The Surgeon General’s Misguided Report on E-Cigarettes

Teen smoking declined to record-low levels in 2016, according to the latest University of Michigan annual Monitoring the Future Study, which examines youth tobacco, alcohol and drug use (data tables here).  The figure at left shows the percentage of high school seniors using alcohol, marijuana, cigarettes and e-cigarettes in the past 30 days over the period 1990-2016.

Cigarette smoking among high school seniors plummeted from 19.2% in 2010 to 10.5% this year.  That is, the smoking rate was cut almost in half after e-cigarettes became readily available.  E-cigarette use also dropped over the past two years. 

Days ago, U.S. Surgeon General Vivek Murthy issued a report asserting that e-cigarette use among youth is “a major public health concern.”  The report recycles dire warnings about vaping that have been issued by FDA tobacco director Mitch Zeller and CDC director Tom Frieden, despite the lack of evidence of significant health risks associated with e-cigarettes.

The report is ostensibly a full review of scientific literature relevant to e-cigarettes and smoking among youth.  But as Case Western University law professor Jonathan Adler pointed out in the Washington Post (here), “there are now several studies that look at the effect of restricting teen access to vaping products showing that such measures increase teen smoking (including among pregnant women). I’ll say that again: Reducing youth access to e-cigarettes appears to increase youth smoking rates…Despite their relevance, these studies are completely ignored by the surgeon general. They’re not even listed in the report’s references.” 

Those studies were discussed in this blog (here and here).  Their omission in the Surgeon General’s report is inexcusable.

Why does the government focus on youth as it wars against e-cigarettes?  These products are responsible for virtually no health problems and certainly no deaths among youth and young adults.  In contrast, the MTF survey documents that alcohol is by far youth’s drug of choice.  In 2016, one-third of high school seniors had an alcoholic drink in the past 30 days, and one in five had been drunk, despite laws against underage sales and consumption. 

Young Americans die from alcohol consumption and abuse.  From 2007 to 2014, CDC data (here) shows that accidental alcohol poisoning killed 930 people age 15-24 years.  And alcohol also contributes to traffic fatalities.  With the exception of the elderly, this age group (15-24 years) suffers the highest death rates due to auto accidents.  Comprising just 14% of the U.S. population, this young cohort accounts for 25% of auto deaths (1,544 in 2014).

The Surgeon General’s report is the latest in a series of misleading and unsupported tobacco diatribes (here and here).  The public would be better served if government committed its limited resources based on the relative impact of a substance on children’s health.  Tobacco products should not be ignored, but Dr. Murthy’s report wrongly damns a safer and satisfying product that is currently helping 2.5 million former smokers (here) become or remain smoke-free.

Mouth Cancer Facts

Baseball star Curt Schilling says he has mouth cancer that was caused by chewing tobacco (here).  His announcement has generated considerable interest in mouth cancer, its frequency and causes.

What is mouth cancer?

Mouth cancer typically appears in the lining of the mouth; it may start as an ulcer or red area that is discovered in a dental or medical exam.  The phrase is often used incorrectly to include cancers of the throat.

Schilling did not disclose the location of his cancer, but he did say that he found a lump in his neck.  This indicates that the tumor had spread to a lymph node, a condition that more likely suggests a tumor of the throat, rather than the mouth. 

How common is mouth cancer?

It is very rare.  Mouth cancer occurs with higher frequency in people who have the risk factors I describe below, but it is possible for someone with no risk factors to develop this disease.  As I described previously (here), among 100,000 men age 40+ years, perhaps three or four with no risk factors will develop mouth/throat cancer each year; only one or two of those cases will be mouth cancer. 

What causes mouth cancer?

The most common cause of mouth cancer is smoking, which can increase risk 10-fold; smokers who drink alcohol have even higher odds.  Alcohol abuse raises the odds about four-fold.

Another recognized risk factor is infection with human papillomavirus (HPV), a sexually transmitted disease discussed previously (here).  HPV is considered by some experts to be a significant cause of mouth cancer, but precise estimates of risk elevation are not available.

Schilling attributes his cancer to chewing tobacco.  There are numerous studies of the risks related to smokeless tobacco (discussed here).  The odds of developing mouth cancer if you use chewing tobacco or moist snuff are about the same as if you didn’t smoke, drink or have HPV.  In other words, one or two users out of 100,000 will develop mouth cancer.   

Smoking and drinking can produce a cancer anywhere in the mouth, esophagus, voicebox and lungs.  HPV is generally linked to cancers of the throat.  In contrast, the most common location, by far, for mouth cancer in a smokeless tobacco user is at or very close to where the tobacco is placed, normally between the cheek and gum.

While rare, every case of mouth cancer is unfortunate, and potentially avoidable.  Have your dentist or physician perform a thorough head and neck exam every year.

Snus Users and Smokers in Stockholm

A new study published in Biomed Central Public Health (available here) describes the socioeconomic and lifestyle characteristics of snus users and smokers in Stockholm County, Sweden. Based on a 2006 survey of 35,000 residents, it was authored by Karin Engström and colleagues at the Department of Public Health Sciences at the Karolinska Institute. In addition to providing interesting information about snus users, this study has important implications for Karolinska Institute claims about the link between snus use and cancer.

Among men, 17% were exclusive snus users, 11% smoked and 2.4% were dual users. Among women, cigarette smoking was dominant (15%), while snus use and dual use were only 3.1% and 0.5% respectively. Given this, I will focus on the findings for men.

It is noteworthy that the prevalence of snus use was highest among men less than 35 years old. This means that young men in Stockholm strongly prefer snus, a lifestyle choice that will have little or no effect on their health as they age.

Snus users were somewhat more likely to have lower education levels than nonusers of tobacco, a trend that was even stronger among smokers. Smokers were also more likely to be unskilled and skilled workers in the very low income group, while snus users were more evenly distributed among all occupational classes and across all income levels.

One of the more interesting results concerned alcohol consumption. Risky alcohol consumption was defined as 14 standard drinks per week; the survey also asked about weekly or monthly binge drinking. Snus users and smokers were more likely to practice risky consumption than nonusers (odds ratios = 1.8 – 1.9), and they were more likely to have weekly binge-drinking episodes (ORs around 3.1).

This information on alcohol abuse among snus users is important, because a Karolinska epidemiology group, led by Olof Nyrén, published studies suggesting that snus use is associated with a small risk of pancreatic, stomach and esophageal cancer (abstracts here and here) among workers in the Swedish construction industry. Alcohol abuse is a strong risk factor for esophageal cancer and may be linked to stomach and pancreas cancer; this makes it a confounder with respect to snus use. In other words, if snus users are more likely to be alcohol abusers, then some of the cancers attributed to snus might instead be caused by alcohol. In many modern epidemiologic studies, standard procedures are used to account for confounders. In this case, to accurately separate the risks due to snus use from those due to alcohol abuse.

But the construction worker studies had no information on alcohol consumption, so alcohol abuse could not be ruled out as a competing risk factor. The lack of information about alcohol in these studies is a serious deficiency that raises questions about the validity of Nyrén’s claims.

In summary, men in Stockholm from all income levels and all occupations prefer snus over cigarettes. The impact of this preference on their health is so small that it is barely measurable by modern epidemiologic methods. Furthermore, snus users, like smokers, are more likely to abuse alcohol, which may be a distinct risk factor for some cancers that has not been evaluated in previous Karolinska Institute reports on snus use.