Joe Nocera’s contentious e-cigarette crusade

paul raeburn photoWe’re very pleased to feature the following guest post by Paul Raeburn, a journalist and blogger whose writing has appeared in The New York Times Magazine, Discover, Scientific American, and other leading outlets. He’s also the author of five books, including the forthcoming The Game Theorist’s Guide To Parenting: How the Science of Strategic Thinking Can Help You Deal with the Toughest Negotiators You Know–Your Kids (2016). He tweets as @praeburn.


On Nov. 3, Joe Nocera bid farewell to his job as an Op-Ed columnist at The New York Times with what he called “a few last opinions.” One of those opinions was this: “There is no doubt [e-cigarettes] could save lives if adult smokers could be encouraged to make the switch.”

Nocera (who is moving to the sports pages at the Times) wrote about e-cigs in a series of eight columns stretching from December, 2013 to October 17th of this year. In those columns, he argued strenuously that the public health community should embrace the e-cigarette to help stop smoking. “It has the same look and feel as the lethal product…but the ingredients that kill people are absent,” he wrote in that first column in 2013. And his stance has never wavered.

e-cigaretteAt first glance, Nocera’s position seems obvious: If smokers switch to a safer substitute to satisfy their nicotine craving, fewer will die from smoking. The problem is that this isn’t a matter of opinion. We need the facts: Will e-cigs cut the death rate from lung cancer and heart disease? Nocera is certain the answer is yes, but the truth is that we just don’t know.

The findings so far on the risks and benefits of e-cigs are preliminary, but they raise the possibility that e-cigs might not help smokers quit. There is also evidence that nicotine is harmful to health, even without the other ingredients in tobacco. And preliminary data suggests e-cigs might encourage kids to smoke, a development that could outweigh any advantages for adults, if true. The net result could be that e-cigs lead to more deaths, not fewer.

None of this research is conclusive. But more studies will be done, and the implications of e-cigs for the public health may soon become clear. And that underscores the main problem with Nocera’s reporting: He is expressing opinions on matters of fact. He is not entitled to an opinion on whether e-cigs might save lives any more than he is entitled to an opinion on whether the sky is blue or the sun sets in the west. The research will give us the answers. Until then, opinions on policies are fair game, but not opinions on matters of fact.

E-cigarettes–which can resemble conventional cigarettes or ball-point pens–use a battery-powered heating coil to vaporize liquid nicotine and other additives so they can be inhaled. E-cigs give users a quick nicotine fix without the carcinogens in cigarette smoke.

It’s possible that they will help millions of smokers give up Marlboros. Or maybe they won’t. Or smokers might choose to use both–cigarettes at work, and in the evening, a cocktail with a pomegranate e-cigarette (a flavor offered by e-cig maker NJOY).

“The Nocera fantasy is that the only thing that happens is smokers switch to e-cigarettes, and a bunch of them quit smoking cigarettes,” says Stanton Glantz, a professor of medicine at the University of California, San Francisco, and a leading tobacco researcher and activist. But that’s not the whole story.

According to the Campaign for Tobacco-Free Kids, existing research on the use of e-cigarettes as an aid to quitting “provides mixed results.” Smoking an e-cigarette is less harmful than smoking a conventional cigarette, so substituting an e-cig for a Marlboro is a good step. But “e-cigarettes could ultimately reduce the number of smokers who would otherwise quit if smokers continue to use them in addition to, and not instead of, regular cigarettes.” And light and intermittent smokers are at greater risk for heart disease and lung cancer than non-smokers.

Again, the research is not conclusive–but it challenges Nocera’s certainty about the benefits of e-cigs. The value of e-cigs is not a matter of opinion.

The situation with kids is likewise disturbing, Glantz says. “We know that youth use of e-cigarettes is exploding. That’s well documented,” he says. And preliminary evidence suggests that “a substantial fraction of kids using e-cigs likely would never have picked up a cigarette.” (Researchers can predict with reasonable accuracy which kids are likely to start smoking, considering such factors as whether a best friend smokes.)

