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Mountain Vapor Blog

Welcome to the blog area of our site where we hope to keep you updated on the trends of the e-cigarette industry as well as product reviews.

Dr. Philip Cole Discovered the Decline in Cancer 20 Years Ago

Last week the American Cancer Society issued a press release that gained global coverage (here, here, here, here, here, here) by emphasizing a “23% drop in the cancer death rate since its peak in 1991.”  Sadly, the organization failed to credit a world renown cancer epidemiologist for discovering that trend two decades ago.  The Cancer Society has, in fact, steadfastly refused to credit the original work, even though it was published in the organization’s journal Cancer in 1996.  This blackout also extends to the society’s technical reports (latest version here).In the 1980s and 1990s, epidemiologists from the National Cancer Institute, the American Cancer Society and other organizations published hundreds of cancer studies, driven by a belief that cancer rates were surging.  The data showed otherwise: the cancer death rate by the late 1980s was, in fact, flat and poised to decline.  Only one epidemiologist appreciated this fact, and had predicted the decline – Dr. Philip Cole of the University of Alabama at Birmingham.In a 1996 report (abstract here), Dr. Cole attributed the decline in cancer deaths primarily to reductions in smoking that had begun in 1965, and to improvements in diagnosis and treatment.  Dr. Cole predicted that “the decline…is likely to continue for at least 20 years and may accelerate.” (my emphasis)Why does the Cancer Society embrace key elements of Dr. Cole’s landmark work, but defy the norm of formally citing the source?The answer may be that the organization is averse to acknowledging that the decline in cancer is linked primarily to the decline in smoking.Dr. Cole and I published a follow-up study in the Journal of Clinical Oncology in 2001, demonstrating that if lung cancer had never existed, the death rate in the U.S. from all other forms of cancer would have declined continuously, starting in 1950. (abstract here).    Dr. Cole is a world-renown epidemiologist whose insightful analysis two decades ago has proven prescient.  The American Cancer Society should recognize his scientific contribution. Original author: Brad Rodu
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“Bootleggers, Baptists and E-Cigarettes”

