ucanquit2 account on February 11: “Smokeless tobacco users are 50x more likely to get cheek, gum & mouth cancer than nonusers.”  The DoD made the same bogus claim two years ago (here). 

I responded to this blatant fabrication with a Tweet of my own on February 15: “Your 50 claim is a complete fabrication by a staffer @theNCI. Here is the explanation: https://tinyurl.com/yxjsnugd . Furthermore, a large federally-funded study documented that men who dip/chew had ZERO excess risk for mouth cancer. ZERO. http://tinyurl.com/hd8nd49

After my Tweet was liked by 24 people and retweeted by 13, a strange chain of events occurred.  The Twitter accounts of many of the above were suspended.  The affected individuals pleaded with @TwitterSupport to make amends.  On February 16, I also asked for a correction:

“To @TwitterSupport, Pls restore me/others. I am a scientist, 25 years published in this field. My tweet was professional and credible. In 2010 @CarlBialik at @WSJ investigated ‘50’ number and reported it was a fabrication used by @AmericanCancer, others http://tinyurl.com/y6a7ox8a.”

That’s right.  Carl Bialik, “The Numbers Guy”, published a weekly column in the Wall Street Journal.  When Carl exposed the “50” myth (here) the American Cancer Society promised to stop using it: “Dr. Thomas Glynn, director of cancer science and trends for the American Cancer Society, said this week that his organization will no longer use the statistic citing a 50-fold increase in risk.”

Yet still today, the Cancer Society and other tobacco prohibitionists tout the 50 number.      

This week’s Twitter account suspensions likely resulted from a complaint by an authoritative anti-tobacco figure or agency.  While I understand that Twitter aims to protect the integrity of the information on its platform, in this case they sanctioned the wrong party.

Note: As I post this on February 19, the suspended accounts have not been restored.  

February 22: Today Jacob Sullum authored an article on the Reason Hit and Run Blog, "Did Twitter Punish Criticism of Government Propaganda About Smokeless Tobacco. (here).  A few hours later affected users reported that their accounts were returned to normal functioning.