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Heads Up – News – Updates 7.1.2019

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Heads Up – News – Updates 6.28.2019

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Heads Up – News – Updates 6.25.2019

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Sunday Science Lesson: Bad categories, bad science

by Carl V Phillips

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San Francisco Board of Supervisors to Vote Tuesday on Banning the Retail Sale of Cigarettes and Marijuana

This Tuesday, the San Francisco Board of Supervisors is scheduled to vote on a proposed ordinance that would ban the sale of cigarettes and marijuana products in the city until the FDA conducts a safety review of these products.The impetus for the proposed ordinance was new data showing that a large proportion of San Francisco youths are still smoking and that the use of marijuana may even be increasing, especially with the recent legalization of recreational marijuana use. The city attorney explained that: "The epidemic is real. It needed attention. We felt it was necessary to step in and make sure we were protecting young people on our streets." He criticized the FDA for not properly vetting cigarettes and marijuana and failing to test the safety of these products, saying that the federal government "abdicated" its responsibility and therefore, the city "had to step in."The supervisor who introduced the ordinance told The Rest of the Story that: "there are strong indications that marijuana actually alters receptors in the brain, making youth more susceptible to addiction." He called marijuana a "gateway" to harder drugs, citing evidence that youth who use marijuana are more likely to initiate the use of other drugs, including cigarettes, inhalants, stimulants, and even opiates. He cited a recent statement from the National Institute on Drug Abuse (NIDA) that "underscore[s] the need for effective prevention to reduce adolescent use of ... tobacco and marijuana in order to turn back the heroin and opioid epidemic and to reduce burdens of addiction in this country."One supporter of the ordinance, a professor at UCSF, warned that: "According to data from the Monitoring the Future study, the use of marijuana among teens has reached epidemic proportions. In 2018, a whopping 36% of high school seniors reported using marijuana in the past year. This is a 50% increase from the level in 1991, which was just 24%." He also noted that in 2018, the prevalence of smoking among high school seniors was still 8%, despite decades of anti-smoking campaigns.According to a spokesperson for the local lung association, "there are numerous flavored marijuana products on the market in San Francisco that are clearly designed to appeal to young people." A review of the menu offered at one San Francisco pot shop -- Urban Pharm on 10th Street in the SOMA district -- revealed a variety of kid-friendly flavors including "super fruit," "jelly roll," "slurricane," "sugar cookies," "sundae driver," "chocolate chip cookies," "orange soda," and "watermelon zkittlez."The Campaign for Marijuana-Free Kids, in testimony before the Board of Supervisors, asked how supervisors could possibly not think that flavors like watermelon Skittles, slurry, chocolate chip cookie, and jelly roll are targeted at youth. "Prohibiting marijuana products in kid-friendly flavors is one of the most important actions we can take to reverse the youth marijuana epidemic and continue reducing youth marijuana use."The UCSF professor was quoted as stating that: "The FDA is complicit in allowing this epidemic to develop. Other cities and states should follow San Francisco’s lead: pass comprehensive flavor bans, followed by legislation to prohibit the sales of cigarettes and marijuana products until they are properly assessed by FDA."The San Francisco city attorney noted that smoking kills more than 400,000 Americans each year, saying: "Young people have almost indiscriminate access to a product that shouldn’t even be on the market. Because the FDA hasn’t acted, it’s unfortunately falling to states and localities to step into the breach." He also praised the city's supervisors for making San Francisco a national leader in the effort to confront cigarette use, which is the leading cause of preventable death in the nation. "San Francisco has never been afraid to lead. That will always be the case when the health of our children is on the line. I want to thank the Board of Supervisors for taking this pioneering step to protect our youth. This temporary moratorium wouldn’t be necessary if the federal government had done its job. Cigarettes are a product that should not be allowed on the market without FDA review. For some reason, the FDA has so far refused to act. If the federal government is not going to act to protect our kids, San Francisco will."According to the website of the office of the city attorney: "Tobacco use is the leading cause of preventable disease and death in the United States. Tobacco kills more than 480,000 people a year in this country. That’s more than AIDS, alcohol, car accidents, illegal drugs, murders and suicides combined." Many small businesses in San Francisco, including marijuana dispensaries, convenience stores, and smoke shops complained that if enacted, this law will severely hurt their sales. The owner of "Store 420" on Powell Street couldn't understand why the sale of marijuana had to be completely banned, rather than just restricting it to stores that do not allow minors. "We have strict age verification procedures and I can tell you that we only sell marijuana products to adults. Why does our business have to be sacrificed to protect kids from a product that - while it may be addictive - does not cause any severe acute health effects and it's not even clear that it causes serious long-term health consequences either?"But the city attorney took issue with the stores' calling this policy a "ban," saying: "This legislation takes a reasoned approach. It doesn’t ban cigarettes or marijuana outright. It simply says that a product can’t be sold in San Francisco until it receives FDA approval. That’s just common sense. If Philip Morris or any company like it wants to sell their product in San Francisco, they should apply to the FDA today for review. If their product really has some kind of psychological benefit to adult smokers, as they claim, rather than a lure to addict another generation, they have the opportunity to get certified before this legislation takes effect."CORRECTION (June 22, 2019 - 12:55 pm EDT): I have just been informed that I didn't get the story quite correct. Cigarettes and marijuana products are all being allowed to stay on the shelves with no regulation at all, regardless of scientific evidence regarding their serious health hazards, their widespread use among youth, and the targeting of youth by flavors like "slurry" and "jelly roll" that are intended to appeal to youth. Instead, the Board of Supervisors is banning the sale of fake cigarettes (i.e., electronic cigarettes) that contain no tobacco, involve no combustion, and have been demonstrated to be much safer than cigarettes and which also have been used by more than 2.5 million Americans to successfully quit smoking completely. I apologize for this error.Original author: Michael Siegel
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Heads Up – News – Updates 6.19.2019

