What Medscape Subscribers Really Thought About Its Tobacco Harm Reduction Programs

 

Earlier this year, Medscape, which describes itself as “the leading online global destination for physicians and healthcare professionals worldwide,” invited me to participate in a series of short continuing medical education (CME) programs on tobacco harm reduction (THR).  Medscape clearly disclosed that the series was sponsored by Philip Morris International, but the programs were firewalled; faculty were not in contact with or influenced by the sponsor.

Topics included, among others, an examination of nicotine, and the differential risks of combusted versus smoke-free tobacco/nicotine products.

I recorded two programs.  The first, “Nicotine Misperceptions: What Does the Evidence Say,” was published online by Medscape around March 1.  The second, in collaboration with Dr. Sally Satel, “Harm Reduction From Tobacco: An Evidence-Based Discussion,” was published April 1.  Dr. Satel also recorded a third program.

Following publication, a few anti-tobacco crusaders objected, threatening “a rapid global boycott by healthcare professionals disgusted by [Medscape’s] behaviour” in two British Medical Journal articles and one in The Examination.  I will not provide links to these, as they include ad hominem attacks on me.  Dr. Satel recounts the sorry tale in this article (here).    

As Dr. Satel notes, Medscape buckled, whining that “use of this funder was a misjudgment that was out of character for Medscape Education and that doing so may have disappointed our members.”

But were Medscape members truly offended by the PM sponsorship?  Evidence from an email I received from a Medscape manager says “NO.”  Shortly after my nicotine program aired, I received an unsolicited email from the manager titled, “One of the best CME programs I have seen in a long time…” Following is the text of that email, with some passages highlighted by me.

“We have the preliminary results from your program that was posted less than a month ago, and I am personally flabbergasted by the participation - over 6000 learners and over 2200 test takers!

“The comments from participants have been incredible as well:

• I can better educate and motivate pts on how to cut down their use of nicotine products. I am also more cognizant now that those who use cigarettes may have a more difficult time quitting. Will refer these pts to our clinical pharmacist who can also help advise and prescribe the appropriate tobacco cessation products.
  

• This was fantastic! This down to earth harm reduction approach is absolutely key to help meet people where they are, as nicotine addiction is so strong! Much better outcomes can be achieved as these presenters described, using less harmful forms of nicotine. As the doctors stated, there is a great need to educate providers, and clarify misconceptions about nicotine vs various methods of ingesting nicotine. I hope this presentation reaches a wide audience! One of the best continuing eds I have done in a while.
  

• Dispelled many myths I previously held about nicotine that I will no longer propagate.

• Thank you for bringing up such an important topic that can bring down the costs of healthcare and truly improve the public health. I am a psychiatric provider and have had a large number of patients successfully quit smoking with harm reduction measures!”

It is tragic that Medscape capitulated to rabid tobacco prohibitionists and stopped providing vital, life-saving information to health professionals.

 

Call It Whatever You Want -- Tobacco Harm Reduction Saves Smokers’ Lives

 

The U.S. desperately needs tobacco harm reduction, starting with reducing the harm from the pronouncements of federal officials.  Case in point: FDA Commissioner Robert Califf’s April 11 tobacco testimony before the House Oversight Committee.

Dr. Califf made so many false statements that I penned a response for Real Clear Health. Following are some additional observations related to his testimony.

Readers know that I don’t tolerate doctors who claim they saw many people die from the ravages of tobacco, when those patients actually died from the smoke!  Similarly, I can’t let the federal official in charge of regulating tobacco get away with mislabeling it in the same fashion as the World Health Organization and the National Cancer Institute.

Dr. Califf wrongly claimed that harm reduction is an industry term.  My late colleague Dr. Philip Cole and I used that term in an article published by the American Council on Science and Health in 1995.  The Institute of Medicine, hardly a tobacco industry tool, titled a 2001 report, “Clearing the Smoke: Assessing the Science Base for Tobacco Harm Reduction (here).”

For 30 years, I’ve been saying, without challenge, “Nicotine, when consumed without the harmful constituents of cigarette smoke, is no more harmful than caffeine.”

Fifteen years ago Britain’s Royal College of Physicians, one of the world’s oldest and most prestigious medical societies, agreed with me, finding, “…that smokers smoke predominantly for nicotine, that nicotine itself is not especially hazardous, and that if nicotine could be provided in a form that is acceptable and effective as a cigarette substitute, millions of lives could be saved.”