E-cigarette users should be concerned about proposed FDA regulations that may eliminate most brands of these potentially life-saving cigarette alternatives, leaving only those products marketed by large tobacco companies with the resources to complete expensive FDA applications.  Who is responsible for the pending e-cigarette regulatory nightmare? A brilliant analysis of e-cigarette regulation titled “Bootleggers, Baptists and E-Cigarettes” has been published online (here) by economists and legal scholars from Clemson University (Bruce Yandle), the University of Texas at Arlington (Roger Meiners), Case Western Reserve University (Jonathan Adler) and George Mason University (Andrew Morriss, now at Texas A&M).  A shorter version with Adler as lead author appeared last year in Cato’s flagship publication, Regulation (here).  I’ll use quotes from both in this column. According to Yandle and colleagues, “Durable regulation emerges most often when there are two distinctly different special interest groups that seek the same policy outcome. One group takes the moral high ground by pursuing a public-interested goal [Baptists] and gives the cooperative politician the ability to justify his actions on normative grounds. The other [Bootleggers], seeking the same policy outcome, is motivated by pecuniary interests, hopes to feather its nest, is often willing to share some of the gains with the politicians who deliver the goods, and does not generally conspire with its publicly interested counterpart that seeks the same regulatory goal.”Yandle developed this concept in 1983, and he recently authored a comprehensive book on the subject (here).  He labeled the two groups “in homage to the political pairing of unlikely interests that was successful in championing laws that shuttered liquor stores on Sunday…the two interest groups would never form a visible coalition in the strict sense of the word. They merely sought the same outcome and were willing to struggle mightily to succeed.  At the height of its success, this powerful pairing entirely shut down the legal sale of alcoholic beverages in counties, states, and—during Prohibition (1920-1933)—the nation as a whole.”  Yandle and colleagues identify the Baptists and the Bootleggers undermining the nascent e-cigarette market.  “Private and public health officials…are the Baptists in this story…  Based on what is known about the health effects of e-cig use, it would seem e-cigs might be hailed as an advance in public health insofar as they offer cigarette smokers a safer product.  Even small reductions in the number of smokers or the amount of tobacco products smokers consume would likely produce substantial gains for public health. Yet e-cigs have been greeted with scorn by health researchers who focus on what is not known about e-cig health effects rather than what is known.”The Bootleggers are a more diverse group.  They consist of cigarette manufacturers, which “havean incentive to either enter the e-cig market themselves, suppress competition from upstart e-cig manufacturers, or both.”  They are joined by “Pharmaceutical companies that make NRT products…They have benefitted from government encouragement that smokers use their products to aid in smoking cessation and government limitations on information on tobacco harm reduction through the use of e-cigs or smokeless tobacco products. [emphasis mine]  Insofaras e-cigs are an alternative for smokers to satisfy their nicotine cravings, they are a threat to the profitability of NRT products.  This is particularly so given recent research suggesting that NRT products do not help many smokers quit.”Perhaps more surprising, state governments are also Bootleggers, as “Tobacco sellers have become, in effect, tax collectors.”  The booty includes excise taxes that have skyrocketed over the past ten years, and payments made from smokers to cigarette manufacturers to the states courtesy of the 1998 Master Settlement Agreement.  Yandle et al. note that “Some states securitized all or part of the MSA cash flow by selling tobacco revenue bonds so they could immediately spend the present value of the future revenue.  The sale of tobacco bonds created a new group of Bootleggers—the bondholders and the state agencies that issued the bonds—with intense interest in the future fortunes of the tobacco companies, their sales, and any competitor that might reduce those revenues.”This is a powerful coalition arrayed against e-cigarettes.  “There is an obvious irony here.  To the extent that e-cigs provide a less hazardous alternative to consumers who seek to break their smoking habit, Bootlegger/Baptist induced regulations that limit e-cig competition and evolution bring with them a social cost measured in lost opportunities to improve human health.  Going further, regulatory actions that limit e-cig marketability introduce uncertainty for yet-to-be-discovered smoking alternatives that might also threaten the market share of traditional tobacco and smoking cessation products. For the sake of human health and freedom of choice, such innovation should be welcomed, not chilled.”The Campaign for Tobacco Free Kids, the American Cancer Society, the Centers for Disease Control, the National Institutes of Health and the Food and Drug Administration (Baptists) are aligned in a powerful coalition with tobacco and pharmaceutical manufacturers and state governments (Bootleggers) against e-cigarettes.  There is more than just irony here.  The e-cigarette is a “disruptive innovation” that not only “threatens the established order”, but holds the potential to help millions of smokers quit.  If this unholy alliance triumphs, public health is doomed.Original author: Brad Rodu
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Who will be duped by error-strewn ‘meta-analysis’ of e-cigarette studies?

Done badly, meta-analysis can be a neat and scientific-sounding way of aggregating junk to create new and more convincing junk

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Chewers and Dippers: Beware Bogus Mouth Cancer Claims by Dentists and Others