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San Francisco Board of Supervisors Poised to Deliver Huge Gift to Philip Morris

Philip Morris - the nation's largest cigarette manufacturer - is about to land a huge legislative gift from the most unlikely of sources: the San Francisco Board of Supervisors.Earlier today, the Board approved an ordinance that will ban the sale of all electronic cigarettes in the city, including both brick-and-mortar and online sales. Before it becomes law, the ordinance is subject to a final vote, which is expected to take place next week.The Philip Morris USA cigarette company could not have dreamed for a more favorable legislative gift from the city of San Francisco. Right now, the chief competitor to the sale of the company's deadly cigarettes is vaping products, which are today the most widely used and most effective product for smoking cessation. In fact, there are at least 2.5 million ex-smokers in the United States who have successfully quit smoking using e-cigarettes and who remain dependent on the availability of these products to stay off cigarettes. However, in San Francisco, unless the Board reverses its decision, these products will soon be taken off the market.Absurdly, the San Francisco Board of Supervisors is allowing the continued, unfettered sale of real cigarettes -- the ones that kill more than 400,000 Americans (including more than 40,000 Californians) each year. The nation's leading brand of cigarettes - which is literally the #1 cause of preventable death in the country - is Marlboro. Due to a giant exemption in the ordinance, Philip Morris will be able to continue selling its deadly Marlboros thanks to the hospitality being shown to the company by the San Francisco Board of Supervisors, which is, ironically, requiring e-cigarettes to gain FDA approval before being sold in the city but not requiring any further assessment or regulation of the safety of Marlboros and other combustible cigarettes.From a public health perspective, this is the most insane piece of legislation I have ever seen. The Board of Supervisors apparently thinks that it is in the interest of the public's health to ban much safer e-cigarettes while allowing deadly cigarettes to remain on the shelves.The San Francisco City Attorney argued that e-cigarettes are "a product that shouldn't even be on the market." So let's get his reasoning straight. He is saying that e-cigarettes shouldn't even be on the market, but cigarettes should! This is contrary to every public health principle in the book. We aim to help the public make healthier choices. Forcing them to consume the most deadly and toxic consumer product on the market is the last thing in the world that any policy maker concerned about public health should be doing.There is no question that this ordinance will result in the deaths of a large number of ex-smokers in the city, who will almost certainly return to cigarette smoking when their vaping products are no longer available. It will be far easier for them to just pick up a pack of Marlboros then to cross the Bay Bridge, the Golden Gate Bridge, or venture down into Daly City to locate a store that sells the e-cigarettes upon which they are currently relying to stay smoke-free. The ordinance will also deter thousands of smokers from trying to quit smoking using e-cigarettes, since the absence of vaping products on convenience store and gas station shelves will leave the market wide open for Marlboro and Camel to retain their current customers, with little threat of losing those customers to the much safer alternative of vaping.Sadly, the Board of Supervisors has been misled by a campaign of misinformation. They have been told that e-cigarettes are deadly - that they increase the risk of heart attacks and stroke. The truth is that there is no evidence to support this claim. In fact, data from the National Health Interview Survey demonstrate that among nonsmokers, vaping is not associated with any increase in the risk of cardiovascular disease.The data that supporters of the e-cigarette ban are citing to buttress their claim that vaping causes heart attacks is