CDC, Sandman, and finding an “honest” appraisal of e-cigarettes

Electronic cigarette versus normal cigaretteNews releases on studies should put the evidence they report in context. But how do you judge a release when there isn’t enough… evidence, that is?

In April, the US Centers for Disease Control and Prevention (CDC) announced youth tobacco survey results with this headline and subhead:

E-cigarette use triples among middle and high school students in just one year

Hookah use doubles; no decline seen in overall tobacco use among middle or high school students

A Promising Candidate for Most Dangerously Dishonest Public Health News Release of the Year” is the sharp critique of the CDC statement from risk communication expert Peter Sandman, Ph.D. His nearly 11,000-word rebuke dissects the CDC release, the news conference performance of CDC Director Tom Frieden, M.D., M.P.H, and a number of the resulting news articles. His key point: the CDC should have trumpeted the decline in regular cigarette smoking reported by the survey of middle and high school students, instead of just blaring alarms about rising e-cigarette use and equating it with regular smoking, given the sharp disparity in health risks.

“But for sure teenage smoking is down. That’s wonderful news, made only a little less wonderful by the fact that teenage vaping is up,” Sandman wrote.

Is it dishonest to put all the attention on reported spikes in e-cigarette use (at least once in past 30 days) between 2013 and 2014 (4.5 percent to 13.4 percent among high school students; 1.1 percent to 3.9 percent among middle school students) and then to say this jump and an increase in hookah use nullified declines in smoking of regular cigarettes, without spelling out comparable year-to-year comparisons of cigarette smoking rates or emphasizing the stark differences in health risks?

If HealthNewsReview had taken on the CDC release, we likely would have dinged it for burying the good news about fewer middle and high school students smoking tobacco cigarettes. The release also would have been knocked for equating cigarette smoking (a well-documented hazard which the CDC itself terms the “leading cause of preventable death”) with e-cigarette use (a poorly understood hazard, but certainly far less harmful for users than tobacco smoking). And including e-cigarettes within the term “tobacco use” is likely to confuse many readers who don’t scrutinize the fine print. Still, a surge in e-cigarette use by children and teens is worthy of broad attention, even though its full meaning is unknown.

But a summary judgment of the “honesty” of the CDC release is a tough call because the evidence that exists doesn’t line up neatly with the fundamental questions we all have. The survey results give us snapshots of what kids are doing. But are the trends good or bad? That’s where too much of the arguing is rooted in beliefs and clouded by uncertainties.

Let’s nail down some specifics:

  • When a cigarette smoker uses e-cigarettes as part of totally quitting, that’s great: their risk of many diseases starts dropping toward the levels of nonsmokers.
  • When a cigarette smoker switches to sustained use of e-cigarettes, that’s far healthier than continuing to smoke, but the long-term effects of e-cigarette vapor are not clear, so it is certainly not as healthful as quitting entirely.
  • When a nonsmoker starts using e-cigarettes, that will almost certainly lead to nicotine addiction, in addition to exposure to those poorly understood components of e-cigarette vapor. The evidence about ultimate health consequences is spotty.
  • When a nonsmoker starts using e-cigarettes and then switches to smoking, that’s as bad as just diving right into smoking cigarettes. The scary scenario is nicotine addiction from using e-cigarettes leading to tobacco smoking that otherwise might not have occurred.

But since we don’t know how many people are on each of these paths, i.e. how many people use e-cigarettes to move away from tobacco versus how many people pick up e-cigarettes who would have otherwise remained nonsmokers, we cannot calculate the total public health consequences of the youth survey results the CDC is reporting.

So how should journalists approach the story of e-cigarette use by kids, and how should readers understand the stories they report?

First, be aware of the long-running battle between public health experts who emphasize the harm reduction potential of e-cigarettes (i.e. nicotine addiction is nothing compared to the massive increase in risk of heart disease, cancer and other maladies caused by the tar and other components of tobacco) and those who contend that replacing one form of nicotine addiction with another, albeit far less deadly, is unacceptable, especially since the chemical components of e-cigarette vapor are poorly documented and their lifetime effects are largely unknown.

Second, these partisan passions can lead to muddling of facts with beliefs, so journalists must press sources to draw lines between what the evidence really shows… and what it just suggests — i.e. what they believe while they wait for more evidence.

Third, when public health experts or advocates call for new policies, such as more or less regulation or taxation of e-cigarettes or regular cigarettes, be aware that “common sense” is a poor guide. As long as tobacco cigarettes are more expensive and less available than e-cigarettes, it’s almost certain that not very many people will switch from vapor to tar-filled smoke. However, harsh taxation and regulation aimed at e-cigarettes could push vaping nicotine addicts in a deadly direction (i.e. toward tobacco).

