In an op-ed piece published yesterday in the Oregonian, the Oregon state health department claims that a substantial proportion of cases of the vaping-associated respiratory illness outbreak are caused not by THC/CBD vaping, but by nicotine-containing electronic cigarettes. The piece claims that: "we can say the hospitalizations and deaths are not exclusively attributable to cannabis use."This is very different from claiming that we do not yet know definitively whether some nicotine-containing e-liquids are causing the illness. Instead, the statement claims that we do know that many cases are being caused by electronic cigarettes. The Rest of the Story The fact that there are 11% of case patients who did not admit to using THC vape carts does not mean that 11% of cases are being caused by e-cigarettes.There are several reasons why not every patient diagnosed with EVALI has admitted to THC use. For one, there is tremendous under-reporting of THC use by hospitalized patients, especially youth. Young people may be very reluctant to admit to THC use, both because they don't want their parents to know and because there are severe consequences, such as suspension from school or inability to participate in sports. In addition, many youth do not know what they are vaping. They are not purchasing the e-liquids themselves from stores but getting them from social sources. Moreover, some nicotine-containing products are adulterated with vitamin E acetate oil, so a person could actually be using a nicotine product but unknowingly vaping contaminated THC oil. It is critical to note that many of the patients who denied the use of THC were later found to have vaped THC oils. In fact, three of the patients who were found to have vitamin E acetate in their lung fluids had insisted that they only used nicotine-containing e-liquids. In the absence of THC urine drug testing, not a single case of EVALI attributable to legal, nicotine-containing e-cigarettes has yet been confirmed. The fact that 100% of EVALI patients tested had vitamin E acetate oil in their lungs is incredibly strong evidence that THC/CBD oil vapes that contain vitamin E acetate oil as a thickening agent is the cause of this outbreak. To continue to tell the public that e-cigarettes are causing this disease and to downplay the role that THC oils are playing is irresponsible.What I find fascinating is that in the midst of an outbreak that we know definitively is being caused, at least in large part, by the vaping of THC carts containing vitamin E acetate oil, the Oregon state health department would be publicly downplaying and undermining this fact. Why is the state health department emphasizing to the public that nicotine-containing e-cigarettes are implicated when there is not yet any evidence that this is the case?Frankly, this has the appearance that the health department is taking advantage of this tragic outbreak to carry out some sort of vendetta against e-cigarettes.It is one thing to mislead the public about the health risks of e-cigarettes outside the context of any specific health recommendation. But I believe it is inexcusable to deceive the public about the role that THC vape carts are playing in an outbreak that is actually killing people and sending thousands to the hospital with respiratory failure requiring mechanical ventilation.In public health, we don't play with people's lives like this. We don't put the lives and health of the public at risk because we want to further our own agendas, even if that agenda were to be a valid one. Of course, I do not think that demonizing e-cigarette use is a valid agenda. But even if it were, you don't play with the lives of the public (and especially youth) to further your agenda.The Oregon state health department needs to immediately correct this misleading op-ed piece.Original author: Michael Siegel

If you believe the security rule is affecting the normal operation of your website, contact your host support team and provide detailed instructions how to recreate this error.They will be able to assist you with rectifying the problem and adjusting the security configuration if needed.Original author: Alex Clark

The American Heart Association has unveiled a new campaign which uses the hashtag #QuitLying and the website quitlying.org. The campaign is directed against "Big Vape" and it attacks e-cigarette companies for lying to the public. Among the lies that the American Heart Association claims e-cigarette companies are making are:(1) that vaping is different than smoking; and(2) that e-cigarettes can help smokers to quit smoking.They claim that the lying on the part of e-cigarette companies is "leading more people to smoking" and has "landed hundreds of e-cigarette users in hospitals."The Rest of the StoryIn a massive ironic twist, it is actually the American Heart Association that is lying, and their lies -- unlike anything that e-cigarette companies have asserted -- are actually leading more people to smoking and possibly landing some vapers in hospitals.The American Heart Association's claim that vaping is no different than smoking is blatantly false. Vaping is fundamentally different than smoking because it involves the heating of an e-liquid that doesn't contain tobacco, while smoking involves the combustion of tobacco. Vaping does not produce any smoke; it produces an aerosol. Smoking produces smoke because that is the product of the combustion process.The American Heart Association's claim that e-cigarettes cannot help smokers to quit is also false. A recent randomized clinical trial published in the prestigious New England Journal of Medicine demonstrated that e-cigarettes are actually twice as effective as the nicotine patch in helping smokers quit. The epidemiological technique that you get from this study to the claim that e-cigarettes cannot help smokers to quit is called lying.Even more ironically, the end result of the American Heart Association's lies is precisely what they attack the e-cigarette companies for doing: these lies are leading more people to smoking and may be landing vapers in hospitals.The American Heart Association's lies are leading more people to smoking because by making smokers think that vaping is no different than smoking and that it can't help them quit, they are undoubtedly persuading many ex-smokers to switch back to cigarettes. After all, if vaping is the same as smoking and if it cannot help you quit smoking, then why bother vaping? You might as well just go back to smoking. These lies are also undoubtedly deterring many smokers from trying to quit using e-cigarettes. If e-cigarettes cannot help you quit, then why bother trying?The truth, of course, is that at least 2.5 million smokers in the U.S. have quit smoking completely using e-cigarettes. By ignoring this evidence and claiming instead that vaping cannot help anyone quit smoking, the American Heart Association is both persuading some vapers to return to smoking and dissuading some smokers from switching to vaping. This will lead people to smoking and eventually result in an increase in smoking-related disease and death.So what about the claim that vaping company lies about e-cigarettes are sending hundreds of people to the hospital? That's not true either. What is sending hundreds of people to the hospital are not e-cigarettes, but tainted THC vaping products in which vitamin E acetate oil has been used as a thickening agent. This lie is undoubtedly going to make the public think that e-cigarettes rather than THC vaping is causing the respiratory disease outbreak, and that will almost certainly result in more people continuing to vape THC than would have if the American Heart Association had told the truth and explicitly warned them not to vape THC.To make matters worse, the American Heart Association is also encouraging teachers to lie to our students about the health facts regarding e-cigarettes and smoking. They instruct teachers to inform students that "There are many unfounded beliefs that vaping is safer than combustible cigarettes." Of course, these beliefs are not unfounded. What is unfounded is the American Heart Association's claim that smoking is no more hazardous than using an e-cigarette. To instruct teachers to further promulgate this lie among students is quite irresponsible.The American Heart Association is also lying to teachers when it states that e-cigarettes "have no standards and can say/claim almost anything to get you to buy them." Actually, e-cigarettes are regulated by the FDA and cannot make any claim they want. For example, they are not allowed to make drug claims, they are not allowed to claim that they are to be used for smoking cessation, and they are not allowed to claim that they are safer than any form of tobacco product use.The rest of the story is that it would be a major public service is someone could fund a #QuitLying campaign to get the American Heart Association to stop lying about electronic cigarettes and to stop putting the lives of the nation's youth at risk by misleading them into thinking that e-cigarettes, rather than THC vapes, are causing the vaping-associated respiratory disease outbreak.Original author: Michael Siegel

