Electronic cigarettes: getting the science right and communicating it accurately
Electronic cigarettes are being used by millions of people worldwide, mostly in an attempt to reduce smoking or stop altogether. Policy makers, smokers, clinicians and the public in general need accurate information on their safety and potential for reducing smoking rates. Unfortunately in some notable cases the science is being misused, with findings being distorted, misinterpreted or misrepresented. Interestingly, up until now this appears to be mainly (though not exclusively) by those who are opposed to electronic cigarettes. Addiction’s goal in this debate is to present evidence as dispassionately as possible whatever it shows, and to correct misinformation where it appears. It is worth highlighting the ways in which science is being misused so that readers can be better placed to evaluate the messages.
Failure to quantify: e.g., statement that e-cigarette vapour contains toxins so creating the impression that they are dangerous as cigarettes, without indicating that the concentrations are typically orders of magnitude less than tobacco smoke.
Failure to account for confounding and reverse causality: e.g., arguing that use of e-cigarettes reduces chances of stopping because in cross-sectional surveys the prevalence of e-cigarette use is higher in smokers than in recent ex-smokers.
Selective reporting: e.g., focusing on studies that appear to show harmful effects whole ignoring those that do not.
Misrepresentation of outcome measures: e.g., claiming that e-cigarette use is prevalent among youth by using data on the proportion who have ever tried and creating the misleading impression that they are all current e-cigarette users.
Double standards in what is accepted as evidence: e.g., uncritically accepting conclusions from observational studies with major limitations when these claim that electronic cigarettes are causing harm, but discounting similar or better controlled studies when these appear to show the opposite.
Discrediting the source: e.g., arguing that researchers who have received financial support from e-cigarette manufacturers (and even companies that do not manufacture e-cigarettes) are necessarily biased and their results untrustworthy, and presenting themselves as having no conflicts of interest when their professional and moral stance represents a substantial vested interest.
These tactics are not restricted to the e-cigarette debate. We must be vigilant in recognising them to ensure that policies are based on the most accurate interpretation of evidence possible. Addiction will seek to adhere to the highest standards of critical review of papers submitted to us whichever direction the findings on e-cigarettes appear to point.
The New York Times has published (here) a reasonably accurate portrayal of the Swedish snus experience that I have chronicled for over a decade (here, here, and here). Reporters Matt Richtel and David Jolly examined Swedish Match’s FDA application to remove the federally mandated mouth cancer and not-safe-alternative warnings from snus products. I have discussed this landmark filing previously (here).
In a companion piece (here) the paper tried to answer two important questions about snus and mouth cancer: “How accurate is the current warning? How dangerous is Swedish snus?”
Despite a wealth of available information, the Times unfortunately failed to nail the answers, even after acknowledging that “Many studies have been done on the question (sic),…” but fretting that “…but as in many fields that involve complex questions and human subjects, the research is imperfect.”
How is the research imperfect? “For instance, some research concluding virtually no oral cancer risk from snus was funded by Swedish Match itself.” The Times fell back on the old canard – the funder influenced the finding, despite total disclosure and high-quality peer review. The paper failed to note that numerous studies, regardless of funding, show “virtually no oral cancer risk” for Swedish snus and American chew and dip.
The Times asked Kristin L. Sainani, a Stanford epidemiologist not involved in tobacco research, to examine the science. She was remarkably indecisive: “‘The weight of the evidence suggests a small increase’ in the risk of oral cancer with snus. In Sweden, users of Swedish snus see virtually no increase in the rates of lip and oral cancer.” In the end she made the correct call: virtually no increase.
Dr. Sainani attempted to provide an anti-snus slant using double negatives: she said that “it is inconsistent with the evidence” to suggest that there is “absolutely no harm to an individual” from snus. In essence, she repeated the no-win argument that snus can’t be proven absolutely safe. That’s an irrational standard that many common foods couldn’t meet.
Dr. Sainani was asked by the Times to resolve the mouth cancer question, yet she is quoted on an entirely different matter: “In fact, she said, Swedish snus users face a doubling of risk of pancreatic cancer…” It appears that Dr. Sainani exclusively used a 2008 review by Boffetta et al., which has been exposed as relying on cherry picked data (here).
Is a snus pancreas cancer risk real? No. Five years ago I detailed how Boffetta fabricated the risk in 2008 (here), and, in 2011, Boffetta acknowledged that his earlier finding was wrong (here). Sainani would have discovered this if she had compared the faulty Boffetta analysis with the most authoritative and comprehensive meta-analysis by Peter Lee and Jan Hamling (here), which found no pancreas cancer risk, in addition to no mouth cancer risk.
The Times article ended with Dr. Deborah Winn, deputy director of the division of cancer control at the National Cancer Institute. Readers of this blog know that Dr. Winn launched the smokeless tobacco mouth cancer scare in 1981 (here and here). While she is the NCI’s top authority on smokeless tobacco and cancer, she demonstrated an appalling disregard of facts in a 2010 congressional hearing (here). In the Times article, her obfuscation continued: “[Winn] considered Swedish snus to be ‘a form of smokeless tobacco,’ which, in general, she said, is generally ‘linked to mouth cancer…Swedish snus in the past has given you cancer, and at the current low levels, I don’t know,’ she said. ‘There could be some risk there.’”
The one data point Winn provided to the Times is false. “She said studies done in the 1990s showed that users of Swedish snus in the 1970s faced a twofold increase in the risk of oral cancer.” There were two studies of Swedish snus and mouth cancer published in 1998. They concluded:
- “[Snus] was not found to be a risk factor for oral cancer in our study.” (here)
- “No increased risk [for head and neck cancer, including oral cancer] was found for the use of Swedish [snus].” (here)
The Times and their quoted experts did a major disservice to their audience; they failed to report the simple truth, that mouth cancer risk for Swedish snus is next to nil.