Gateway Claims Aimed at E-Cigarettes: Counterfeit, Déjà Vu

In their war against e-cigarettes, government officials often claim that the devices are a gateway to smoking.  CDC director Dr. Tom Frieden asserted (here) that “…many kids are starting out with e-cigarettes and then going on to smoke conventional cigarettes.”  The National Cancer Institute last March promoted (here) Dr. Stanton Glantz’s tortured analysis of youth e-cigarette use (discussed here and here).  While his data failed to support a gateway effect, his employer, the University of California San Francisco, made the claim anyway (here).     

Politicians also have a penchant for yelling “fire” about smoke-free devices.  U.S. Senator Richard Durbin and Democratic colleagues in the House and Senate issued a report in April titled “Gateway to Addiction” (here).  The term “gateway”, obviously used as an attention-grabber on the cover, appeared only once in the text -- as a nonspecific example of how e-cigarettes “could also increase public health risks” for non-smokers.

The marijuana gateway claim didn’t gain currency until the 1950s.  Back in the 1930s, Harry Anslinger, the first commissioner of the Federal Bureau of Narcotics (here) and the driving force behind the prohibitive Marijuana Tax Act of 1937, denied a gateway claim during Congressional hearings.  According to the excellent history of marijuana prohibition by Richard Bonnie and Charles Whitebread (here), Representative John Dingell asked Anslinger “whether the marihuana addict graduates into a heroin, an opium or cocaine user.”  The Commissioner replied unequivocally, “No sir; I have not heard of a case of that kind. I think it is an entirely different class. The marihuana addict does not go in that direction.”

By 1951, Anslinger changed course while testifying in favor of the Boggs Act, which increased federal penalties for narcotics and marijuana.  Endorsing marijuana’s new reputation as a treacherous gateway drug, he said: “The danger is this: Over 50 percent of those young addicts started on marijuana smoking. They started there and graduated to heroin; they took the needle when the thrill of marijuana was gone.”

So began marijuana gateway scaremongering, which Dr. James Anthony, professor of epidemiology and biostatistics at Michigan State, labels as “…‘vapors’ that emerged from a political cauldron during the middle of the 20th century when it was very difficult to find definitive and convincing evidence of harmful effects of cannabis use – over and above (1) the sometimes extremely severe consequences of criminal penalties for simple cannabis possession and use, and (2) adverse effects on mouth, nose, throat, and lung.” (abstract here)   

This should sound strikingly familiar to vapers (e-cigarette users) and tobacco harm reduction advocates.  As they did with marijuana, prohibitionists make the gateway claim against e-cigarettes in the near-total absence of “definitive and convincing evidence” of harm.

High School Seniors’ Tobacco Use: Another Year in Decline

Smoking by teens has declined to record-low levels, according to the latest University of Michigan annual Monitoring the Future Study, which examines youth tobacco, alcohol and drug use in 2013 (data tables here).  The figure at left, which shows the percentage of high school seniors using alcohol, marijuana, cigarettes and smokeless tobacco in the past 30 days over the period 1975-2013, is highly informative. 

Cigarette use continued a long-term decline, reaching 16.3%, the lowest prevalence since the survey’s introduction in 1975.  Cigarette use was lower than marijuana use (22.7%) for the fifth consecutive year.  Smokeless tobacco use among boys was 14.6%, and among girls 1.4%. 

The CDC issued a press release in September describing a scary but unsubstantiated gateway scenario, crystallized by CDC Director Tom Frieden: “Many teens who start with e-cigarettes may be condemned to struggling with a lifelong addiction to nicotine and conventional cigarettes.”

Frieden’s speculation was based on data from the National Youth Tobacco Survey in 2012, indicating that 0.054% of high school students in the U.S. used an e-cigarette at least once in the 30 days prior to the survey and had not smoked or used any other tobacco product.  Of the nearly 15 million high school students in the U.S., that’s about 8,000.  Meanwhile, about 1.8 million students smoked. 

Smoking prevalence among high school seniors has declined every year since 2007, about the time that e-cigarettes were introduced in the U.S.  With numbers like this, it is unlikely that e-cigarette use has contributed to teen smoking. 

The CDC Abuses the Facts About E-Cigarettes – Part I

The headline on the Centers for Disease Control’s September 5 press release was dire: “E-cigarette use more than doubles among U.S. middle and high school students from 2011-2012” (here).  The agency’s shocker generated reams of coverage (examples include USA Today, the Los Angeles Times, the Chicago Tribune and CBS News).