Testimony of Michael Siegel, MD, MPHProfessor, Boston University School of Public HealthNovember 22, 2019The Department of Public Health justified its emergency order by arguing that removing vaping products from the market would protect the public – and especially youth – from the vaping-associated respiratory disease outbreak that has now affected more than 2,000 people and caused 47 deaths. However, unbeknownst to many, this emergency order was not successful in removing all vaping products from the market. In fact, the Department’s emergency order exempted – and therefore failed to remove from the market - a large number of flavored e-liquid products that are highly popular among youth and which Massachusetts youth continue to use, despite the emergency order. These flavored e-liquids are used by 63% of youth who vape regularly. Unfortunately, all of the following flavors are exempt from the ban and remain on the market today throughout the Commonwealth, easily accessible to youth.The exempted flavors include all of the following:     "Mario Carts Vanilla Glue,"     "Heavy Hitters Vape Strawberry,"     "Honey,"     "Gelato,"     "Blueberry,"     "Banana Sherbet,"     "Jillybean,"     "Super Lemon Haze,"     "Romulan Grapefruit,"     "Sour Tangie,"     "Biscotti,"     "Pineapple Express,"     "Mango,"     "Juicy Melon,"     "Strawnana,"     "Granddaddy Purp,"     "Forbidden Fruit,"      "Lemon Lime,"      "Golden Goat,"        "Butter,"        "Orange Cream,"        "Banana Cream,"        "Strawberry Banana,"        "Grapevine,"        "Lime Sorbet,"        "Potent Pineapple,"        "Pure Pear,"        "Red Apple,"        "Blue Raz,"        "Strawberry Sherbet,"        "Grape Soda,"        "Pink Sherbet,"        "Cactus Cooler,"        "Sunset Sherbet Sauce,"        "Sunset Gelato,"        "It's Yo Birthday,"        "Wedding Cookies,"        "Orange Cookies,"        "Girl Scout Cookies,"        "Grape Pie,"        "Cookies n Cream,"          "Apple Jacks,"          "Banana OG,"          "Birthday Cake,"          "Black Berry Kush,"          "Blue Dream,"          "Blueberry Kush,"          "Bubble Gum,"          "Candy Land,"          "Cherry Pie,"          "Cotton Candy,"          "Fruity Pebbles,"          "Gelato,"          "Grape Ape,"          "Honey Berry,"          "Honey Dew,"          "Ice Blue Raspberry,"          "Key Lime Pie,"          "Lemon Berry,"          "Lemon Head,"          "Lemon Slushie,"          "LSD,"          "Mai Tai,"          "Mango Kush,"          "Maui Wowie,"          "Mimosa,"          "Mojito,"          "Orange Chai,"          "Orange Cookies,"          "Orange Daiquiri,"          "Peach,"          "Pineapple Express,"          "Pot of Gold,"          "Purple Punch,"          "Rose Gold,"          "Russian Cream,"          "Sour Apple,"          "Strawberry Shortcake,"          "Sweet Aromatic,"          "Tangie,"          "Vanilla Kush,"          "Water Melon,"          "Wedding Cake," and          "Zskittlez."All of these flavors remain on the market, despite what policy makers are telling the public. The truth is that while the sale e-liquids that contain nicotine has been banned, all of the above flavors, which are available in THC vape cartridges, remain on the market.And in fact, it is these products, not the nicotine e-liquids sold in retail stores, that are responsible for the respiratory disease outbreak. Recently, the CDC found that the lungs of every single one of the 29 patients whose lung fluids were tested contained vitamin E acetate. This is a thickening agent that is used only in THC vape carts and possibly in black market, counterfeit or adulterated nicotine cartridges, but not in legal nicotine-containing e-liquids sold at stores.You can now easily see why the ban on the sale of nicotine e-liquids at retail stores is no longer justified. There is simply no evidence that these products are causing the outbreak, and there is incontrovertible evidence that vitamin E acetate oil – or some chemical contained in that oil – is now implicated as the culprit. Therefore, the only rational action for the Department to take at this point is to discontinue the emergency ban on nicotine-containing vaping products sold at retail stores in the Commonwealth.Not only is this ban not preventing any outbreak cases – because those cases are not being caused by the banned products – but the ban is likely making the outbreak worse. Why? Because youth who can no longer access nicotine e-liquids are simply switching over to many of the sweet, fruity, alcohol-based, and other attractive flavors that are readily available in THC vape products.The tragedy, of course, is that these flavored THC e-liquids are precisely the ones that are killing many people and causing life-threatening illness. Banning nicotine e-liquids is not preventing youth from dying due to respiratory failure. But it may actually increase the number of kids who develop respiratory failure.With flavors like Girl Scout Cookies, Cookies and Cream, Mimosa, Banana Sherbet, It's Yo Birthday, Russian Cream, Gelato, Grape Soda, Potent Pineapple, and Super Lemon Haze available, do you really think that youth are just going to completely stop vaping?In the short time that JUUL has limited access to many of its flavors (such as mango and creme), youth have just shifted over to vaping the mint-flavored JUUL pods. They didn't stop vaping because some flavors were taken off the market. Youth are resourceful, vaping is cool, and they will simply switch to whatever flavors are available.Those flavors will be vape juices like Zskittlez, Bubble Gum, Cotton Candy, and Cherry Pie.And the only difference will be that instead of the risk of mild respiratory irritation (with most nicotine-containing e-liquids) or nicotine addiction (with JUUL), the major risk for our nation's youth will now be DEATH from lipoid pneumonia or chemical pneumonitis. How is that good public health policy?Moreover, the ban on electronic cigarettes is already having devastating impacts on the public’s health.Sales data reported by PiperJaffray for the four weeks ending October 20 (when the Massachusetts emergency ban was in effect for 25 of the 28 days) and the four previous weeks (mostly before the ban went into effect) were compared to sales data for the previous year. The PiperJaffray analysis revealed that there has been a substantial shift from vaping to smoking in the state. This indicates that ex-smokers in Massachusetts who were reliant on e-cigarettes to stay smoke-free are now returning to smoking in large numbers.Nationally, there was very little difference in the rate of decline in cigarette sales between these two time periods from 2018 to 2019. The rate of decline decelerated by just 0.3 percentage points (from -7.8% to -7.5%). However, in Massachusetts, the rate of decline decelerated by a massive 5.7 percentage points (from -9.8% to -4.1%).The emergency ban on e-cigarettes did not prevent any respiratory disease cases, but it did send tobacco stocks soaring. Because the stock analysts understood that this ban would result in a substantial return to smoking among vapers. In fact, recent survey data of Massachusetts e-cigarette users revealed that a substantial proportion of them reported returning to smoking after the emergency order went into effect.As you may know, I did not believe that the emergency order was justified when it was issued on September 24thbecause it was clear to me that the outbreak was being caused primarily, if not solely, by THC vaping products. However, even if it was justified on September 24th, it is not justified on November 22nd, after overwhelming evidence has been uncovered that unequivocally ties the outbreak to cannabis vaping cartridges or other black market products that have been adulterated with vitamin E acetate oil.I therefore recommend that the Department rescind the emergency order as it relates to nicotine e-cigarettes sold at retail stores in the Commonwealth.Original author: Michael Siegel