As a practicing oral and maxillofacial pathologist for over 25 years in the Southeast U.S. – also known as Smokeless Tobacco Country – I diagnosed over a thousand mouth cancers in smokers and heavy drinkers, but few in nonsmokers who used moist snuff or chewing tobacco.  Large epidemiologic studies conducted over the past 40 years confirm the much higher mouth cancer risk posed by cigarettes versus smoke-free products (hereand here).  Recognizing the public health impact of this data, I have given hundreds of lectures to dentists and other health professionals about the benefits of switching inveterate smokers to safer smoke-free tobacco – a scientifically validated form of harm reduction.  On occasion, I am confronted by a dentist who insists that they have seen in their practice many oral cancers caused by smokeless tobacco.  Given that smokeless tobacco users’ cancer risks are no higher than those of nonusers (discussed hereand here), the possibility of a dentist seeing numerous smokeless-related cancers is remote.  A dentist in Oklahoma recently made that claim to one of my tobacco harm reduction colleagues.To test the validity of that claim, we can focus on data involving men age 45 and older, as smokeless tobacco use among women is rare.  Incidence (new case) rates for mouth cancer in Oklahoma are unknown, but CDC data reveals (here) that the death rate from mouth cancer among men in Oklahoma is about 11% higher than the U.S. rate.  From that, we can assume that the Oklahoma incidence rate is also 11% higher.  According to the Surveillance, Epidemiology and End Results (SEER) program at the National Cancer Institute (here), the national incidence rate for mouth cancer is 23 cases per 100,000 men age 45+ years per year.  With census data showing there are 716,468 men age 45+ years in Oklahoma, applying the 11% adjustment we can extrapolate that there are 183 cases of mouth cancer in Oklahoma annually.If every case of mouth cancer in Oklahoma was diagnosed by the state’s 2038 dentists (here) – and that is highly unlikely – on average, each dentist would see one case every 11 years.  (This estimate is similar to one we provided in a research article in 2007 -- abstract here).  Some dentists might see an unusually large number of smokers and heavy drinkers in their practice, so they might see a few more mouth cancers.  But their totals would still be minuscule.The fact is, dentists and other general health professionals do not see high numbers of dippers and chewers with mouth cancer.Original author: Brad Rodu
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Credulous or cynical? Science journalists played yet again by e-cigarette pseudoscience and spin

I’ve just written to Sarah Knapton, Science Editor at the once-proud Telegraph titles. She has picked up one of the most idiotic American press releases ever written and turned it one of the most idiotic UK news stories ever written*: E-cigarettes are no safer than smoking tobacco, scientists warn – an outrageous headline buffed [...]Original author: Clive Bates

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Attack on E-Cigarettes as Gateway Products Draws from Same Old Playbook

Tobacco opponents who falsely claim that e-cigarettes are a gateway to smoking dissuade smokers from switching to safer smokeless products, leaving smokers at greater risk of fatal disease.The tobacco prohibitionists’ playbook was developed some 15 years ago, when Dr. Scott Tomar, of the CDC and the University of Florida, published a smokeless tobacco study (abstract here) with a pronounced gateway spin:“Some men may use snuff to quit smoking, but U.S. men more commonly switch from snuff use to smoking. Some smokers may use snuff to supplement their nicotine intake, and smokers who also use snuff are more likely than nonusers to try to quit smoking but tend to have less success.”    My letter to the editor (which was not published) noted:“Recently Tomar reported that 1998 National Health Interview Survey data show that snuff users are 3 to 4 times more likely to have quit smoking than have never users.  However, he also suggested that more American men switched from snuff use to smoking than vice versa.  We disagree with some of Tomar’s interpretations of the available data and offer alternative explanations for his findings.  “Tomar suggests that the data show that snuff use is a ‘gateway’ to cigarette smoking among adolescents and young men because ‘former’ snuff users were current smokers in this adult survey.  However, Tomar has inferred causation solely from temporal patterns (post hoc, ergo propter hoc).  If snuff had been a ‘gateway’ to smoking for some individuals, they would have been much older when they started to smoke than smokers without a snuff history.  The survey shows no such difference, suggesting that snuff was merely an adjunct for some smokers.  More importantly, Tomar did not evaluate the gateway possibility for other forms of tobacco use.  For example, survey data also reveals that pipe smoking was much more of a ‘gateway’ than was snuff.  Yet it is obvious that few adolescents initiate tobacco use by smoking a pipe.  A more reasonable interpretation of all the available information is that there is a subset of smokers who additionally have used other forms of tobacco.   “Tomar interprets his findings as evidence that switching smokers to ST is not a workable public health strategy.  We point out that for over twenty years the dominant public health message from tobacco prohibitionists has been that ST use is as dangerous as smoking.  This erroneous, even dangerous, message is reinforced by the mandated warning on packages of ST (“This product is not a safe alternative to cigarettes”).  Most smokers have accepted this message and continue to smoke.  Tomar’s study only confirms this and suggests further, and unfortunately, that some ST users also accepted it and switched to cigarettes.  Tobacco users need to be told the truth, that ST use is associated with only 2% of the mortality risks of smoking, and that it is an effective form of nicotine substitution for smokers unable to achieve abstinence.  Only then can a harm reduction strategy be tested and judged.”Prohibitionists today are using the same groundless gateway attack to vilify e-cigarettes, even as teen smoking is dropping at an unprecedented rate (here).Original author: Brad Rodu
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Mischaracterization of E-Cigarette Risks Skews Smokers’ Perceptions, Hurts Their Health