In an earlier blog post, I criticized the CDC’s media ploy for positioning e-cigarettes as a new childhood tobacco epidemic (here).  Based on additional research, I have uncovered serious flaws in the agency’s analysis – errors and omissions that made the CDC’s message more appealing to the media, but less conscionable in terms of public health.

Analyzing the 2012 National Youth Tobacco Survey (NYTS), the dataset the CDC used to generate its report, I discovered the falsehood of this key statement in the agency’s press release:  “Altogether, in 2012 more than 1.78 million middle and high school students nationwide had tried e-cigarettes.”  This assertion was highlighted in most major media reports.

In fact, the NYTS did not collect information on the number of students who had used e-cigarettes in 2012.  Instead, the survey asked if students HAD EVER TRIED e-cigarettes, “even just one time”; that number is 1.78 million.  The only number in the survey that is applicable to 2012 is the 554,179 students who used an e-cigarette on “at least one day” in the past month.  That is only 31% of the number wrongly reported by the CDC.

Another statement in the CDC release is seriously misleading: “The study also found that 76.3 percent of middle and high school students who used e-cigarettes within the past 30 days also smoked conventional cigarettes in the same period.”  That statement implies that 24% of e-cigarette users were not smokers, and gives the distinct impression that e-cigarettes are emerging as a first-use tobacco product.

Not so fast.  The NYTS also measured other forms of tobacco use, including smokeless tobacco, cigars, pipes, hookah, snus and dissolvable tobacco.  In addition to the 76.3% of e-cig users who were concurrent cigarette smokers, another 12.9% were using other tobacco products.  That means the percentage of e-cigarette users who weren’t using any other tobacco product was only 10.8%, a tiny fraction.  Of this group, about half had “ever tried cigarette smoking, even one or two puffs”. 

There is another feature of this and other federal surveys that you need to understand: the numbers that the CDC reports (e.g. 1.78 million) are not actual counts but are national estimates based on a complex sampling strategy.  This is not necessarily a problem, but it provides needed context, especially when the number of survey respondents is small.  For example, the total number of youths in this survey who used an e-cigarette in the past 30 days was 500, and the number of vapers who did not use any tobacco product nor had ever tried smoking was around 20.

The bottom line: Among all middle and high school e-cigarette users, only 10.8% were not concurrently using any other tobacco product, and half of those had tried to smoke in the past. 

CDC director Tom Frieden may wish to use his position as a bully pulpit to oppose e-cigarette use, but abusing the facts is inexcusable.

In a future post I’ll discuss other key findings from the NYTS that were omitted by the CDC.

Misinformation From Federal Officials, 2013 Edition

“See, in my line of work,” said President George W. Bush in 2005, “you got to keep repeating things over and over and over again for the truth to sink in, to kind of catapult the propaganda.”

Confusing truth with propaganda is a chronic disease among federal officials.

I documented in 2010 that three FDA appointees repeatedly conflated “tobacco” and “smoking” in a high-profile New England Journal of Medicine article (here).  Three years later, federal officials are still distorting the truth. 

Mitch Zeller, director of the FDA Center for Tobacco Products, supplied these appalling comments in a November 6 Robert Wood Johnson Foundation interview:

“It’s really stunning that in 2013 – with everything that we know about the harms associated with TOBACCO use – that it remains the leading cause of preventable death and disease both in this country and globally.” (emphasis added)

Stunning, indeed, but the fact is that smoking is the killer, not tobacco.  Zeller knows the truth. He has spent over 30 years working on tobacco issues, as associate commissioner and director of FDA’s first Office of Tobacco Programs, at the American Legacy Foundation, and as a vice president at the influential consulting group Pinney and Associates. 

Zeller, in the same interview, did acknowledge the continuum of risk: “there are different nicotine containing and nicotine delivering products that pose different levels of risk to the individual.  Right now the overwhelming majority of people seeking nicotine are getting it from the deadliest and most toxic delivery system, and that’s the conventional cigarette.”  Having recognized this, FDA officials should stop using TOBACCO as a synonym for smoking.

CDC Director Dr. Tom Frieden also suffers from the fact-vs.-propaganda flu when it comes to tobacco and smoking.  In a recent interview with USA Today, he said:

“We work 24/7 protecting Americans from threats, whether these threats are from this country or anywhere in the world, whether they are natural or man-made, whether they are infectious or chronic.  Overall, if you look at what’s making Americans sick and killing us, TOBACCO remains, unfortunately, the leading cause of preventable death, more than 440,000 people a year, more than 1,000 a day, every single day, are killed by TOBACCO.”

