Wednesday, February 23, 2022

Different Strokes for Different Smokes: More Evidence That All Quitting Options Are Vital


Investigators at the University of Nebraska Medical Center in Omaha and the University of California San Francisco have published an important study in JAMA Network Open on “Exposure to toxicants associated with use and transitions between cigarettes, e-cigarettes, and no tobacco.”

Hongying Dai and colleagues looked at 55 tobacco exposure biomarkers (mostly toxins) in the urine of adult smokers, vapers and dual users in the first wave of the Population Assessment of Tobacco and Health Study.  They compared this data with urine samples from the same participants one year later in Wave 2, when the participants may or may not have changed their tobacco use status.

While Dai and coauthors “found complex patterns and heterogeneous health outcomes associated with transitions between cigarettes and e-cigarettes,” the results can be succinctly summarized.  First, “transitions from dual use or exclusive cigarette use to exclusive e-cigarette use and transitions from any tobacco use to no use” were associated with sharp declines in toxins. Second, “transitions from exclusive e-cigarette use to cigarette use or dual use” were associated with “moderate to large effect” increases in toxin levels.  And third, “transition from exclusive cigarette smoking to dual use of cigarettes and e-cigarettes” didn’t provide any meaningful change in urinary toxins.

The authors found that “only a small percentage of [Wave 1] exclusive cigarette smokers and dual users transitioned to exclusive e-cigarette use at [Wave 2] (1.2%and 5.6%, respectively), which could limit ben

efits in moving combustible cigarette smokers to less hazardous, noncombustible e-cigarettes.”  This is an important statement, because it acknowledges less e-cigarette harm by referencing an FDA press release from 2017 (here).  More importantly, it is followed by a solid explanation for the low transition rate to vapor: “low effectiveness in early generations of e-cigarettes in delivering nicotine [the PATH Waves were in 2013 and 2014, when e-cigarettes were not very effective], lack of knowledge among cigarette users to distinguish harmful effects between dual use and exclusive e-cigarette use, or the effects of negative public health messaging [emphasis added, references omitted].”

All of the above is informative, but the real news from this study is demonstrated in the following table.  It reports levels of cotinine – a breakdown product of nicotine – in the urine of participants, according to the product they used at Wave 1, and one year later at Wave 2.  Cotinine levels are widely used to indicate tobacco use levels.  In general, higher cotinine indicates more tobacco use.  Higher cotinine, especially with cigarette combustion, also means greater exposure to toxins. 


Urinary Cotinine Levels* at PATH Waves 1 and 2, According to Product Use
Wave 1 Product (n users)Wave 1 CotinineWave 2 Product/Cotinine

NoneCigarettes OnlyE-Cigarettes OnlyDual Use

Cigarettes (247)1585

Cigarettes (1820)2273

Cigarettes (32)1833

Cigarettes (257)3068


E-cigarettes (44)162

E-cigarettes (14)502

E-cigarettes (121)727

E-cigarettes (31)972


Dual use (42)2136

Dual use (315)2690

Dual use (36)2792

Dual use (252)3179

*in nanograms per milliliter of urine


One can readily see that cotinine levels were high in smokers and/or dual users in both waves.  Cotinine levels among e-cigarette users were much lower, confirming that in 2013-14, the products did not deliver nicotine very effectively.

Everyone in the first four rows of the table smoked cigarettes in Wave 1, so one might expect that their cotinine levels in that wave would be the same.  Instead, there were huge differences between them, depending on where the smokers ended up at Wave 2.  The 247 smokers who had a cotinine level of only 158 ng/ml at Wave 1 quit everything at Wave 2 and had negligible cotinine.  The highest Wave 1 cotinine levels were in smokers who continued to smoke at Wave 2, while the smokers who ended up with e-cigarettes went from 1833 ng/ml at Wave 1 to 713 at Wave 2. 

The same is true for the other two categories: The e-cigarette users and dual users at Wave 1 who quit completely at Wave 2 started out with much lower cotinine levels. 

The take-home message is hugely important.  Tobacco users at Wave 1 may have self-selected their Wave 2 product use based on their cotinine status at Wave 1.  This says that those who quit completely, switched to e-cigarettes, or stayed with cigarettes were entirely different groups of smokers, each with distinct nicotine needs.  Because no one can predict how individual smokers will be able to quit, they should be provided access to all quit-smoking options.



Wednesday, February 16, 2022

CDC Exploited the 2021 Teen Vaping Survey, But Still Withholds Raw Data from Independent Researchers


For years, I have objected that federal agencies selectively release information from their national surveys months or years before making the data available to all external researchers (here, here, here, here and here).  This practice guarantees that government officials control the narrative about behaviors that they deplore.  The Centers for Disease Control and the Food and Drug Administration have perfected this practice, perpetuating the myth of a teen vaping “epidemic” by releasing selected narrative-reinforcing data points from the annual National Youth Tobacco Survey long before providing outsiders with the raw data. 