actually from a cross-sectional study which shows an association with people reporting ever having had a heart attack and currently vaping. But the explanation for this association is quite simple: when people have a heart attack, they are highly motivated to quit smoking. Many of them switch to vaping, and that is why there are so many former smokers with a history of a heart attack who now vape.Supporters of the ban also claim that vaping leads youth to start smoking. There is no scientific evidence to support this claim. In fact, the truth is exactly the opposite. Youths who become regular vapers are much less likely to start smoking. Talk to any kid who Juuls. They will tell you that smoking is disgusting and that they wouldn't even think of it. In fact, that is the entire appeal of Juul. It is an enticing alternative to smoking for kids who would never even think about smoking. The culture of smoking is being replaced by a culture of vaping --- not the opposite.The press release announcing the introduction of the ordinance explained that: "Banning vaping products that target young people and push them towards addiction to nicotine and tobacco is the only way to ensure the safety of our youth."But if it is true that vaping is pushing kids towards tobacco, then certainly banning the sale of tobacco products (i.e., cigarettes and smokeless tobacco) would be the most effective solution. I don't for a minute believe that any politician who is serious about trying to prevent youth smoking would propose as a solution allowing cigarettes to remain on the shelves without any further restrictions whatsoever. But that is precisely what the Board of Supervisors is poised to do.In the same press release, the City Attorney boasted that: "San Francisco has never been afraid to lead, and we’re certainly not afraid to do so when the health and lives of our children are at stake."If San Francisco wants to lead, then why isn’t it taking cigarettes off the shelves? After all, the chief concern about vaping is that it is a gateway to tobacco use. What possible sense does it make to ban e-cigarettes in order to prevent kids from smoking, but to leave the cigarettes readily accessible on the store shelves?The truth is that the Board of Supervisors is apparently afraid to lead because they are willing to take the politically expedient step of requiring safety testing for e-cigarettes, but they are not willing to place the same requirement on real cigarettes. In fact, tobacco cigarettes have already had their safety testing and they failed miserably. That's apparently of no concern to the San Francisco Board of Supervisors.The message that San Francisco is about to send to the rest of the nation is absurd: the best way to protect kids from cigarettes is to leave cigarettes on the store shelves.This story is so ironic that one would think it would be fine material for the Onion. However, I'm afraid that it is so far-fetched that it wouldn't even qualify. After all, who would honestly believe that a board of policy makers who allegedly are aiming to prevent an epidemic of cigarette smoking among youth would attack that epidemic by doing nothing about the sale of cigarettes in their city and focusing their entire efforts on fake cigarettes.Hopefully, the absurdity of what they are about to do will be realized by the Board of Supervisors this week before it is too late. They need to take a step back from the hype and hysteria and examine the issue from a public health perspective. If they truly do that, they can come to no conclusion other than that it is completely counter to the basic principles of public health to remove a safer alternative from the market, thus forcing consumers to be stuck using the single most hazardous consumer product on the market.I'm happy to speak to any of the Supervisors and set the record straight on this issue.If the ordinance does pass, it will have to go down as the greatest legislative favor ever done in this century to help boost a cigarette company's profits.Original author: Michael Siegel
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Heads Up – News – Updates 6.14.2019