Accurate perception of the safety of e-cigarettes relative to cigarettes declined in the UK from 2013 to 2014, according to a study from King’s College and University College London. Leonie Brose and colleagues conducted a longitudinal web-based survey of smokers and ex-smokers from 2012 to 2014 (abstract here).  They found that 67% of smokers in the first two years perceived e-cigarettes as less harmful, but only 60% held that view in 2014.  That decline was mirrored in a 6-point increase (from 11% to 17%) in the percentage who believed that e-cigs and cigarettes are equally harmful.The researchers note that their results were in line with other UK surveys that “found significant increases in the proportion who considered e-cigarettes to cause about the same level of harm to the user as cigarettes from 2013 to 2015 (references here and here).”  They also observe that “the proportion of US smokers aware of e-cigarettes who perceived them to be less harmful than cigarettes was smaller in a survey conducted in 2012/2013 than in surveys conducted in 2010 (here).”Brose et al. speculate that the decline in perception of e-cigarettes as less harmful “may be due to a predominance of reports and discussions focusing on the risks of e-cigarettes without comparison to the much greater risks posed by cigarettes.”  I have often written about the danger of biased and misleading communications (examples here, here, here, hereand here).The UK researchers found that “accurately perceiving e-cigarettes as less harmful than cigarettes predicted subsequent use of e-cigarettes among respondents who had not previously tried an e-cigarette.”  In other words, understanding that e-cigarettes are safer than smoking is critical for motivating smokers to switch.  Conversely, scaremongering and obfuscation of relative safety discourages smokers from quitting their far riskier behavior.Original author: Brad Rodu
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Escaping the EU directive on e-cigarettes

I’ve written and presented many times on the utter mess the EU Tobacco Products Directive (TPD 2014/40/EU) has made of regulating low-risk alternatives to smoking: notably Article 20 that regulates e-cigarettes and Article 17 that bans snus.

EU legislation is especially ill-suited to regulating new disruptive and controversial technologies that regulators don’t understand – [...]Original author: Clive Bates

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Effect of Further Cigarette Tax Increases on Youth Smoking Appears Minimal or Nil

Most states and many cities have in the last 20 years initiated or raised tobacco excise taxes.  The fact that both the amount and rate of tax increases differ widely across jurisdictions provides economists valuable data to gauge the effect of these adjustments on smoking behaviors.Historically, higher cigarette taxes resulted in decreased smoking, especially among youths. In 2008, economists Christopher Carpenter and Philip Cook published a study concluding that “large state tobacco tax increases [from 1991 to 2005] were associated with significant reductions in smoking participation and frequent smoking by [high school students].” (abstract here).  They found that a one-dollar increase in the cigarette tax was associated with a 5.9 percent decrease in current (past 30-day) smoking and a 4.1 percent decrease in frequent smoking (in the past 20 days).  They used information from the Youth Risk Behavior Surveys for that period.  However, there is little evidence that cigarette tax surges over the last 10 yearsdiscouraged youth smoking, according to economists Benjamin Hansen (University of Oregon), Joseph Sabia (San Diego State University) and Daniel Rees (University of Colorado Denver).  They looked at state cigarette taxes and youth smoking rates during 2007-2013, and their results were published at the National Bureau of Economic Research (here). Hansen and colleagues found that a one-dollar increase in the cigarette excise tax was associated with a 0.7 percent increase in current smoking… and a 0.2 percent increase in frequent smoking.  Neither result was statistically significant.I have noted previously that youth smoking rates declined substantially over the past several decades (here).  Hansen et al. acknowledge that “youth smoking participation fell precipitously from the late 1990s to the mid-2000s.”  It now appears, however, that further increases in cigarette taxes may not produce additional reduction in youth smoking rates.Original author: Brad Rodu
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Is the Harvard E-Cigarette Buttery Flavor Study Credible?