And if you like to dream up public health nightmares, it’s not unthinkable that fostering an aura of expensive danger around tobacco cigarettes might enhance their rebel allure. “Ooh, look at bad boy Johnny. He’s smoking real cigarettes!” After all, once-secret tobacco industry documents revealed marketers used exactly that twisted logic to snag vulnerable youth. Some studies even indicate that some PSAs created by tobacco companies that appear (to staid, nonsmoking adults) to push an anti-smoking message could perversely draw some teens toward smoking.

The HealthNewsReview.org criteria calling for independent sources, quantification of harms and benefits, and a clear grasp of the quality of studies are guideposts that are particularly helpful to journalists facing the writhing mass of uncertainty and opinions enveloping stories like this recent CDC study on youth tobacco use.

Addendum:

The folks at Slow Medicine today pointed us to some recent commentaries that attempt to shape clinical/public opinion regarding e-cigarettes:


Andrew Holtz is one of our longtime contributors and a past president of the Association of Health Care Journalists. He has written extensively about tobacco issues — you can see more of his work at HoltzReport.   

You might also like

Comments (4)

We Welcome Comments. But please note: We will delete comments left by anyone who doesn’t leave an actual first and last name and an actual email address.

We will delete comments that include personal attacks, unfounded allegations, unverified facts, product pitches, or profanity. We will also end any thread of repetitive comments. Comments should primarily discuss the quality (or lack thereof) in journalism or other media messages about health and medicine. This is not intended to be a forum for definitive discussions about medicine or science. Nor is it a forum to share your personal story about a disease or treatment -- your comment must relate to media messages about health care. If your comment doesn't adhere to these policies, we won't post it. Questions? Please see more on our comments policy.

Glen Appleton

June 12, 2015 at 10:28 am

Quote: [When a cigarette smoker switches to sustained use of e-cigarettes, that’s far healthier than continuing to smoke, but the long-term effects of e-cigarette vapor are not clear, so it is certainly not as healthful as quitting entirely.]

The word “certainly” should not be used in this context. There is a percentage of smokers that quit cold turkey that will turn to other unhealthy habits (such as overeating) to compensate for the oral fixation, hand to mouth habit, and mild depression onset by the lack of nicotine and MAOIs they were getting from cigarette smoke. These are often overlooked in the analysis of smoking cessation, but they are likely not trivial when considering the health benefits of switching to a safer nicotine product over complete cessation.

Quote: [When a nonsmoker starts using e-cigarettes, that will almost certainly lead to nicotine addiction, in addition to exposure to those poorly understood components of e-cigarette vapor. The evidence about ultimate health consequences is spotty.]

Again, the work “certainly” in the context of nicotine addiction is not appropriate. There were years of research with NRT products that demonstrated that addiction (dependence) to nicotine isolated from the MAIOs and other reinforcing chemicals in cigarette smoke was either not experience by the test subjects, or was experienced at a very low rates. Recent studies on vapor products (which use the same nicotine and other ingredients of NRT) have reinforced those results.

Quote: [When a nonsmoker starts using e-cigarettes and then switches to smoking, that’s as bad as just diving right into smoking cigarettes. The scary scenario is nicotine addiction from using e-cigarettes leading to tobacco smoking that otherwise might not have occurred.]

The occurrences of vapor product users switching to combustible cigarettes is statistically insignificant. Furthermore, there’s no possible way to know that if vapor products didn’t exist, these same people wouldn’t have just gone directly to smoking, which is a much more likely scenario.

charlie

June 12, 2015 at 11:34 am

Nicotine patches and gum have been sold over the counter for 18 years in the U.S. because it is NOT addictive.

Murray B

June 17, 2015 at 1:49 pm

This is a more balanced article than most but every study I have heard about indicates that nicotine by itself is not addictive. That is why we can easily buy things like nicotine gum. Only when nicotine is combined with other things in cigarette smoke does it appear to become addictive. Most fluids used in these evaporators do not contain nicotine but those that do usually do not contain the other things that could make nicotine addictive. A former smoker could be a nicotine addict but a non-smoker that vapes nicotine is unlikely to ever become addicted to the drug.

Hans Schmidt

June 21, 2015 at 8:23 am

Quote: [When a nonsmoker starts using e-cigarettes, that will almost certainly lead to nicotine addiction]. Wrong. A lot of kids experiment with e-cigarettes and only a small minority become weekly users. This is just the opposite of “one cigarette and you are hooked for a lifetime”. NRTs are not addictive because nicotine is not addictive. A study of Prof. Etter concludes: “Some e-cigarette users were dependent on nicotine-containing e-cigarettes, but these products were less addictive than tobacco cigarettes. E-cigarettes may be as or less addictive than nicotine gums, which themselves are not very addictive.”