Dr. Califf should stop supporting the cigarette industry by trashing vastly safer cigarette substitutes.  That's called tobacco harm escalation.

 

 

Are Vape Aerosols Really Toxic?

 

My readers know that I have focused on exaggerated or fraudulent population-based research on vapor products.  But anti-tobacco crusaders have also published numerous studies, predominantly funded by the National Institutes of Health, that widely exaggerate the toxicity of vape aerosols and, through university press releases taken up verbatim by uncritical media, spread like an uncontrollable virus. 

There is an antidote, in the form of Dr. Roberto Sussman, an astrophysicist based at the Institute of Nuclear Sciences, National Autonomous University of Mexico.  He offers the following review that I am proud to post.  BR

 

The easy publication and wide media diffusion of questionable and unreliable studies is a widespread phenomenon that generates the misperception that e-cigarette aerosols are much more toxic than the evidence shown by well-designed and conducted studies.

Dr Califf has apparently ignored three extensive reviews:

• Soulet, S. and Sussman, R.A. Critical Review of the Recent Literature on Organic Byproducts in E-Cigarette Aerosol Emissions.  Toxics, 10, 714.

• Soulet, S. and Sussman, R.A. Critical Review of Recent Literature on Metal Contents in E-Cigarette Aerosol. https://www.mdpi.com/2305-6304/10/9/510 Toxics, 10, 510.

• Sussman, R.A., Sipala, F., Emma, R., and Ronsisvalle, S. Aerosol Emissions from Heated Tobacco Products: A Review Focusing on Carbonyls, Analytical Methods, and Experimental Quality. Toxics 2023, 11, 947.

The reviews provide a critical evaluation of 65 emission studies published between 2018 and 2022 (12 on metals, 36 on organic byproducts and 17 on heated tobacco products, HTPs). The first 2 reviews concern the presence of metals and organic byproducts in e-cigarette aerosols.

To evaluate the 65 reviewed studies, my colleagues and I considered the following 5 conditions of experimental quality: (1) reproducibility and replicability of experiments; (2) consistency between supplied power, coil resistance, airflow rate and puffing parameters; (3) tested devices must be in good conditions; (4) appropriate evaluation of exposure and (5) analytic methods.

We show in the e-cigarette reviews that all studies reporting high levels of toxicants (metals or organic in comparison with toxicological markers) exhibit moderate to severe flaws of experimental design, failing to comply with at least 3 of the 5 quality conditions, making their toxicity assessments either questionable or completely unreliable. As a contrast, all studies complying with (at least) 4 of the 5 quality conditions reported low toxicity levels (below toxicological markers and way below tobacco smoke). Our HTP review showed that all except 2 of the studies (9 industry-funded and 8 independent), are reliable. We also comment and criticize various claims that question the relative safety of HTP aerosols in reference to tobacco smoke. 

We believe that these reviews completely demolish all claims of alleged high toxicity of vape aerosols, particularly pronouncements like “contain toxic compounds,” some of which constitute rhetoric devoid of evidence or in some cases they are based on studies that we documented are unreliable.

There are numerous questionable and/or unreliable studies – all funded by the NIH and other public institutions in the US – that are widely cited in order to promulgate the sense of a toxic crisis.  Here are some of the worst offenders (citation numbers taken from Google Scholar):

Olmedo, P., Goessler, W., Tanda, S., Grau-Perez, M., Jarmul, S., Aherrera, A., ... & Rule, A. M. (2018). Metal concentrations in e-cigarette liquid and aerosol samples: the contribution of metallic coils. Environmental health perspectives, 126(2), 027010.  329 citations

Bitzer, Z. T., Goel, R., Reilly, S. M., Elias, R. J., Silakov, A., Foulds, J., ... & Richie Jr, J. P. (2018). Effect of flavoring chemicals on free radical formation in electronic cigarette aerosols. Free Radical Biology and Medicine, 120, 72-79. 151 citations

Kim, S. A., Smith, S., Beauchamp, C., Song, Y., Chiang, M., Giuseppetti, A., ... & Kim, J. J. (2018). Cariogenic potential of sweet flavors in electronic-cigarette liquids. PloS one, 13(9), e0203717. 109 citations

Zhao, D., Navas-Acien, A., Ilievski, V., Slavkovich, V., Olmedo, P., Adria-Mora, B., ... & Hilpert, M. (2019). Metal concentrations in electronic cigarette aerosol: Effect of open-system and closed-system devices and power settings. Environmental research, 174, 125-134.  94 citations