It is being widely reported in the media that there was recently a case of "popcorn lung" in Canada that was due to the use of e-cigarettes. These reports are exaggerated and inaccurate representations of a medical journal article published in the Canadian Medical Association Journal.The article reports the case of a 17-year-old patient who presented with severe respiratory failure requiring mechanical ventilation. A chest CT scan revealed a "bud-in-tree" pattern which is consistent with a diagnosis of bronchiolitis. Because the study authors had heard that some e-liquids contain a flavoring called diacetyl, which has linked to popcorn lung disease in popcorn factory workers who were exposed to very high doses of the pure chemical, they speculated that this could be a case of popcorn lung attributable to the use of e-cigarettes.The Rest of the StoryIt is very unlikely that this case represents popcorn lung attributable to electronic cigarette use, and there is certainly no documentation or hard evidence to draw such a conclusion. Importantly, the authors are merely speculating when they suggest that this could be popcorn lung and that it could be attributable to e-cigarettes. It also could be a different type of bronchiolitis, and it could be attributable to the use of THC vape carts, which the patient admitted using very heavily prior to becoming sick. These THC vape carts were apparently not purchased from a licensed cannabis dispensary.Importantly, the authors themselves acknowledge that they were unable to confirm a diagnosis of popcorn lung.First, they were unable to examine the patient's airway pathology. As they state: "the transbronchial biopsies did not include airway mucosa for evaluation." Thus, although they identified the presence of bronchiolitis, they are unable to assess any pathology taking place in the airway mucosa.Second, they did not even conduct testing for lipoid pneumonia. The authors acknowledge that: "because of the preparation method, no staining for lipoid pneumonia could be done."Third, the "bud-in-tree" pattern is a non-specific pattern seen in a wide variety of respiratory diseases and illnesses. It is not specific to popcorn lung. In fact, the differential diagnosis of a "bud-in-tree" pattern includes inhalation of chemical toxins.Fourth, as the authors acknowledge, several of the confirmed case patients in the U.S. also had the "bud-in-tree" pattern. So the presentation of this patient is not entirely inconsistent with that of other case patients.Fifth, there is a wide variety of ways in which patients' lungs have responded to the inhalation of vitamin E acetate oil and any contaminants in it. These presentations have ranged from lipoid pneumonia to chemical pneumonitis to crypotogenic organizing pneumonia to acute eosinophilic pneumonia. The point is that different people respond differently to whatever in vitamin E acetate oil is causing this outbreak. There are a variety of presentations and although this presentation does have some different features from many previous ones, it is not clear that this represents a completely different entity due to a completely different cause.Sixth, the patient reported heavy use of what were apparently black market THC vape carts. It is entirely possible that his respiratory illness is due to cannabis vaping, not e-cigarettes.Finally, the study authors were unable to provide one key piece of evidence that would absolutely be necessary to establish that the disease in question was caused by diacetyl: they failed to document that there was diacetyl in the e-liquids used by the patient and they were unable to verify that diacetyl was present at levels that are sufficient to cause popcorn lung.Sadly, many e-cigarette opponents are already using this case as justification for banning e-cigarettes. This is a disservice to the millions of former smokers whose health and lives depend on the continued availability of e-cigarettes.Original author: Michael Siegel

With more than 2,000 cases of severe respiratory failure--mostly among youth and young adults--and 42 deaths resulting from vaping-associated respiratory illness, one might expect that the House Energy and Commerce Committee would have done something to help curtail this outbreak when it voted yesterday on legislation to address the youth vaping crisis.While this week's newspaper headlines provided some information about the Committee's actions on the proposed youth vaping legislation--for example, that the bill, which bans e-cigarette flavors other than tobacco, passed by a 28-24 vote--those headlines only tell part of the story. The Rest of the StoryThe rest of the story is that the very members of the Committee who purported to be acting in the best interests of the health of the nation's youth blocked an effort to help curtail the terrible respiratory disease outbreak that currently represents the most acute and serious threat to the health of our nation's youth. And they did so in a way that protects a $2.5 billion illegal industry that is ravaging the health of our youth.According to an article by Politico: "A Republican-backed amendment to make marijuana vapes subject to FDA regulation failed after Pallone urged a vote against the provision, saying it's not the focus of the legislation."Not the focus of the legislation? You've got to be kidding me!Youth are literally dying or getting life-threatening illnesses requiring mechanical ventilation (and in one case, a double lung transplant) due to the widespread use of black market, flavored marijuana vapes and the Committee chair urged a vote against regulating these products so that the outbreak can be brought under control?The Committee chair urged a vote against banning marijuana vapes that come in flavors like Birthday Cake, Black Berry, Blue Dream, Blueberry, Bubble Gum, Candy Land, Cherry Pie, Cotton Candy, and Fruity Pebbles?By failing to address the epidemic of marijuana vaping that is afflicting our nation's youth and resulting in severe disease and in some cases, death, the members of the Committee who voted against regulating marijuana vapes have done a huge disservice to the public's health and an equally huge favor to a $2.5 billion illegal industry.In fact, the most recent estimates from BDS Analytics reveal that illegal (black market) THC vapor sales represent fully one half of all marijuana sales in the nation. We're talking about a $2.5 billion industry that is completely unregulated and completely responsible for the respiratory disease outbreak that we are currently experiencing. And the Committee voted to let this illegal industry off the hook and instead go after the legal, regulated vape shops that have helped literally millions of Americans to quit smoking by switching completely to flavored vaping products.Don't be fooled by the rhetoric. This bill is not about protecting the health of youth. If that was the primary concern, the bill's supporters would have supported the amendment to pull from the market the products that are actually causing the respiratory disease outbreak.Moreover, it would have pulled from the market not only fake cigarettes, but the real ones as well. There is simply no public health justification for banning almost all e-cigarettes, but leaving Marlboros -- the #1 cause of preventable death in this country -- on the shelves. If the House Energy and Commerce committee truly wanted to protect the health of our nation's youth, they would get rid of the real cigarettes, not just the fake ones.Original author: Michael Siegel