In a response to Nocera’s Oct. 17 column, Matthew L. Myers, the president of the Campaign for Tobacco-Free Kids, wrote that e-cigs must be “marketed so they do not re-glamorize smoking among young people…The concern about youth is serious. In 2014, over a quarter of a million youths who had never smoked a cigarette had used e-cigarettes.” Will e-cigs encourage those young people to smoke conventional cigarettes? We don’t know. But we should know before hailing e-cigarettes as a public-health bonanza.

Additionally, although the nicotine vapor from e-cigs has fewer carcinogens than tobacco smoke, it is far from safe. Nocera has written repeatedly, including in his farewell column, that smokers “smoke for nicotine, but they die from the tar.” The implication is that nicotine is relatively safe. But it isn’t.

In addition to nicotine vapor, e-cigs produce formaldehyde, acetaldehyde, acrolein, volatile organic compounds such as toluene, tobacco-specific nitrosamines, and metals like nickel and lead, according to the Campaign for Tobacco-Free Kids. It acknowledges that the levels of these toxins are lower than what’s found in cigarette smoke, but e-cigs still carry health risks.

Finally, while e-cig makers deny they are targeting children, e-cigs “often contain flavorings including fruit and candy flavorings that are not permitted in regular cigarettes,”  according to the Campaign for Tobacco-Free Kids. It said that in January, 2014, researchers had identified 7,700 e-cigarette flavors available online. That’s not proof that e-cig makers are targeting kids; far from it. But it does, once again, poke holes in Nocera’s certainty that e-cigs are good for the public health.

The point is that what’s needed here are controlled studies–not reporters’ opinions. Nocera is not the only columnist or commentator who has made the mistake of confusing opinions and facts. Anyone who professes not to “believe” in climate change or evolution is doing the same thing. Climate change can be measured; it’s not a question of belief. Nor is evolution.

Reporters covering medical stories should keep this in mind. It’s fine to speculate, and it’s fine for op-ed columnists to have strong opinions. But it’s not appropriate for columnists to let opinions substitute for facts, just because the facts happen to be murky.

In a lengthy email, Nocera explained his interest in e-cigs. “I don’t smoke, and never have,” he wrote. Two of his grown children smoke, he wrote, and “I dearly want them to quit.” For him, e-cigarettes are the kind of long sought “harm reduction” that can reduce illness and death in smokers even if they are unable to quit.

“There are very few voices in the mainstream media that support the harm reduction potential of e-cigarettes–which is one reason I’ve stayed at it,” he wrote. “I think it is such a huge potential life-saver that I want to shout it from the rafters. I don’t feel apologetic about that.”

Nocera also addressed a question regarding his wife’s affiliation with the tobacco maker Philip Morris. From 2002-2008, according to her LinkedIn profile, she was director of external communications for Altria, the parent company of Philip Morris USA, which launched an e-cigarette brand last year. “She has never had a thing to do with e-cigarettes,” he wrote. “I came by my opinion honestly and honorably.”

This isn’t the first crusade Nocera has mounted. He has written multiple columns critical of the National Collegiate Athletic Association, and from mid-2013 until the middle of 2014 he published The Gun Report, an attempt to tally all of the gun deaths in the country. It’s strong reporting from a respected journalist.

He should use the same care when opining on e-cigs. Reducing smoking-related cancer and heart-disease deaths is a campaign worthy of Nocera’s tenacity. But a more skeptical and careful approach to the risks and benefits of e-cigarettes would serve him well in that campaign.

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Comments (16)

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Tom Tom

November 18, 2015 at 7:44 am

“He is not entitled to an opinion on whether e-cigs might save lives any more than he is entitled to an opinion on whether the sky is blue or the sun sets in the west. ”
The sky is blue, sun sets in the west, ecigs save lifes. Read more, think more, write a little less until you educate yourself.