A month ago, I warned vapers to avoid e-liquids containing buttery flavorings diacetyl (DA) and acetyl propionyl (AP, also known as 2,3-pentanedione) – chemicals associated with bronchiolitis obliterans, a serious, sometimes fatal lung disease seen in workers producing buttered popcorn.  This week, faculty at the Harvard School of Public Health reported that DA, AP and/or acetoin (a similar flavoring) are present in popular e-cigarettes’ aerosols.  The study, whose lead author is Joseph G. Allen, appears in Environmental Health Perspectives (abstract here). If true, the report would implicate major e-cigarette manufacturers, but there are irregularities in the researchers’ methods and findings.  Allen used a custom lab device “that drew air through the e-cigarette for eight seconds at a time with a resting period of 15 or 30 second [sic] between each draw. Eight seconds was chosen to make certain that each draw had adequate time for the entire contents to be forced out of the smoking device and through the sampling media…The samples were collected until the e-cigarette cartridges or cartomizers were exhausted, determined by the lack of visible emissions in the chamber.”  (emphasis mine)  In other words, the researchers used an aggressive procedure that vaped the samples dry.  Each “puff” was eight seconds long – an unrealistic length of time that could have produced higher-than-normal temperatures, combustion and smoke.This is significant because at least two previous studies by Fujioka and Shibamoto (here) and Pierce et al. (here)  found that cigarette smoke contains both DA and AP.  Pierce reported that the smoke of a single cigarette has up to 1,037 micrograms of DA and 165 micrograms of AP.  She noted that DA is approved as a cigarette tobacco additive in Germany and the UK, and AP is also permitted in the UK.  However, according to Pierce, this “strongly suggests that pyrolysis products of tobacco and other cigarette components comprise a substantial fraction of the [DA] and [AP] concentrations in mainstream smoke.”  If the Allen e-cigarette methodology generated smoke, their results could have been compromised. Another quirk of the Allen study was the resampling of “several of the same flavors from the same package (ie, testing two e-cigarette cartridges from the same pack)” for six of the flavors in the table at left.  It is troubling that the researchers failed to adequately explain why they ran these extra samples on only some products.  More importantly, they didn’t offer a valid explanation for a wide divergence in values.  The researchers found no acetoin in one Pina Colada sample, but it was present in other samples at 17, 46 and 130 micrograms.  One Classic sample had no detectable acetoin, while another had 38 micrograms.  Allen suggested that these differences might be due to “variable chemical doses.”  That explanation would be questionable if the sampled products were produced by major manufacturers with tight quality control systems, which seems to be the case here.While, inexplicably, the Harvard researchers did not identify the e-cigarette aerosol brands under study, the brands can be inferred from the data. They are likely:A – Mark TenB – VuseC – bluD – NJOYE – White CloudF – South Beach SmokeG – VolcanoH – Tasty VaporI – Unknown   Since Pina Colada is a blu e-cigarette from Lorillard, and Classic is a Mark Ten product from Altria, ingredients can be expected to be highly consistent among samples taken “from the same pack”, as was done in this study.  Allen and colleagues also suggested that variability could be related to the fact the researchers “relied on a visual determination of emissions of the e-cigarette in the chamber” to determine that the e-cigarette was “fully spent.”  A maxim in toxicology is to use methods that have been validated for the products and agents under investigation.  Eyeballing a stop point is not a validated method.    As I advised previously, vapers should only use liquids that are certified to be free of buttery flavors that are suspected respiratory toxicants.  However, laboratory investigations of e-cigarettes should use validated methods to assure credibility.  The results of the Harvard Buttery Flavor Study do not meet this standard.Original author: Brad Rodu
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Another Smokeless Tobacco Myth: The Dangerous White Patch