In a move that defies public health logic, the Massachusetts Senate today voted for a bill that would ban the sale of virtually all e-cigarettes, but would allow non-mentholated real cigarette brands to remain on the shelves of all stores, including convenience stores and gas stations where youth have easy access to these products.There is simply no public health justification for taking e-cigarettes off the market but allowing youth to continue to have unfettered access to real tobacco products. The average annual death toll of these products is starkly different:Flavored e-cigarettes: 0Real cigarettes: 480,000Given the morbidity and mortality burden differential between these two products, how can the state Senate ban the former, but leave the latter free to addict and eventually kill the youth of the Commonwealth?The Rest of the StoryI'm sorry, but there is simply no justification for banning the sale of most electronic cigarettes but allowing real cigarettes, which kill more than 400,000 Americans each year, to remain on the shelves, almost completely unregulated.One of the major arguments that supporters of the bill offered to support their call for a ban on all flavored e-cigarettes is that when JUUL pulled its flavors other than mint and menthol from store shelves, youth simply switched to mint and menthol flavors. But if that's true, then shouldn't we be concerned that if flavored e-cigarettes are banned, youth will simply switch to tobacco-flavored e-cigarettes?If the Senate is genuinely concerned about youth vaping, then there is no justification for it failing to call for a ban on all e-cigarettes. By its own logic, leaving tobacco-flavored e-cigarettes will simply result in youth switching to tobacco-flavored e-cigarettes.OK, so you're thinking that kids are not going to switch from a candy- or fruit-flavored e-liquid to a tobacco-flavored one? Fine, but if that's the case, then it's even less logical to argue that kids are going to switch from fruit-flavored e-cigarettes to the harsh, tobacco-flavored real ones. You can't credibly make the argument that youth will avoid the tobacco flavor of e-cigarettes, but get hooked on the tobacco flavor of real cigarettes.The truth, of course, is that kids are not getting hooked on flavored e-cigarettes and then progressing to tobacco-flavored real cigarettes. They are using flavored e-cigarettes specifically because they want to avoid the health consequences that they all know are associated with the tobacco-flavored real cigarettes.So if youth are not going to switch from flavored e-liquids to tobacco-flavored e-liquids, what are they going to switch to?The answer is THC e-liquids, many of which are packaged in kid-friendly brands like "Apple Jacks," "Banana OG," "Birthday Cake," "Black Berry Kush," "Blue Dream," "Blueberry Kush," "Bubble Gum," "Candy Land," "Cherry Pie," "Cotton Candy," "Fruity Pebbles," "Gelato," "Grape Ape," "Grape Stomper," "Green Crack," "Honey Berry," "Honey Dew," "Ice Blue Raspberry," "Key Lime Pie," "Lemon Berry," "Lemon Head," "Lemon Slushie," "LSD," "Mai Tai," "Mango Kush," "Maui Wowie," "Mimosa," "Mojito," "Orange Chai," "Orange Cookies," "Orange Daiquiri," "Peach," "Pineapple Express," "Pot of Gold," "Purple Punch," "Rose Gold," "Russian Cream," "Sour Apple," "Strawberry Shortcake," "Sweet Aromatic," "Tangie," "Vanilla Kush," "Water Melon," "Wedding Cake," and "Zskittlez."These are precisely the black market products that have led to more than 2,000 cases of severe respiratory failure, most among young people, with 42 fatalities.The Senate's proposal to ban all flavored e-cigarettes would result in a shift from flavored e-liquids to the increased use of flavored e-joints, and it would make the current respiratory disease outbreak much worse, potentially resulting in more deaths. Does the Senate really want those severe illnesses and deaths on its hands?This is before we even get to talking about the effects that a flavored e-cigarette ban would have on adults, which include a mass return to cigarette smoking or entrance into a new black market for flavored e-liquids, which might eventually result in an even worse disease outbreak in the future, since the number of adults using these products and thus subject to any contaminant that may arise in these black market products will be immense. The Senate has apparently written off adult smokers completely. This is a complete betrayal of the Commonwealth's stated objective of reducing tobacco use by increasing successful quit rates and reducing disparities in access to prevention and cessation services.The rest of the story is that the state Senate has steered away from its mission to protect the health of the public, and this bill to ban flavored e-cigarettes would severely harm the health of both youth and adults across the Commonwealth.Original author: Michael Siegel