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Heads Up – News – Updates 6.13.2019

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Heads Up – News – Updates 6.12.2019

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Heads Up – News – Updates 6.10.2019

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Detailed interview on vaping and bans on flavored e-cigarettes - WICN's Public Eye

Detailed interview on vaping, especially bans on flavored e-cigarettes, on WICN's Public Eye. Click on archives for Sunday, June 9th.Original author: Michael Siegel
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Heads Up – News – Updates 6.05.2019

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
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Walgreens, resist calls to deny people access to safer alternatives.

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
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Anti-THR, anti-vaxx, disease denial, and the political science of institutional “knowing” of falsehoods

by Carl V Phillips

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“Reason(s) you vape” questions on surveys are generally stupid

by Carl V Phillips

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Tobacco Wars collateral damage: feature, not bug

by Carl V Phillips

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Lawsuit Against Juul/Altria Alleging Fraudulent Misinformation Provides Fraudulent Misinformation

Parents of a Florida teenager who became addicted to Juul have sued Juul, Altria, and Philip Morris USA based on a number of claims, including fraud, negligence, and violation of the RICO statute (the compliant is here). Dr. Stan Glantz and Lauren Lempert provide a nice summary of the reasoning behind the lawsuit and the specific claims being made. The case was filed on Monday in the federal district court for the middle district of Florida.The Rest of the StoryAlthough the main complaint is that the company fraudulently provided misinformation about the product, its health risks, and its addictiveness, the complaint itself provides a huge amount of misinformation and distortion of the scientific facts related to vaping and Juul. Here is a sampling of the false or completely unsupported information that is claimed in the complaint:1. Vaping causes chronic obstructive pulmonary disease (COPD): The lawsuit claims that "just like traditional cigarette smoke," vaping causes COPD because it "introduces foreign substances into the lung." There is absolutely no evidence to support this claim. Despite at least 12 years of use and prolonged vaping by millions of Americans, I'm not aware of a single case of COPD that has been documented to be caused by vaping. While vaping does cause acute respiratory irritation, there is no evidence at this point that prolonged exposure to e-cigarette aerosol is extensive enough to cause permanent lung obstruction.2. Nicotine is a carcinogen: The lawsuit claims that "nicotine itself is a carcinogen." The leading, objective, international body that studies carcinogens (the International Agency for Research on Cancer [IARC]) has not declared nicotine to be a carcinogen.3. Juul delivers carcinogens to users: The lawsuit claims that Juul "delivers toxins and carcinogens to users." However, the complaint does not specify exactly what toxins or carcinogens Juul delivers to users. Studies of the aerosol produced by Juuling, to the best of my knowledge, have not demonstrated the presence of detectable levels of carcinogens.4. Juul is designed to transition users to cigarette smoking: The lawsuit claims that Juul is designed to make it "easier for e-cigarette users to transition to conventional cigarettes." The truth is the exact opposite. Juul was designed specifically to transition conventional cigarette smokers to vaping. Juul Labs would be stupid if they designed the product such that its users would transition back to smoking. The company makes no money if its users go back to smoking. In fact, the economic incentive for Juul is to eliminate smoking altogether. The more smokers who switch from conventional cigarettes to Juul, the more money the company makes. There is abundant evidence that Juul has succeeded in transitioning hundreds of thousands of smokers away from conventional cigarette use, but