Douglas Hicks

November 18, 2015 at 9:27 am

Murky facts?
E-cigarettes should be promoted as a smoking cessation.
Prof Linda Bauld – University of Stirling, Stirling, UK
http://bit.ly/1QJSXqa
——————————————–
E-cigarettes: an evidence update – Publications – GOV.UK
http://bit.ly/1Nsdf5K
————————————-
How and why I changed my mind on e-cigarettes
Jim McManus.
Director of Public Health in Hertfordshire
https://jimmcmanus.wordpress.com/2015/11/15/how-and-why-i-changed-my-mind-on-e-cigarettes/
—————————————
What to Advise to Respiratory Patients Intending to Use Electronic Cigarettes – Riccardo Polosa – Discovery Medicine
http://bit.ly/1MfSPeM
—————————————
“[e-cigs…] pose very small or maybe no health risks, they do not attract new users to nicotine so far, and they have the potential to help smokers to switch to something safer”
Professor Peter Hajek, Director of QMUL’s Tobacco Dependence Research Unit, talks about his research on e-cigarettes.
http://bit.ly/1uTEY2b

Ryan R

November 18, 2015 at 1:53 pm

If it makes drug companies money, it’s ‘Safe & Effective’
If not, it will always be ‘unproven’, ‘uncertain’, ‘unknown’

https://www.youtube.com/watch?v=YQZ2UeOTO3I

cigarbabe

November 18, 2015 at 2:43 pm

Why is it that those who seem to be biased against THR/ nicotine /ecig use always claim there is an alarming absence of data concerning their fears about what harms there may be? As a former three pack a day 37 year smoker who tried many many times to quit with the usual products {and failed} I was finally able to quit in just three days using an early ecig device. I’ve been using it for more than 5 years and my doctors are thrilled with the improvements in my lung function. I have yet to see any negatives from using my devices over all this time save for the occasional “vapors tongue”. Since another commenter posted links to studies which you claimed we have no knowledge of I’ll refrain from reposting them. Please immerse yourself in these studies and you should come to the same conclusions as Nocera did….unless you simply refuse to accept it like most of the PH entities.

John Conner

November 18, 2015 at 6:13 pm

You state there is no research… Did you bother to look for any? There is more every day clearly showing e-cigs offer a fraction of the harm of traditional cigarettes, if any at all. Public Health England, Rutgers School of Public Health, CDC, NCBI, American Center for Cancer Research, Onassis Cardiac Surgery Center in Greece, Gilbert Ross MD- medical and executive director of the American Council on Science and Health, International Journal of Environmental Research And Public Health, Professor Igor Burstyn of Drexel University School of Public Health, American Association of Public Health Physicians, Health New Zealand, University of Auckland and University of Geneva have all released studies finding little to no harm, greater rates of smoking cessation, nicotine dangers, and an overall dismissal of everything stated in your article. The formaldehyde study you cite was disproved some time ago (by the head researcher involved, no less), as the devices were tested at temperatures no human would use or enjoy. This article is simply more fear-mongering and ignorance at the cost of hundreds of thousands of lives.

Michael

November 18, 2015 at 6:58 pm

Ban the e-cigarette is just killing smokers and children that will smoke regular cigarettes in the future… How simple is that. There is no known proved case that somebody got harmed by the vape of an e-cigarette… None in 10 Years! If you know a case, please provide the facts to allow other to verify the results. By the way, if smokers should switch to the e-cigarette to gain a better health there is a need to make it attractive and than you need a good “taste”. If it taste like “dead food” or nothing… Ok.. What should i assume? 10.000 dead smokers more per year?

Releasing Studies with kids and breathing problems from Hong Kong, the city with the highest air pollution, sure. Pointing to a study that an “overheated” e-cigarette can produce toxins and at the same time? Nobody can consume this but sure, if you give a child a burned burger which contains even more toxins or just a salami pizza (Salami can cause cancer… Ups). This is ok? Yep, makes sense. Coming up with a study that Vape “can” contain “bad” stuff but forget to mention that this can be compared to regular exhaled air, which can be also deadly by the way. 50mg Nicotine is bad and can be deadly… Based on a Study from… Oh, close to the Civil War (1856)! How can somebody call this serious concerns by still ignoring the latest results from science.

Let me make it clear, e-cigarettes should be not be sold to children.. But the rest of the regulations ist just mad, any other product like coffee, soft drinks or food would fail with the same “level” of regulation.