Anyone who thought the Massachusetts state Senate's probable passage of a bill tonight that will ban the sale of flavored e-cigarettes and menthol tobacco cigarettes is motivated by a pure desire to protect kids and reduce tobacco-related diseases is mistaken. The supporters of this legislation showed their true colors tonight by rejecting an amendment that would have required that the state allocate a mere 10% of the money it receives from the Master Settlement Agreement to smoking prevention and cessation programs.It was quite a sight to witness. Senator after senator got up and spoke about how terrible smoking is and how we have to protect kids from tobacco and nicotine and fight Big Tobacco and their devious tactics.And then, they used a classic Big Tobacco tactic themselves from voting to continue the diversion of nearly 100% of the Master Settlement Agreement money to non-tobacco-related causes.It seems disingenuous to me to put on a grand political show about how much you care about the problem of tobacco use and smoking and nicotine addiction and how much we need to protect kids from Big Tobacco and its deceptive tactics and then to follow that up by immediately using a classic Big Tobacco strategy yourself and by refusing to put your money where your mouth is by adequately funding smoking prevention and cessation programs in the state.To be honest, I stood motionless and in shock as I watched the roll called and senator after senator voted to continue the diversion of MSA funding. Ironically, it was mostly Democratic senators who voted against the amendment and Republican senators who voted for the amendment, which was sponsored by Senator Bruce Tarr (R - First Essex and Middlesex). The Rest of the StoryIn 1992, Massachusetts voters approved an initiative measure (Question 1) that increased the cigarette tax by 25 cents per pack and allocated the money to tobacco prevention and cessation programs. The program was funded at a level of more than $100 million for the first year and approximately $96 million the second year. However, Governor Jane Swift slashed the budget by 95%, diverting funds away from tobacco prevention and cessation and towards the general budget, violating the will of the voters.In fact, getting states to divert cigarette tax revenue funding away from tobacco control was a favored tactic of the tobacco industry. They succeeded in convincing Governor Pete Wilson to do this in California prior to Governors Swift and Weld doing this in Massachusetts.In 1998, the state of Massachusetts entered into a settlement of its lawsuit against Big Tobacco, under which the tobacco companies agreed to make an annual payment of funds to the state. This was called the Master Settlement Agreement (MSA). Although the intent of the MSA funding was to provide money for smoking prevention and cessation (since that was the topic of the lawsuit), the state has diverted most of these funds away from tobacco-related purposes.So between the Question 1 revenue and the MSA revenue, the state is bringing in millions of dollars each year that are supposed to go to tobacco prevention and cessation, but which instead have been diverted to the general budget, violating the will of the people and the intent of the state's lawsuit against Big Tobacco and its subsequent settlement of the lawsuit.Senator Tarr's proposal would have re-allocated merely 10% of the MSA revenue to tobacco prevention and cessation. As he said on the Senate floor, theoretically 100% of this revenue should be spent on tobacco-related programs, but at least approving a 10% allocation would demonstrate that the Senate views tobacco use prevention and cessation as a priority, as senators had said throughout the entire first part of the session, prior to the amendment being introduced.Well, right after the amendment was introduced, they suddenly changed their tune. All of a sudden, everything they had said previously was thrown out the window. They voted to continue the unconscionable diversion of almost all the MSA funding away from tobacco prevention and cessation programs.In 2019, Massachusetts received $236.6 million from the MSA. However, it allocated only $4.2 million to tobacco prevention and cessation. This represents a measly 1.8% of the MSA funds.According to CDC best practice recommendations, Massachusetts should be spending a minimum of $46 million a year on tobacco prevention. An allocation of 10% of MSA funds to tobacco control would represent an expenditure of $24 million, which is still only about half of the CDC recommended funding level.The rest of the story is that the hypocrisy of the state Senate's actions tonight is striking. After talking about how much they care about reducing tobacco-related disease and death, the Senate adopted a Big Tobacco tactic and voted to continue the diversion of MSA funding away from tobacco prevention. Tonight was a great display of politics, but not of public health.Original author: Michael Siegel

by Carl V Phillips

In a resolution that is the most dangerous health-related policy proposal from a medical or health organization that I have seen in my career, the American Medical Association (AMA) today called for the complete removal from the market of the #1 competitor to Big Tobacco profits. The resolution also calls for hundreds of thousands of ex-smokers to return to smoking and for the removal from the market of a critical off-ramp that has helped 2.5 million American smokers to quit for good. In addition, the resolution calls for the creation of a dangerous new black market for e-cigarettes and e-liquids.If this sounds crazy, let me assure you that this is not a re-publication of an Onion article.In fact, it is true that today, the American Medical Association called for the complete and immediate removal of all electronic cigarettes from the market. Since e-cigarettes are the #1 threat to the consumption of real tobacco cigarettes, this recommendation would remove the greatest competitor to cigarette sales and would therefore represent a huge gift to Big Tobacco.In calling for an e-cigarette ban, the AMA is also calling for hundreds of thousands of ex-smokers to return to smoking since that is the effect that such a policy would have on a large proportion of the 2.5 million ex-smokers who currently rely upon e-cigarettes to stay off of the real ones.In addition, the AMA is calling for the creation of a new, dangerous black market for e-cigarettes and e-liquids because the overwhelming majority of those vapers who do not return to cigarette smoking will turn instead to the black market in an act of desperation to avoid having to go back to smoking.The Rest of the StoryI'm sorry to have to say this, but right now the AMA is a great threat to the health of the public. Don't let this organization fool you. This has nothing to do with protecting the public's health. It is all about gaining publicity and political advantage for the organization. How do we know that the AMA is not being sincere?Because the AMA president gave the following as the justification for the recommendation:"It’s simple – we must keep nicotine products out of the hands of young people."If it is imperative that we keep nicotine products out of the hands of young people, then why in the world did the AMA not call for a ban on the sale of all real cigarettes as well?There is absolutely no way in which the AMA can justify calling for a ban on e-cigarettes while allowing real tobacco cigarettes to stay on the market. While e-cigarettes have not killed anyone, tobacco cigarettes kill more than 400,000 people each year. It is therefore ludicrous that the AMA is calling for a ban on the fake cigarettes while allowing the real ones to remain!I defy anyone who is an AMA member to provide a public health justification for banning e-cigarettes but not cigarettes.There simply is none.This is a misguided resolution that has no public health justification, would do immense public health damage, and would substantially increase cigarette consumption in this country. It is a huge gift to Big Tobacco.The AMA has a long and sordid history of promoting tobacco use through the help it has provided to Big Tobacco, but this resolution takes the cake. It takes the cake because it is now 2019, and we should be long past the point of cowing down to Big Tobacco. But the AMA has done exactly that.The AMA should be ashamed of itself for being willing to call for a ban on e-cigarettes, but not touching the real cigarettes that are killing hundreds of thousands of Americans each year and which are still the number one cause of preventable death.Original author: Michael Siegel