Interestingly, while the CDC quietly acknowledged that the so-called epidemic had subsided in 2020, and that teen vaping rates plummeted in 2021 (here), the agency’s PR machine continued to generate sensational storylines:

“E-Cigarette Use in Teens Prevalent During COVID-19 Pandemic” (here)

“E-cigarette use among youth remains a serious public health issue during the COVID-19 pandemic” (here)

“CDC, FDA data find 2 million current teen e-cigarette users” (here)

Jacob Sullum, a senior editor at Reason magazine, said this about the government response to 2021 NYTS data: “The Centers for Disease Control and Prevention (CDC), which conducts the survey, and the Food and Drug Administration (FDA), which regulates ‘electronic nicotine delivery systems,’ both welcomed this evidence that the ‘epidemic’ of underage vaping is abating. Just kidding.”  In fact, Sullum accused the agencies of ignoring the decline in underage vaping precisely because it weakens the case for government action.

The CDC’s timing of data dumps is telling. Tobacco research and policy experts were not only impressed by the teen vaping decrease in 2020, but also by the speed in which the CDC released that year’s NYTS data.  The agency published its report on teen vaping on December 18 (here), and released underlying data on December 21 (here). 

The 2021 NYTS is being handled differently. The CDC published its corresponding report on October 1, but over four months later, the data is still under wraps.  It’s hard to say if the delay is related to the sharp decrease in teen vaping last year, but it is clear that the delay allows the crisis narrative to persist. That is unacceptable.



Thursday, February 10, 2022

UC San Diego Claims No Evidence for Quit-Smoking Via E-Cigarettes, Medicines or Cold Turkey


The anti-tobacco journal Tobacco Control just published another e-cigarette study by Dr. John Pierce and co-workers from the University of California San Diego (here).  I’ve dissected Pierce’s previous work here, here and here. 

This time, Pierce’s group used the FDA’s Population Assessment of Tobacco and Health Survey to determine what aids current and former smokers used to quit and how successful they were.  As in his earlier work, Pierce counted anyone who took even one puff on a cigarette as a failed quitter.   

First, let’s look at the main results, from Tables 3 and 4 of the study


From Pierce Table 3. Abstinence From Cigarettes (Even 1 Puff) for 12+ Months Among Smokers Who Used Various Products in their Last Quit Attempt
ProductNumberPercent Abstinent

Other tobacco5814%
Any medicine48916%



From Pierce Table 4. Abstinence From Cigarettes (Even 1 Puff) for 12+ Months Among Recent Former Smokers Who Used Tobacco Products
ProductNumberPercent Abstinent



Other tobacco


No tobacco57653%


Dr. Pierce provided generous click-bait quotes to the media, including the following:

“This is the first time we found e-cigarettes to be less popular than FDA-approved pharmaceutical aids, such as medications or the use of patches, gum, or lozenges.”

To render e-cigarettes as “less popular,” Dr. Pierce first gamed the numbers by combining smokers trying any prescription medicine and/or six different nicotine products, four of which are available over-the-counter. 

Furthermore, who can blame American smokers for vapor’s declining popularity?  They have been told incessantly, and incorrectly, that e-cigarettes are as or more dangerous than combustible cigarettes. 

Dr. Pierce opined, “There's no evidence that the use of e-cigarettes is an effective cessation aid,” and he doubled down on that position in an email to United Press International: “We are not finding any evidence in this very large nationally representative study that smokers who switch to get their nicotine from e-cigarettes are less likely to relapse back to cigarette smoking.”  

Frankly, if one sees no evidence for e-cigarettes in the above tables, one would have to conclude that there's no evidence that anything is an effective cessation aid. 

What did the Pierce study actually document in comparing e-cigarettes and FDA-approved medicines?  Co-author Karen Messer, Ph.D., said, “using e-cigarettes to help a quit attempt resulted in seven fewer successful quitters [out of 100] than were seen with approved pharmaceutical cessation aids.”

Drs. Pierce and Messer emphasized those seven for a reason: their one-puff abstinence rate was only 9% for e-cigarette users versus 16% for medicine users.  Both aids helped some smokers quit, but they failed 91% and 84% of the smokers who tried them.

With failure rates like these, smokers who are desperate to quit should have access to every safer option.  It doesn’t matter which quit aid smokers use, so long as it works for them.  Smokers also deserve far more rigorous analysis and forthright counsel than that provided by abstinence-only activists.