Thursday, October 29, 2020

E-Cigarettes = Nicotine Medicines = Prescription Medicines = Cold Turkey: All Help Some Smokers Quit


Thirty-six co-authors, peer review, and they still got it wrong.

Dr. John Pierce and 35 colleagues have published a study in the journal PLoS One analyzing data from FDA Population Assessment of Tobacco and Health (PATH) surveys.  Their work was touted in a University of California San Diego press release titled, “E-cigarettes Don’t Help Smokers Quit and They May Become Addicted to Vaping.”  But their study actually proved that e-cigarettes are as helpful as medicines promoted by anti-tobacco crusaders.

The study followed participants in all three waves of the PATH – one year apart in 2014, 2015 and 2016.  I will describe how Pierce and colleagues conducted this complicated analysis. 

Pierce et al. selected participants who were smoking every day when they enrolled in PATH Wave 1 (n= 9,021).  They then selected those who had tried to quit smoking “in the past 12 months” between Waves 1 and 2, but who were still smoking daily (n= 2,443).  In other words, those daily smokers had tried, but did not quit, during the year between the first two waves.  Daily smokers who had not tried quitting were excluded.

Pierce divided those 2,443 daily smokers who had failed to quit between Waves 1 and 2 into three groups: those who had tried stop-smoking medicines (a prescription and/or over-the-counter medicinal nicotine, n=442); those who had tried e-cigarettes (n=566, 116 of whom had also used stop-smoking medicines); and those who had used neither (i.e., had gone cold turkey, n=1,435).

After the three groups of smokers had failed between Waves 1 and 2, Pierce compared them at Wave 3 (one year after Wave 2) with respect to three outcomes: abstinent from cigarettes for 12+ months; abstinent from cigarettes for 30+ days; and abstinent from all tobacco. 

The researchers found that the first two outcomes for all groups were similar: “Twelve-month cigarette abstinence was ~10% and comparable across all methods used to quit… There was no net risk difference in 30+ days cigarette abstinence at W[ave]3 between the e-cigarette group and either the no e-cigarette control, the no [cold turkey group] or the [medicine group].”     

While the authors apparently approved their press release headline – “E-cigarettes Don’t Help Smokers Quit” – they failed to note that e-cigarettes had helped people quit as often as medicinal nicotine, other medicines or going cold turkey.  In fact, all of the quit aids helped some smokers.  The headline should have read: “E-cigarettes, Nicotine Medicines, Prescription Medicines and Cold Turkey All Help Some Smokers Quit.”

Another red flag with this study is that it focused only on 2,443 “daily smokers” at Wave 1 who had tried to quit between Waves 1 and 2, but were also daily smokers at Wave 2 and additionally had information at Wave 3.  That number represents a remarkably narrow subset of all daily smokers at Wave 1 (about 27% of the 9,021 daily smokers at Wave 1).

Even more important, the authors completely ignored former smokers at both Waves 1 and 2 who had already used e-cigarettes (and other aids) to quit in the year before.  The Wave 1 former smokers were documented by my research group in a 2017 research study.  It is entirely inappropriate for Pierce et al. to issue a press release claiming that “E-cigarettes don’t help smokers quit” when they produced results only for a select population of daily smokers who remained daily smokers after trying to quit. 

While Pierce et al. narrowly defined their study groups, another study of PATH Waves 1 to 3 has produced diametrically opposite results.  Investigators at New York University, Ohio State, Georgetown and Columbia, led by Allison Glasser, coauthored a study that concluded: “…consistent and frequent e-cigarette use and increasing use over time, as well as flavors and device type, are associated with smoking cessation among adult smokers.”  They also found that “flavors may play a facilitating role in cigarette smoking cessation among adults. Use of a rechargeable device consistently…was also associated with a higher likelihood of smoking cessation within the past year when compared with use of disposable devices, although this effect was only found among daily smokers.”

The Pierce study and its PR spin underscore the importance of critical analysis and fact-checking of all research reports, even when “co-written” by dozens of authors and ostensibly peer reviewed.



Wednesday, October 21, 2020

Good News: Young Adults Sustain the High School Smoking Decline!


In January, I discussed results from the 2019 National Youth Tobacco Survey (NYTS) showing that vaping among high school students increased considerably over the past five years, as use of cigarettes declined at a rapid rate (here).  With the release of 2019 data from the National Health Interview Survey (NHIS), which I summarized a week ago (here), it is useful to compare high school vaping and smoking rates with those among young adults 18-24 years old, as seen in the chart at left.

The prevalence of smoking in 2014 – the first year that the NHIS collected vaping information – was 16.6%; it had fallen by over one-half by 2019, to 7.7%.  That was even better than the decline in smoking among high schoolers, which fell from 9.2% in 2014, to 5.7% in 2019 (in the chart below, for easy comparison). 

Vaping surpassed smoking among young adults in 2019 for the first time at 9%, only a modest increase from 5.1% in 2014.  Note that all NHIS vaping and smoking figures include about two percentage points of dual use; high schoolers showed about five percentage points of dual use during the same period.