It has been well established that using e-cigarettes is far safer than smoking. Clinical studies show that smokers who switch to e-cigarettes experience immediate and dramatic improvement in both their lung function and in their cardiovascular function. They also experience a dramatic reduction in levels of chemical toxins. Any parent who suggests to their kids that e-cigarettes are as dangerous as real cigarettes is lying.However, this fact has not stopped the American Heart Association from urging parents to hide from their kids this important factual information. The American Heart Association actually recommends that if your kid asks you whether e-cigarettes are any safer than tobacco cigarettes, you not answer the question directly but immediately divert attention to the fact that nicotine will harm their brain and that their e-cigarette battery might explode and kill them.Here is an excerpt from a fact sheet that the American Heart Association recommends parents use to answer this question from their kids:"Aren’t e-cigarettes safer than conventional cigarettes?• Because your brain is still developing, scientific studies show that it isn’t safe for you to use any tobacco product that contains nicotine, including e-cigarettes.• Whether you get nicotine from an e-cigarette or a cigarette, it’s still risky.• Some e-cigarette batteries have even exploded and hurt people." The Rest of the StoryI find it disturbing that the American Heart Association is recommending that parents essentially lie to their kids by deceiving them into thinking that e-cigarettes are as hazardous as real cigarettes. But it is even more disturbing that the American Heart Association is recommending that parents refuse to directly answer the questions that their kids may ask about the relative harms of e-cigarettes vs. tobacco cigarettes.The rest of the story is that the American Heart Association is so obsessed with disseminating hysterical claims about the health effects of e-cigarettes that they are willing to stoop to the level of recommending that parents risk their entire relationship with their kids by lying to them and not directly answering their questions.Frankly, I don't think there is a kid in America who would fall for this crap and not realize that their parent is spewing out nonsense. This will most likely result in their kid wanting to immediately get together with their friends and vape up a storm.I have my own recommendation for the American Heart Association: Stop telling parents how to talk to their own children, especially if you are going to recommend that they use lies, misinformation, question avoidance, and deception. Both the parents and their children, and the quality of their relationships, will be far better off without your inane advice.NOTE: In fairness to the American Heart Association, the "fact sheet" to which they link is not their own. It was apparently produced by the U.S. Department of Health and Human Services. Nevertheless, by choosing to refer parents to this fact sheet, they are essentially providing this advice.Original author: Michael Siegel

Last week, the American Heart Association issued a press release whose headline read: "E-cigarettes take serious toll on heart health, not safer than traditional cigarettes."But while the American Heart Association was busy disseminating this message throughout the world, the results of an actual clinical trial of this very research question demonstrated the almost immediate improvement in cardiovascular health that occurs when smokers switch to e-cigarettes. The study compared smokers who switched to e-cigarettes to those who continued to smoke. Endothelial function (a measure of damage to the lining of arteries) and blood vessel stiffness were measured at baseline and after one month. The study reported that: "TC [tobacco cigarette] smokers, particularly females, demonstrate significant improvement in vascular health within 1 month of switching from TC [tobacco cigarettes] to EC [e-cigarettes]. Switching from TC to EC may be considered a harms reduction measure."The investigators concluded that: "The main findings from this present study are that within 1 month of switching from TC to EC, smokers demonstrate a significant improvement in vascular function. ... there is an early benefit to vascular function from switching from TC to EC. Within the switching time frame of 1 month, chronic smokers demonstrated significant improvements in vascular endothelial function."The Rest of the StoryThe difference between the hysterical propaganda from the American Heart Association and the hard evidence from this randomized clinical trial is striking. While the American Heart Association is trying to convince the public that there is no difference in cardiovascular health effects between vaping and smoking, this paper provides solid clinical evidence that smokers who switch to e-cigarettes experience an immediate improvement in cardiovascular health.Why the American Heart Association would want to deter smokers from quitting is beyond my comprehension. And to do that while spreading false information about health risks is irresponsible.Original author: Michael Siegel

If you believe the security rule is affecting the normal operation of your website, contact your host support team and provide detailed instructions how to recreate this error.They will be able to assist you with rectifying the problem and adjusting the security configuration if needed.Original author: KNoll-Marsh

But You Can Drive With Marijuana or Cartons of Marlboros in Your Car To Your Heart's Content Jacob Sullum, a senior editor at Reason, has revealed a striking set of provisions in the bill (H4183) passed by the Massachusetts House of Representatives on Wednesday. These provisions would allow the police to seize your vehicle if you possess any DIY or black market e-liquids in your car.The relevant provision in the bill reads as follows:"When the commissioner or a police officer discovers an untaxed electronic nicotine delivery system in the possession of a person who is not a licensed or commissioner-authorized electronic nicotine delivery system distributor, the commissioner or police officer may seize and take possession of the electronic nicotine delivery systems and any vending machine or other receptacle including, but not limited to, a motor vehicle, boat or airplane in which the electronic nicotine delivery systems are contained or transported."Because a DIY e-liquid or a black market e-liquid would meet the definition of an "untaxed electronic nicotine delivery system," possessing either in your car would make your vehicle subject to seizure.  Moreover, if you merely possess a DIY or black market e-liquid (in any location), you are subject to a potential $5,000 fine for the first offense and up to $25,000 for subsequent offenses.Youth are also subject to the penalties in H4183. So if a youth were caught possessing a black market CBD, THC, or nicotine cartridge, they would be subject to a $5,000 fine; $25,000 if they are caught twice.   Even worse, the bill essentially requires you to have a receipt for your e-cigarette or e-liquid purchase to prove that you paid the excise tax. The bill contains a provision that presumes your e-cigarette was not taxed unless you can prove it. So even if you possess a legal e-cigarette (meaning one you purchased from a licensed smoking bar), if you don't have the receipt that e-cigarette could cost you an extra $5,000 above its purchase price. If you're caught twice possessing a JUUL pod without a receipt, that pod four-pack will cost you $25,019.99.The Rest of the StoryToday, I reveal that if this law is enacted, it will be illegal for any person in Massachusetts to possess any electronic cigarette, vaping device, e-liquid, e-cigarette battery, cartridges, or even e-liquid vials that you obtained prior to the effective date of the law. In other words, you have to discard every single e-cigarette device, component, or e-liquid that you possess on the day the law goes into effect. Otherwise, you are subject to a fine of up to $5,000 for the first offense and up to $25,000 for subsequent offenses.The relevant provision in HB4183 reads as follows:  "A person who knowingly purchases or possesses an electronic nicotine delivery system not manufactured, purchased or imported by a licensed electronic nicotine delivery system distributor or licensed electronic nicotine delivery system retailer shall, in addition to any other penalties provided by this chapter or chapter 62C, be subject to a civil penalty of not more than $5,000 for the first offense and not more than $25,000 for a second or subsequent offense."So for example, suppose you bought a JUUL device at Walgreen's in 2018. Walgreen's was not a licensed electronic nicotine delivery system retailer at the time you made the purchase. You could therefore be considered to be in a possession of an e-cigarette that was not obtained from a licensed dealer. What you thought was a cheap $14.99 expenditure may actually be an expenditure of $5,014.99.What is so striking about this legislation is how severely it treats e-cigarettes, while treating much more hazardous Marlboro cigarettes leniently. In fact, this bill has absolutely no implications for the sale, purchase, or possession of the product responsible for the most preventable deaths in Massachusetts. But it levies a potential $25,000 fine and forfeiture of your car if you are caught twice with a DIY e-cigarette device or liquid in your vehicle.I just don't understand the extent of this hysteria around e-cigarettes. There is no doubt that youth addiction to e-cigarettes, which essentially translates into youth use of JUUL, is a major problem. But you don't have to shut down the entire e-cigarette market, criminalize people who are trying to save their lives, create a new black market, and push youth towards THC vaping in order to solve this problem. You can do it with one simple law: limit the nicotine level in e-cigarettes.In the UK, there isn't a problem with youth addiction to JUUL. But in the UK, JUUL does not contain 54 mg/mL of nicotine. It contains only 17 mg/mL because there is a legal nicotine limit. In fact, H4183 contains a provision that limits e-liquid nicotine levels to 20 mg/mL, except those sold at smoking bars. If the legislature merely enacted that one provision, but including all e-cigarettes (not just those sold at smoking bars), it could significantly curtail the youth vaping epidemic without all of the severe negative health consequences.Original author: Michael Siegel