no evidence that Juul has transitioned anyone to cigarette smoking.5. Juul is defectively designed: The lawsuit claims that the Juul e-cigarette is "defectively designed" because it delivers nicotine so effectively. The truth is that this is actually an incredibly effective design because it provides the greatest chance that a smoker will successfully quit smoking by switching to vaping. The problem with most other e-cigarettes is precisely that they do not deliver nicotine effectively. Juul corrected this problem and as a result, it has become the most effective smoking cessation product currently on the market. This is demonstrated by the tremendous market share that Juul holds among adult smokers trying to quit. 6. Juul aggravates nicotine addiction in cigarette smokers: The lawsuit claims that the company knew that Juul "posed a risk of aggravating nicotine addiction in those already addicted to cigarettes." There is no evidence to support this claim and the truth is likely the opposite. While smokers who switch to Juul are obviously still addicted to nicotine, they are no longer addicted to smoking. The behavior of smoking is a huge component of the addiction to nicotine that is observed in cigarette smokers. By eliminating that aspect of the addiction, the overall addiction is almost certainly lessened.7. Juul fails to inform users that its product has not been found to be safe: The lawsuit claims that the company "fails to inform users that its products have not been found to be safe." The truth is that Juul says right on its web site that: "No tobacco-based or nicotine e-liquid product should be considered safe." In addition, Juul informs customers that: "Inhalation of e-vapor from JUUL may aggravate pre-existing respiratory or heart conditions. Additionally, ingestion of nicotine, at any level, may cause other conditions (such as an increase in your heart rate and blood pressure, may cause dizziness, nausea, and stomach pain)." The company also warns users about ingesting the e-liquid, informing them that the product: "Contains nicotine, which is an addictive chemical and can be poisonous. Avoid contact with skin and eyes. Do not drink."8. Juul falsely claimed that it is not affiliated with Big Tobacco: It is true that Juul claimed that it had no affiliation with Big Tobacco. But that was prior to its partial acquisition by Altria. You can hardly blame the company for making a true statement, as long as they no longer make that claim. A Google search revealed that, ironically, the only current internet source of the claim that "Juul Labs is not Big Tobacco" is the lawsuit itself.9. Juul and Altria plan to use Juul as an entry point for youth to start smoking Marlboro cigarettes: Not only is there no evidence to back up this claim, but it is patently ridiculous. You don't get kids addicted to Marlboro by marketing Juul. You get kids addicted to Juul by marketing Juul. Data from the PATH study demonstrate that becoming a regular vaper is a path away from smoking, not towards smoking. In fact, the only kids who currently progress to smoking are those who do not become regular vapers. Why would a company think that by addicting kids to a mango-flavored product, they would suddenly develop a desire for the harsh taste of Marlboro? Altria may have a history of being sinister, but they are not stupid.None of this is to deny the fact that Juul use among youth has become a serious public health problem that needs to be addressed urgently. None of this is to deny that Juul carries some responsibility for having created the problem. However, it doesn't seem fair to file a lawsuit against the company for making false claims by putting false claims into the complaint.Ultimately, I go far beyond nearly all of my colleagues in public health because I believe that the use of nicotine salts is simply not a viable long-term option for a harm reduction strategy that is based on trying to get smokers to switch to vaping. Nevertheless, I don't think it is appropriate to sue the company based on alleged facts that are either completely undocumented or simply untrue.Original author: Michael Siegel
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New Study Finds Vaping is Not Associated with Cardiovascular Disease among Never Smokers; But Tobacco Control Researcher Dismisses Findings