It is noteworthy that the prevalence of vaping in young adults never reflects the high prevalence in high school students.  Take 2019, when high school vaping reached 27%, but registered 9% among young adults.  There are several reasons for this.  First, NYTS high school vaping rates are hyperinflated compared with other federal surveys, as I demonstrated here.  That is not the case with smoking rates, which in 2019 were 5.7% among high schoolers (NYTS) and 7.7% among young adults (NHIS).  Second, current use of these products among teens is “once in the past month,” whereas current use among adults is “every day or some days.”  Third, a small increase in tobacco use after high school is expected, as 18-year-olds escape parental and school supervision, and tobacco can be purchased legally.  It is likely that national adoption of Tobacco 21 will make further inroads into smoking and vaping.

One final impressive trend: Contrary to the scaremongering about a purported teen vaping epidemic, total vaping and smoking is down among young adults.  This is news featured only at Tobacco Truth.



Wednesday, October 14, 2020

Swedish Research Proving HPV Vaccine Prevents Cancer Mirrors that Country’s Life-Saving Snus Experience


Research from the Karolinska Institute in Stockholm and Lund University, published in the New England Journal of Medicine, proves beyond a shadow of a doubt that the human papillomavirus (HPV) vaccine protects women from cervical cancer.  It showed that vaccinated women had only 37% of the risk of contracting that cancer compared with women who weren’t vaccinated (incidence rate ratio [IRR] = 0.37, 95% confidence interval [CI] = 0.21 – 0.57).

Earlier vaccination was even better.  Girls younger than 17 years were 88% less likely to get cervical cancer (IRR = 0.12, CI = 0.00 – 0.34), while protection among women age 17 to 30 was over 50% (IRR = 0.47, CI = 0.27 – 0.75).

These critical findings mirror the Swedish tobacco experience: Snus use helps Swedes avoid the deadly consequences of smoking, acting to some extent as a “vaccine.”  I began chronicling the Swedish experience in 2002, with a series of published studies and, in 2003, Congressional testimony in which I demonstrated how use of snus protected Swedish men from smoking-related lung cancer.

Here is a full list of my published work on the Swedish snus experience, with PubMed links.  Proof of the Swedish snus vaccine is documented in # 10.

Rodu B, Stegmayr B, Nasic S, Asplund K.  Impact of smokeless tobacco use on smoking in northern Sweden.  Journal of Internal Medicine 252: 398-404-2002. 


Rodu B, Stegmayr B, Nasic S, Cole P, Asplund K.  Evolving patterns of tobacco use in northern Sweden.  Journal of Internal Medicine 253: 660-665, 2003.


Rodu B, Stegmayr B, Nasic S, Cole P, Asplund K.  The influence of smoking and smokeless tobacco use on weight among men.  Journal of Internal Medicine 255:102-107, 2004.

Rodu B, Cole P.  The burden of mortality from smoking: comparing Sweden with other countries in the European Union.  European Journal of Epidemiology 19: 129-131, 2004.  


Eliasson M, Asplund K, Nasic S, Rodu B.  Influence of smoking and snus on the prevalence and incidence of type 2 diabetes amongst men: the northern Sweden MONICA study.  Journal of Internal Medicine 256: 101-110, 2004.

 Rodu B, Jansson C. Smokeless tobacco and oral cancer: a review of the risks and determinants.  Critical Reviews in Oral Biology and Medicine 15: 252-263, 2004. 


Stegmayr B, Eliasson M, Rodu B.  The decline of smoking in northern Sweden.  Scandinavian Journal of Public Health 33: 321-324, 2005.


Rodu B, Nasic S, Cole P.  Tobacco use among Swedish schoolchildren.  Tobacco Control 14: 405-408, 2005.


Rodu B.  Snus and the risk of cancer of the mouth, lung, and pancreas.  Lancet 370:1207-1208, 2007.


Rodu B, Cole P.  Lung cancer mortality: comparing Sweden with other countries in the European Union.  Scandinavian Journal of Public Health 37: 481-486, 2009.


Rodu B, Heavner KK, Phillips CV.  Snuff use and stroke. Epidemiology 20(3):468-469, 2009.


Rodu B, Heavner KK.  Errors and omissions in the study of snuff use and hypertension.  Journal of Internal Medicine 265: 207-208, 2009.  


Rodu B, Jansson J-H, Eliasson M.  The low prevalence of smoking in the northern Sweden MONICA Study, 2009.  Scandinavian Journal of Public Health 41: 808-811, 2013.  

I have also explored the Swedish experience in my blog (examples herehere, here, here, and here).

The new Karolinska/Lund publication also indirectly addresses a topic I’ve discussed: why randomized clinical trials don’t work well for harm reduction.  The NEJM authors underscore the key deficiencies: “Randomized, controlled trials cannot readily evaluate vaccine effectiveness against invasive cervical cancer because of the long lead time (the time from HPV infection to the clinical detection of cervical cancer) and the low risk of cervical lesions after vaccination.”

The long lead times for smoking-attributable diseases and the minuscule risks of vastly safer smoke-free products make population-based studies far more informative for analysis of tobacco harm reduction.