If you believe the security rule is affecting the normal operation of your website, contact your host support team and provide detailed instructions how to recreate this error.They will be able to assist you with rectifying the problem and adjusting the security configuration if needed.Original author: KNoll-Marsh

If you believe the security rule is affecting the normal operation of your website, contact your host support team and provide detailed instructions how to recreate this error.They will be able to assist you with rectifying the problem and adjusting the security configuration if needed.Original author: KNoll-Marsh

Yesterday was a dream come true at the Massachusetts State House for Philip Morris USA - the nation's largest domestic cigarette manufacturer. The House voted to approve a bill that bans the sale of all e-cigarettes except those with tobacco flavoring, bans the sale of menthol cigarettes, and imposes a 75% excise tax on all e-cigarettes. According to an article in the Boston Globe, the aim of the legislation is "to protect young people from the harmful effects of tobacco."The Rest of the StoryIf the purpose of this legislation is to protect young people from the harmful effects of tobacco, then it is an utter failure. It makes it much easier for a youth in Massachusetts to get their hands on a Marlboro cigarette than a cherry vape. In addition, since proponents of the law argue that e-cigarettes are a gateway to smoking, there are now thousands of youth vapers in Massachusetts who would no longer be able to vape, so by the proponents' own reasoning, there is going to be a large increase in youth smoking in the state if this bill is enacted.But that's not the worst of it.If policy makers think that by banning flavored e-cigarettes they are going to put an end to youth vaping, they are deceiving themselves. Youth are not vaping because the products are flavored. They are vaping because vaping is now viewed as cool. The phenomenon that is cool is vaping, not the use of flavors. If flavored, nicotine-containing e-liquids are no longer available, youth are not simply going to stop vaping. What they are going to do is to change what they are vaping. And instead of vaping flavored nicotine e-liquids, they are going to shift towards the use of black market THC e-liquids. Those are precisely the products that are causing this terrible outbreak of severe respiratory failure.In other words, what this legislation would do is to create a shift in youth vaping from the vaping of nicotine to the vaping of marijuana (and perhaps CBD as well). Youth who use drugs tend to use whatever is most available. Whatever e-liquids are being supplied by the school suppliers is what kids will vape. The overwhelming majority of youth vapers are not buying the e-liquids themselves from retail stores. They are purchasing them from friends, classmates, or school dealers who serve as the distribution channel for these products. Whatever e-liquids they have available are the e-liquids that kids will use. And if this law goes into effect, what the kids who are distributing these drugs will have available is THC carts instead of flavored nicotine-containing pods.The damage doesn't end there.If enacted, this ban is going to cause many ex-smokers to return to cigarette smoking. Ex-smokers who rely upon flavored e-liquids to stay off cigarettes are going to return to smoking in large numbers. The majority of those who don't will turn to black market e-liquids, and we all now understand the dangers of an unregulated black market. In addition, this legislation removes a major off-ramp for adult cigarette smokers who are trying to quit smoking.In the short time that the emergency ban on the sale of e-cigarettes has been in place in Massachusetts, the state has already experienced significantly higher rates of cigarette consumption than would have occurred without the ban -- this is based on actual sales data, not self-reports of smoking behavior.On top of all of this, the legislation imposes a whopping tax on electronic cigarettes, which essentially removes any incentive for smokers to switch to tobacco-flavored vapes, the only ones which will remain on the legal market.So the end result of this legislation will be a significant increase in the level of cigarette consumption in Massachusetts. That's a victory for Big Tobacco. But not all the companies will benefit equally. Most sub-brands of Newport, Kool, and Salem are menthol-flavored, while most sub-brands of Marlboro are non-mentholated. What this legislation essentially does is ban the sale of Newport, Kool, and Salem while allowing the sale of Marlboro cigarettes to remain unfettered.There is simply no public health justification for banning some brands of cigarettes, but leaving others on the market.The big question this raises is this: If the legislature is willing to ban menthol cigarettes, then why isn't it willing to ban the sale of all cigarettes? There is no evidence that menthol cigarettes are any more dangerous than other cigarettes. Thus, there is ultimately no justification for singling them out and allowing other brands to reaming on the market to continue to kill thousands of Massachusetts residents each year.This bill is a dream come true for Philip Morris USA because it essentially removes all of its major competition. First, the bill eliminates the overwhelming majority of the e-cigarette market in Massachusetts, so Philip Morris no longer has to worry about competition from much safer alternative products. Now all its competition will come from products that are equally deadly.However, even many of those products are being removed from the market. The main competitors to Marlboro, such as Newport, Kool, and Salem are largely being removed from the market. Philip Morris couldn't have hoped for a more favorable piece of legislation had they written the bill themselves.Original author: Michael Siegel