If you use smokeless tobacco for a long time and hold it in the same place in your mouth, the surface of your lip or cheek, called the mucosa, where the tobacco sits might thicken and turn white. A layer of white keratin is reacting to the irritating effect of the tobacco.  The reaction is similar to the development of calluses on a worker’s hand.  White patches in the mouth related to smokeless tobacco are nearly always benign.Physicians and dentists refer to these spots as “leukoplakia” – “leuko” meaning white and “plakia” meaning plaque or patch.  Regrettably, many health professionals don’t know that smokeless use is far safer than smoking and that a wealth of research shows that smokeless tobacco-related callouses hardly ever turn into anything more serious.  As an oral pathologist, I have decades of experience examining these patches and I have researched this issue extensively.  A 1990 study (abstract here) is typical; it showed that white patches were common in baseball players who chewed and dipped.  Upon biopsy, all were benign.  The link between white patches and cancer is virtually zero for dippers and chewers.  On the other hand, white patches in smokers are matters of concern.  Smoke permeates the lining of the mouth, throat, airway and lungs, delivering thousands of toxic agents.  As I discussed in a 1995 journal article, studies show that white patches in smokers are much more likely to be associated with mouth cancer (abstract here).     Too many doctors have blindly included smokeless tobacco in their anti-tobacco crusade without learning the facts. You ought to share this blog entry with your physician and dentist, and tell them that more information is available in my book (hereand here).Original author: Brad Rodu
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A billion lives?

A promising new documentary film is on the way to our screens: A billion lives –“a true story of government failure, big business and the vaping revolution”. See trailer above.

It gets its name from the often-quoted figure that one billion lives may be lost to diseases caused by smoking in the 21st Century. [...]Original author: Clive Bates

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Memo to the FDA: Please Correct Errors on Your Website

The FDA website includes several glaring errors on its Established List of Harmful and Potentially Harmful Constituents in Tobacco Products or Tobacco Smoke (here).  For example, the list wrongly identifies acrylamide as both a respiratory and a cardiovascular toxicant.  It is neither of these.  It is a probable human carcinogen, according to IARC, and it was correctly labeled in the list published in the federal register (here).  I recently collaborated with scientists from BAT to publish a comprehensive analysis of acrylamide in smokeless tobacco products from Sweden and the U.S. (here).  Our study showed that it is present in all products we tested, but “exposure… from consumption of smokeless tobacco products is small compared with exposure from food… or cigarette smoking.”Other agents on the list are also incorrectly classified: acetone, acrolein, acrylonitrile and aflatoxin B1.  Another, acetamide, was omitted completely.I described the problem to an FDA staffperson in late September, and she told me that a technical specialist would call back.  That did not happen, and the agency web page has not been corrected. Government communications, including web resources, should contain accurate information.Update, December 1, 2015: I am pleased to report that today the FDA corrected the webpage errors identified in this entry.  My compliments to agency officials. Original author: Brad Rodu
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Smoking and vaping among young people in England – reassuring new report

Children at play

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Fearless or clueless? Portland researchers defence of their flawed e-cigarette formaldehyde study

“Any idea what this is or what you do with it?“

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FDA and CDC Generate Smokeless Scaremongering

While the FDA and CDC refuse to acknowledge that smokeless tobacco causes almost no disease, agency staff have produced a fresh study (abstract here) showing that smokeless tobacco users have higher trace levels of nicotine and some contaminants than do smokers.  This meaningless finding (explained below) leads to grossly misleading headlines, such as “Smokeless Tobacco More Toxic Than Cigarettes, Study Says” from Time’s Alexandra Sifferlin. (Other recent tabloidish stories from this reporter include “Flavor Science Explains How You Can Hear the Way Your Food Tastes,” “I Tried It: A 6 am No-Booze Dance Party on a Boat,” and “Healthiest Halloween Candy”).   The media was served up a juicy quote from the FDA’s Brian Rostron, the study’s first author, in a press release (here): “exposure to nicotine and the cancer-causing tobacco constituent NNK were higher among exclusive smokeless tobacco users than exclusive cigarette smokers. This continues to put smokeless tobacco users at risk for adverse health effects, including cancer.”First, nicotine is not a toxin, and it doesn’t cause any “adverse health effects, including cancer.”  Second, while the study found higher levels of NNK among smokeless users than smokers, that does not support the claim that “smokeless tobacco users [are] at risk for adverse health effects, including cancer.”  Decades of epidemiologic studies involving millions of Americans show that smokeless tobacco users’ risks are infinitesimal.  British researchers estimate that U.S. smokeless-related cancer deaths are zero.Third, from 1999 to 2012, the period of the study, trace levels of NNK dropped by two-thirds in smokeless tobacco users.And finally, the results show that smokeless tobacco users had lower levels of mercury (in their blood) and arsenic (in their urine) than nonusers of tobacco.  In fact, smokers also had lower levels of these metals.  The study authors did not discuss the health implications of these findings.       Public health officials should focus on meaningful research and provide appropriate scientific context for their findings, rather than scaremonger via the media and deter smokers from transitioning to markedly less harmful smoke-free products.Original author: Brad Rodu
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FDA Authorizes Eight New Snus Products