A new study published online ahead of print in the American Journal of Medicine reports that there is no association between vaping and cardiovascular disease among never smokers.Like previous studies of its kind, this was a cross-sectional study that examined the association between current vaping/smoking status and ever having been told that one has cardiovascular disease (including heart attack, coronary artery disease, or stroke). Previous studies used data from the National Health Interview Survey (NHIS) or the Population Assessment of Tobacco and Health (PATH) study; this paper used data from the Behavioral Risk Factor Surveillance Survey (BRFSS).The authors reported no association between current vaping and self-reported cardiovascular disease among never smokers. However, they found that among current dual users there was an increased odds of having ever been told that one has cardiovascular disease.In response to the study, one prominent tobacco control researcher concluded that dual use is causally associated with cardiovascular disease, while dismissing the negative finding that e-cigarette use was not associated with vaping among never smokers. He wrote: "The fact that the authors did not find an effect of e-cigarettes alone may be because they stratified the sample on e-cig and cigarette use, which reduces the sample size for each comparison, and so the power to detect an effect."The Rest of the StoryThis reminds me of what the tobacco industry used to do. If they saw a finding that they liked, they would emphasize that finding, but if they saw a finding that they didn't like, they would just dismiss it. This is sometimes called "cherrypicking." I've never picked cherries, but I assume that when doing so, one only picks the cherries that you like and disregards the ones that you don't.As objective scientists, we can't cherrypick. It allows one to have a pre-conceived conclusion and then to simply publicize findings that support the conclusion while dismissing those that do not. It appears that this is what is going on here.Cherrypicking is becoming more and more common among tobacco control researchers and advocacy groups. Recently I spoke at a conference on vaping, and one of the other speakers on the panel told the audience that there was no evidence vaping can help people quit smoking. The basis of that conclusion was that "there is no clinical trial that shows vaping to be effective ... we need a clinical trial." When I then pointed out that a randomized, clinical trial published last month in the prestigious New England Journal of Medicine found that vaping was twice as effective as nicotine replacement therapy for smoking cessation, they simply dismissed it, saying: "Well I still don't think it's effective." (The same person also did not think there is enough evidence to conclude that vaping is any safer than smoking.)The reality is that many tobacco control researchers and advocates will not be convinced by any amount of data. You could have two clinical trials, both finding that vaping is effective for some smokers, and they would still dismiss the findings. (In fact, we do have two clinical trials -- it's amazing to see how many tobacco control advocates continue to insist that there have not been any clinical trials on the use of vaping for smoking cessation.)Here, a positive finding is accepted and touted, while a negative finding is just dismissed. The reasoning given -- that the study didn't have the power to detect an effect -- doesn't hold water because the sample size of never smoking vapers in the study (15,863) exceeded the number of dual users (12,908).But even the conclusion that dual use is causally associated with cardiovascular disease is unsupported by the evidence presented in the paper. This is a cross-sectional study, so it is entirely possible that the onset of cardiovascular disease preceded the vaping. In fact, this is almost certainly the case for most of the study subjects because e-cigarettes have been popular for only about eight years, and it takes decades for cardiovascular disease to develop.It may actually be that the cardiovascular disease "caused" the vaping because having a heart attack or stroke is a strong stimulus for a smoker to try to quit, and many smokers try to quit by using e-cigarettes.Moreover, dual users are almost certainly a different population from exclusive vapers and one systematic difference between the groups is likely that dual users have a heavier or more intense smoking history, making it more difficult for them to get off of e-cigarettes. If this were the case, it would explain the observed finding that dual use was associated with a higher risk of reporting cardiovascular disease.  The bottom line is that we can't draw causal conclusions from a cross-sectional study like this one, especially one in which it is impossible to determine which came first: the heart attack or the vaping. So to tout the association between dual use and heart disease as a causal finding is bad enough. But cherrypicking findings that support a pre-determined conclusion, while dismissing those which do not support that conclusion, is sinking to the level of the tobacco industry which we once criticized for doing the very same thing.Original author: Michael Siegel
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What is a lie?, revisited.

by Carl V Phillips

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