Sorry but for me this is only a inquisition, most released “results” are just cherry picking to hide the most relevant facts and to “keep” and “protect” other interests. The health of the people is not the interest and this is not just my personal opinion. I still have to ask how a lot of people can get sleep at night… Iam also sure Nocera will get a lot of good and healthy sleep.

Just read a few articles from the UK incl. Cancer Research UK where saving people seams to have a higher priority.

Paul

November 18, 2015 at 7:47 pm

The levels of carcinogens from ecigs have been proven to be minimal/inconsequential when tested properly. They absolutely help people quit smoking and the witch hunt has produced nothing of substance so far.

castello2

November 18, 2015 at 11:41 pm

You may need to do a bit more research. http://tobaccoanalysis.blogspot.com/2014/10/new-research-suggests-that-anti-smoking.html

Marc Beishon

November 19, 2015 at 6:39 am

I think you’re being a bit unfair to Nocera. He does cite experts in his columns, and there has been no evidence that e-cigs are anything but far less harmful than tobacco cigarettes, and also no evidence that they are being taken up by non-smokers. Of course the gold standard is conventional smoking cessation methods and of course we want controlled trials, but there aren’t many in train and they are hard to generalise to a population level. In the meantime it would seem all the evidence points to benefits to public health of e-cigs.

Chris Hughes

November 19, 2015 at 8:17 am

“And preliminary evidence suggests that “a substantial fraction of kids using e-cigs likely would never have picked up a cigarette.” (Researchers can predict with reasonable accuracy which kids are likely to start smoking, considering such factors as whether a best friend smokes.)”

Both of these points are absolutely false. Mr. Glantz would like to obfuscate the CDC data to promote whatever agenda it is that drives him by conflating kids that take a single puff of an ecig with kids that are regular users of the product. Of that latter category, I believe the CDC data shows that over 90% were previously smokers. The second point about predicting youth smoking is false. Were it true, schools would no doubt be required to give kids tests to identify the smokers, and monitor them.

The fact remains that there is an ever expanding body of science globally that clearly shows these products are 95%-99% less harmful than smoking combustible cigarettes. The bigger picture is that much (certainly most) of the opposition to these products comes from individuals and groups with close ties to the same pharmaceutical companies that make, market, or hold patents on nicotine replacement products such as patches/gums/lozenges/medications. Virtually nobody with these ties will ever volunteer that information. For example, I’ve seen information indicating that Mr. Glantz has done work for Pfizer. The Campaign for Tobacco Free Kids certainly receives a tremendous amount of funding from Pfizer, GlaxoSmithKline, and Johnson & Johnson, yet Matt Meyers stubbornly refuses to disclose that conflict. Ditto for the American Cancer Society, the American Lung Association, the American Academy of Pediatrics. If you strip away the voices of individuals and organizations with likely conflicts of interest, it significantly effects the overall dialogue.

And in a society where researchers live and die by their next grant, is it surprising that a dearth of “conclusive” studies exists? I was taken aback by the research presentations at the FDA workshops this year. Virtually all of them concluded with “but this issue still requires more research.” It’s almost like almost every piece of research presented was carefully crafted to be a sales pitch for their next grant application. That’s just the world that we live in.

“Finally, while e-cig makers deny they are targeting children, e-cigs “often contain flavorings including fruit and candy flavorings that are not permitted in regular cigarettes,””

That’s an absolute joke. I own a small ecig shop and my best selling flavor by far is a strawberry gummy candy with menthol flavor. I do not sell online, and also don’t sell to anyone under 20 (even though my state does not prohibit sales to minors). Customers have to be 20 to even enter my store. Never mind the fact that I’m a 50 year old man and the 3 flavors I am currently using pomegranate/raspberry flavored, strawberry banana flavored, and lemon poundcake flavored. The entire notion of youth appeal was turned on it’s head a couple years ago with a study by Saul Shiffman that pretty clearly showed that youth actually had a preference for tobacco flavored eliquids, and single malt scotch eliquids (go figure, two things they are legally prohibited from having), yet adults preferred fruity and candy flavors. This accusation is nothing more than advancing a position based on sound bites rather than science.