The CDC routinely publishes the exact number of deaths from smoking: it’s currently 392,681 among smokers and 49,400 from secondhand smoke.  But that’s not the number of deaths from TOBACCO.  In truth, the number of deaths attributable to smokeless tobacco is so low that the CDC and the American Cancer Society have never reported it, even though they have the information (here). 

Americans expect their government to protect them from threats; among the most insidious and destructive is intentionally misleading public health statements from federal officials.

More Exaggeration and Fear-Mongering From the CDC

Recently I discussed the irresponsible theatrics from federal officials about slight increases in e-cigarette use by teenagers (here).  That report appeared in the CDC’s September 6 issue of Morbidity and Mortality Weekly Report (here).  It turns out that this issue contained another grossly exaggerated CDC study that was tailor-made for major media treatment, and it succeeded.

The study, which examined death statistics from 2001 to 2010, claimed that 200,000 out of the 800,000 deaths each year among Americans from heart disease, stroke and hypertension are avoidable. 

As usual, CDC Director Dr. Tom Frieden was the scaremonger-in-chief: “These findings are really striking.  We're talking about hundreds of thousands of deaths that don't have to happen.  It's possible for us to make rapid and substantial progress in reducing these deaths.” (here).

Here is what the CDC didn’t tell Americans about these scary statistics. 

First, the CDC used a completely unrealistic definition to define these deaths as avoidable: anyone dying from heart disease, stroke or hypertension before the age of 75.  Hoping for a world where no one dies prematurely from any disease is admirable, but badgering Americans about “improving health-care systems and supporting healthy behaviors” as a way to eliminate ALL deaths from heart disease, strokes and high blood pressure up to age 75 is preposterous.

The biggest problem with the CDC report is that it cherry-picked a relatively flat period (2001-2010) of decline in these deaths.  Never mind that the decline over the period was 28% in men and 31% in women!  It completely ignored what has happened over the entire 45-year period for which data is available (here).  Look at the chart to see the astounding decline in these deaths since 1968, 78% in both men and women! 

The decline in cardiovascular deaths among Americans is nothing short of astonishing and breathtaking.  Of course, there’s always room for improvement.  But the CDC should be ashamed to create health care crises using isolated and exaggerated statistics.

Irresponsible E-Cigarette Theatrics from Federal Officials

The anti-tobacco movement continues to ignore evidence that millions worldwide have switched from smoke to vapor.  Witness today’s press release (here) from the Centers for Disease Control and Prevention (CDC): “There is no conclusive scientific evidence that e-cigarettes promote successful long-term quitting.”  Yet in the absence of proof, extremists insist that e-cigarettes are a gateway to smoking for teenagers.  A new CDC report adds fuel to that gateway fire in the nation’s media. 

The report (available here) uses information from the 2011 and 2012 National Youth Tobacco Surveys (NYTS).  In 2012, 2.8% of high school students used an e-cigarette in the past 30 days, compared with 1.5% of students in 2011.  Over 80% of e-cigarette users also had smoked cigarettes in the past 30 days. 

There is no information in the CDC report or in the NYTS relating to gateway.  The NYTS asks teenagers at what age they first smoked a cigarette.  However, since the teens were not asked at what age they first used e-cigarettes, gateway analysis is impossible.  Still, that didn’t stop CDC Director Tom Frieden from speculating: “Many teens who start with e-cigarettes may be condemned to struggling with a lifelong addiction to nicotine and conventional cigarettes.”

The report’s findings are hardly surprising.  The market for e-cigarettes is rapidly expanding, and youths who smoke cigarettes will also experiment with vapor products.  Yet federal officials’ headline-ready comments put the findings in apocalyptic terms.  Dr. Tim McAfee, director of the CDC Office of Smoking and Health, said, “These dramatic increases suggest that developing strategies to prevent marketing, sales, and use of e-cigarettes among youth is critical.” 

The report is an unabashed pitch for FDA e-cigarette regulation, which is likely coming in October.  Mitch Zeller, director of the FDA’s Center for Tobacco Products, also exaggerated the findings to justify FDA action: “These data show a dramatic rise in usage of e-cigarettes by youth, and this is cause for great concern as we don’t yet understand the long-term effects of these novel tobacco products…These findings reinforce why the FDA intends to expand its authority

over all tobacco products and establish a comprehensive and appropriate regulatory framework to reduce disease and death from tobacco use.”

Zeller, a respected authority on tobacco use, knows that cigarettes cause 99% of “disease and death from tobacco use.”  Here, he deliberately conflates the risks of smoke-free and combustible tobacco products in the context of teenage use.

Federal authorities should restrict youth access to all tobacco products, but it is unacceptable for them to characterize e-cigarettes as gateway products when they are, in fact, helping to eliminate the smoking plague.