The Journal of the American Heart Association on June 5, 2019, published a bogus research article, “Electronic cigarette use and myocardial infarction among adults in the US Population Assessment of Tobacco and Health [PATH],” by Dharma N. Bhatta and Stanton A. Glantz (here).  Drs. Bhatta and Glantz used PATH Wave 1 survey data to claim that e-cigarette use caused heart attacks. However, the public use data shows that 11 of the 38 current e-cigarette users in their study had a heart attack years before they first started using e-cigarettes. The article misrepresents the research record; presents a demonstrably inaccurate analysis; and omits critical information with respect to (a) when survey participants were first told that they had a heart attack, and (b) when participants first started using e-cigarettes.  The article represents a significant departure from accepted research practices.  I provided the JAHA editors with details about the false results on July 11 and July 18, and I urged them to consider an investigation and retraction.  They failed to provide a substantive response (here). As the JAHAeditors apparently need further encouragement to retract this article, I invite researchers at 776 ICPSR-member universities, government agencies and other institutions to conduct their own investigation of the article’s false claims.  Investigate and Take Action on the Bhatta-Glantz False Findings in Three Easy Steps 1.  Download the PATH Wave 1 public use dataset from ICPSR (here) using your preferred software (5 minutes).  The data is available in the popular programs SPSS, SAS, STATA or R. 2. Identify participants who are current users of e-cigarettes and who report having had a heart attack, then run a simple crosstabulation of the age range at which they had the heart attack and the age range at which they first used e-cigs (5 minutes).  Here are easy-to-follow programming codes for SPSS, SAS, STATAand R.*  The resulting table will reveal that 11 of the 38 current e-cigarette users were first told that they had a heart attack years before they started using e-cigarettes. 3. Send an email to the JAHA editors, asking them to retract the article (5 minutes).  Here are their email addresses: Barry London, Editor-in-Chief This email address is being protected from spambots. You need JavaScript enabled to view it.  Daniel T. Eitzman, Deputy Editor This email address is being protected from spambots. You need JavaScript enabled to view it.  Janice Weinberg, Statistical Editor This email address is being protected from spambots. You need JavaScript enabled to view it. Thank you for your assistance in correcting the scientific record on e-cigarettes and heart attacks. *You can download these programs with confidence.  I developed them with trusted colleagues. Original author: Brad Rodu

by Carl V Phillips

Later this week, the American Heart Association will hold its annual scientific conference in Philadelphia. In anticipation of the conference, the American Heart Association issued a press release yesterday announcing the results of a new study on e-cigarettes that will presented at the conference. The headline of the press release is:"E-cigarettes take serious toll on heart health, not safer than traditional cigarettes."One of the two papers that is being presented which purportedly support the conclusion that e-cigarettes are no safer than tobacco cigarettes in terms of heart health is a study of cholesterol levels in e-cigarette users compared to current smokers and nonsmokers.The study is described as follows:"Researchers evaluated healthy adults (ages 21-45) without existing cardiovascular disease and taking no daily medications in the Cardiovascular Injury due to Tobacco Use (CITU) Study. The study's 476 participants included 94 non-smokers; 45 e-cig smokers; 52 e-cig and t-cig smokers; and 285 t-cig smokers. Analysis was adjusted for age, race, sex, and non-smokers, sole e-cig or t-cig use, or combination e-cig and t-cig use."The findings were as follows:"Total cholesterol was lower and the bad cholesterol, LDL, was higher in sole e-cigarette users compared to nonsmokers.Good cholesterol, HDL, was lower in dual smokers."  And the study conclusion was as follows:"Although primary care providers and patients may think that the use of e-cigarettes by cigarette smokers makes heart health sense, our study shows e-cigarette use is also related to differences in cholesterol levels. The best option is to use FDA-approved methods to aid in smoking cessation, along with behavioral counseling."The Rest of the StoryThis study found a cross-sectional association between e-cigarette use and riskier lipoprotein (cholesterol) profiles. Based on that cross-sectional correlation, the investigators conclude that e-cigarette use leads to higher "bad" cholesterol levels and therefore, switching from smoking to vaping does not improve cardiovascular health.But let's examine this more closely.In a cross-sectional study, you have to be very careful in extrapolating from correlation to causation because this type of study design is very susceptible to confounding -- that is, a third variable that is associated with both smoking/vaping status and cholesterol levels and makes it look like they are related but the relationship is actually driven by this third variable.In this example, there is a very strong potential confounder: diet. It is very likely that smokers and former smokers have significantly less healthy diets than nonsmokers and therefore, worse cholesterol profiles. There may be differences in physical activity as well, which would lead to a finding of worse cholesterol profiles in current and former smokers than in nonsmokers.In fact, studies have shown (example) that when you compare cholesterol levels in former smokers and nonsmokers, the former smokers have worse cholesterol profiles. Since most vapers are former smokers, it is almost certainly the case that vapers have worse cholesterol profiles than nonsmokers.Thus, this paper provides no evidence of any effect of vaping on cholesterol levels. That relationship is completely confounded by diet and physical activity, and it has already been demonstrated in the literature that former smokers have worse cholesterol profiles than nonsmokers, even before e-cigarettes were ever invented!This is why I think that the conclusion of this paper (that e-cigarette use leads to an unhealthy cholesterol profile and that vaping is therefore just as dangerous as smoking in terms of heart health) is unwarranted and indicates a bias against e-cigarettes.Even if vaping did increase LDL cholesterol and lower HDL cholesterol, this wouldn't indicate that vaping is more dangerous than smoking. There are many other impacts of smoking on cardiovascular health that would need to be examined. And most importantly, one would need to understand the long-term effects of vaping before concluding that it is more dangerous than smoking.The worst part of this story, however, isn't the evident bias against e-cigarettes in the research. The worst part of the story is the recommendation that smokers not switch to e-cigarettes in order to quit smoking. That is really bad advice. The reality is that 90% of smokers who try to quit using nicotine replacement therapy will fail. So advising vapers to try nicotine patches is tantamount to telling 90% of them to go back to smoking. Moreover, the best scientific evidence available - a randomized clinical trial - showed that e-cigarettes are twice as effective as the nicotine patch for smoking cessation.The rest of the story is that the bias against e-cigarettes is leading to unfounded scientific conclusions, deceptive communications to the public about the health effects of e-cigarettes, and misguided medical advice.Original author: Michael Siegel