Bitzer, Z. T., Goel, R., Reilly, S. M., Foulds, J., Muscat, J., Elias, R. J., & Richie Jr, J. P. (2018). Effects of solvent and temperature on free radical formation in electronic cigarette aerosols. Chemical research in toxicology, 31(1), 4-12. 88 citations

Son, Y., Mishin, V., Laskin, J. D., Mainelis, G., Wackowski, O. A., Delnevo, C., ... & Meng, Q. (2019). Hydroxyl radicals in e-cigarette vapor and e-vapor oxidative potentials under different vaping patterns. Chemical research in toxicology, 32(6), 1087-1095. 67 citations 

Son, Y., Bhattarai, C., Samburova, V., & Khlystov, A. (2020). Carbonyls and carbon monoxide emissions from electronic cigarettes affected by device type and use patterns. International journal of environmental research and public health, 17(8), 2767. 64 citations

Ooi, B. G., Dutta, D., Kazipeta, K., & Chong, N. S. (2019). Influence of the e-cigarette emission profile by the ratio of glycerol to propylene glycol in e-liquid composition. ACS Omega 4 (8): 13338–13348, PMID: 31460462. 62 citations

Korzun, T., Lazurko, M., Munhenzva, I., Barsanti, K. C., Huang, Y., Jensen, R. P., ... & Strongin, R. M. (2018). E-cigarette airflow rate modulates toxicant profiles and can lead to concerning levels of solvent consumption. ACS omega, 3(1), 30-36. 60 citations

Tehrani, M. W., Newmeyer, M. N., Rule, A. M., & Prasse, C. (2021). Characterizing the chemical landscape in commercial e-cigarette liquids and aerosols by liquid chromatography–high-resolution mass spectrometry. Chemical research in toxicology, 34(10), 2216-2226.  57 citations 

El-Hellani, A., Al-Moussawi, S., El-Hage, R., Talih, S., Salman, R., Shihadeh, A., & Saliba, N. A. (2019). Carbon monoxide and small hydrocarbon emissions from sub-ohm electronic cigarettes. Chemical research in toxicology, 32(2), 312-317. 48 citations

Fowles, J., Barreau, T., & Wu, N. (2020). Cancer and non-cancer risk concerns from metals in electronic cigarette liquids and aerosols. International journal of environmental research and public health, 17(6), 2146. 47 citations

Williams, M., Li, J., & Talbot, P. (2019). Effects of model, method of collection, and topography on chemical elements and metals in the aerosol of tank-style electronic cigarettes. Scientific Reports, 9(1), 13969. 46 citations

Here are two studies (one of them cited above) with misleading conclusions that have been widely cited, while corresponding articles dealing with their deficiencies have been ignored.

Misleading: Williams, M., Villarreal, A., Bozhilov, K., Lin, S., & Talbot, P. (2013). Metal and silicate particles including nanoparticles are present in electronic cigarette cartomizer fluid and aerosol. PloS one, 8(3), e57987. 825 citations

Ignored: Farsalinos, K. E., Voudris, V., & Poulas, K. (2015). Are metals emitted from electronic cigarettes a reason for health concern? A risk-assessment analysis of currently available literature. International journal of environmental research and public health, 12(5), 5215-5232. 118 citations

Misleading: Olmedo P, Goessler W, Tanda S, et al. Metal Concentrations in e-Cigarette Liquid and Aerosol Samples: The Contribution of Metallic Coils. Environ Health Perspect. 2018 Feb 21;126(2):027010. doi: 10.1289/EHP2175. PMID: 29467105; PMCID: PMC6066345. 329 citations

Ignored: Farsalinos KE, Rodu B. Metal emissions from e-cigarettes: a risk assessment analysis of a recently-published study. Inhal Toxicol. 2018 Jun-Jul;30(7-8):321-326. doi: 10.1080/08958378.2018.1523262. Epub 2018 Nov 2. PMID: 30384783. 15 citations

Another important distinction between the last two articles can be seen by their Altmetrics Score, which is a measure of how much attention they have received.  The Altmetrics Score of the Olmedo et al article is 46,891.  In contrast, the score of the article by Farsalinos and Rodu is 139.

Stay tuned.  We have submitted a review of 98 studies (some widely cited) that have tortured cells/rodents by exposing them to overheated and carbonyl-loaded aerosols, which evidently renders their assessment of vaping safety totally unrealistic and unreliable.

The articles I have highlighted represent just the tip of the anti-tobacco harm reduction iceberg that is killing smokers all over the world.