The FDA today granted Swedish Match permission to market eight new snus products in the U.S.  This is the first time that new tobacco products have received a marketing order via the agency’s premarket tobacco product review process.  Swedish Match demonstrated (here) that the products are “beneficial to the population as a whole including users and non-users...[taking] into account the increased or decreased likelihood that existing tobacco users will stop using such products, and the increased or decreased likelihood that those who do not use tobacco products will start using them.”The products (here) consist of loose or pouch (portion) variants of Swedish Match’s General Snus:1.  Loose2.  Dry Mint Portion Original Mini3.  Portion Original Large4.  Classic Blend Portion White Large5.  Mint Portion White Large6.  Nordic Mint Portion White Large7.  Portion White Large8.  Wintergreen Portion White LargeSwedish Match filed a modified risk application for the products in June 2014, asking the FDA to change mandated warning labels (discussed hereand here).  No decision has been announced.    Original author: Brad Rodu
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Red Flag for Vapers: Avoid Some Flavoring Agents

As a health professional, I started telling smokers to switch to smokeless tobacco in 1994, based on decades of definitive epidemiologic evidence for the relative safety of smokeless tobacco.  But I was slow to endorse e-cigarettes as a reduced-risk option for smokers.  There is no parallel body of evidence for e-cigarettes, but then, there is no scientific evidence that would link vapor inhalation to cancer, heart attacks or strokes.  That is significant, but as a pathologist, I must consider whether long-term vapor consumption can cause respiratory problems.  There is little human experience with intense, long-term inhalation of propylene glycol, vegetable glycerin and other agents, including flavorings.  Konstantinos Farsalinos and colleagues in 2014 reported a laboratory analysis of 159 e-cigarette liquids from 36 manufacturers/retailers in six European countries and the U.S.  They found that almost 70% of the samples contained varying amounts of diacetyl (DA) and/or a similar flavor compound, acetyl propionyl (AP).  Although these substances naturally occur in fermented products like cheese and beer, they are also added to foods to provide a butter-like flavor.  They are generally recognized as safe by the FDA when added in small quantities to foods.DA and AP are known, however, to cause bronchiolitis obliterans, a serious, sometimes fatal lung disease in exposed workers (here, here, here), most notably in plants producing buttered popcorn (here).Farsalinos estimated the amount of DA and AP that vapers would inhale using the tested liquids.  He concluded, “The median daily exposure levels were slightly lower than the strict [National Institute on Occupational Safety and Hazards]-defined safety limits for occupational exposure and 100 and 10 times lower compared with smoking respectively; however, 47.3% of DA and 41.5% of AP-containing samples exposed consumers to levels higher than the safety limits.”Farsalinos’ study should have prompted e-liquid suppliers to abandon those agents. They have not.Raquel Rutledge, a reporter for the Milwaukee Journal Sentinel, recently worked with a Marquette University chemist to test liquids sold in local vape shops (here).  She “bought five e-liquids dubbed top-sellers by sales clerks… and had them tested for [DA and AP]… All five contained both chemicals.”  According to her story, some had high levels.Staff at the vape shops selling the liquids were unaware of the presence of these toxins.It is unacceptable for any vape shop to sell liquids with flavoring ingredients that are proven respiratory toxicants.  Vapers should only use liquids that are certified to be free of these agents.Original author: Brad Rodu
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Youth E-Cigarette Bans Increase Youth Cigarette Smoking

Smoking increased significantly among teens aged 12-17 in states that banned e-cigarette sales to minors compared with states that didn’t impose bans, according to a study in the Journal of Health Economics (abstract here) by Yale School of Public Health’s Abigail Friedman.Dr. Friedman used smoking data from the National Survey on Drug Use and Health (2002 to 2013).  She accounted for other youth smoking factors that vary among states, such as cigarette taxes, smoke-free air laws and medical marijuana laws.Dr. Friedman concludes: “Across the board, this paper’s analyses find that reducing e-cigarette access increases smoking among 12 to 17 year olds. The effect is large: over the 8 years preceding the first bans on e-cigarette sales to minors, smoking in this age group fell an average of 1.3 percentage points per two year period. The estimated 0.9 percentage point rise in smoking due to bans on e-cigarette sales to minors counters 70 percent of the downward pre-trend in states with such bans.”She notes, “This paper’s findings will prove surprising for many: policy discussions to date have not considered that banning e-cigarette sales to minors might increase teen smoking.  Assuming that e-cigarettes are indeed less risky to one’s health than traditional cigarettes, as suggested byexisting evidence on the subject, this result calls such bans into question.” (emphasis in original)Dr. Friedman makes a bold suggestion – one that is sensible and defensible: Ban e-cig “sales to those younger than 16 instead of 18, as initiation of regular smoking first spikes at the former age.”  E-cigarette companies and advocates support bans on e-cig sales to minors.  While health organizations like the American Cancer Society and Heart Association object to youth e-cig use, they oppose bans for two reasons: 1) e-cig companies support them, and 2) according to the health groups youth bans are not as effective as higher sales taxes and smoke-free or clean-air laws (discussed here). E-cigarette opponents have been quick to challenge the Yale study.  In a Winston-Salem Journal article, Dr. John Spangler of Wake Forest Baptist Medical Center called the study flawed because it “does not account for unmeasured factors, such as racial and ethnic population mix in states.”  This is a false charge, as the researchers adjusted “for the percent of [each] state’s population identifying as Black, as a different racial minority, and as Hispanic.”  These factors were noted in all three results tables. Other e-cig prohibitionists support the bizarre logic of University of California- San Francisco professor Stanton Glantz, who has argued in the past that banning e-cigarette sales to kids only makes teens want them more.  Dr. Friedman’s study turns this argument on its head: Banning e-cig sales increases teen smoking.Original author: Brad Rodu
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How Many Americans Smoke – 2014

In June, the Centers for Disease Control released data from the 2014 National Health Interview Survey, an annual report which has been used for half a century by the CDC to generate national smoking prevalence estimates.  The agency generally publicizes cherry-picked data on surveys to emphasize its mission to eradicate tobacco (e-cigarette use by teens, here), but it hasn’t commented on smoking rates.  In this column, I offer smoking prevalence estimates from the 2014 NHIS.The chart below shows the prevalence of current smoking among adults in 2005, 2010 and 2014. The CDC had previously reported on smoking trends from 2005 to 2010 (here), so we can compare that period with 2010 to 2014, during which time e-cigarettes gained traction in the U.S.  Among men, smoking declined about 10% from 2005 to 2010, and about 12.5% during the latter four years (the diagonal bars in the chart).  The earlier decline among women was modest (4.4%), but the drop from 2010 to 2014 was an impressive 14.5%.  The prevalence of former smoking was relatively stable for men and women in all years, which belies the notion that e-cigarettes created a surge in quitting.  The declines in current smoking are likely a reflection of the increasing percentage of Americans who have never smoked and the long decline in teenage smoking (hereand here).    In summary, in 2014 the number of Americans who smoke dropped below 40 million for the first time in the 50 years that the NHIS has provided smoking statistics.  The number of former smokers in 2014 was 52.2 million.These numbers do not support the claim of tobacco prohibitionists that e-cigarettes are “re-normalizing” smoking.  Rather, the decline in smoking continues.Original author: Brad Rodu
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