I could criticize this article further in a variety of ways, but at the end of the day it’s just part of the background drone of the radical “quit or die” movement, that completely opposes any form of tobacco harm reduction for smokers. People that would have no problem with smokers using nicotine patches, or fruity flavored nicotine flavored gum (what utter hypocrisy) for decades, because it pleases the sponsors.

Angel Tibbs

November 19, 2015 at 11:06 am

Unlike Tobacco Control, who has a vested interest in being funded to continue to pretend to combat smoking, Nocera has actually talked to real ex smokers who now vape. The reason TC is getting it horribly wrong – and inadvertently protecting cigarettes, the proven killers – is that they aren’t listening to us. I am 55, I do like pomegranate, but Njoy has way too high a nicotine content for me. Until TC control listens, and continues to pontificate rather than pursuing true science on these, rather than foregone conclusions based only on tobacco cigs, they’ll never get it right. But I will tell you this: nine million vapers in this country would NOT be quitting smoking without vaping. They would still be smoking. How is that rational, when we know ad nauseum what smoking is proven beyond any doubt to do?

John

November 19, 2015 at 12:38 pm

Oh the kids… same old story… take flavored vodka off the shelves first

Paul Raeburn

November 19, 2015 at 2:27 pm

The comments demonstrate precisely the point I was trying to make in my post. Nocera is certain that e-cigs will save lives. So are some of those who have commented. But the research does not yet show a clear benefit. Yes, smoking one e-cigarette is probably less harmful than smoking one cigarette. But do smokers use e-cigs to replace cigarettes, or do they smoke both and thus smoke more? We don’t yet know.

Further, we now see ads for “smoking”–meaning ads for e-cigs–all around us. We banned ads for smoking and now they are back, because e-cigs are not regulated. Will the ads for e-cigs glamorize smoking and lead kids to smoke either e-cigs or cigarettes? Will e-cigs help some smokers quite? Sure. But how many? And will the quitters outnumber the kids who are induced to smoke by the ads? We don’t know. My point is that Nocera–and the e-cig enthusiasts among the commenters–should be far more tentative until we know the facts.

    Jeff McMahon

    November 19, 2015 at 9:07 pm

    Facts:
    1. The concentration of toxins in e-cigarette vapor is orders of magnitude lower than in cigarette smoke. Benzoapyrene, the prime carcinogen in cigarette smoke, is absent. The levels of heavy metals and aldehydes are low and comparable to amounts contained in an FDA-approved nicotine inhaler: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4154473/
    2. Despite gateway and renormalization speculations, smoking is at an all-time low among children and adults since the rise of e-cigarettes: http://www.hngn.com/articles/150513/20151114/cdc-u-s-smoking-rate-drops-record-low.htm
    3. 6 RCTs have found them to be associated with cessation and reduction: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4378973/
    4. E-cigs are used almost exclusively by current and former smokers: https://www.ucl.ac.uk/news/news-articles/0514/200514-e-cigarettes-help-smokers-to-quit
    5. There are many different types of e-cigs, and usage patterns. Daily use of open tank systems does increase the likelihood of quitting (http://www.ncbi.nlm.nih.gov/pubmed/25896067) Non-daily use of cigalikes does not. The majority of vapers responding here are probably using the former. The majority of observational studies that are being used to claim that e-cigarettes impede cessation are probably measuring the latter. Studies with measurements more precise than “ever use in past 30 days” tend to find a benefit (see 7). They also show the negative correlation associated with non-daily use seen in less precise studies.
    6. 1 out of 5 people who quit last year did so with the help of an e-cigarette: http://www.cdc.gov/nchs/data/databriefs/db217.htm
    7. Compared to daily cigarette smokers, recently quit smokers are more than four times as likely to be daily users of e-cigarettes: http://ntr.oxfordjournals.org/content/early/2015/11/02/ntr.ntv237.abstract

    Opinions corresponding to facts above:
    1. Saying toxins are merely “lower” undersells it. The way Myers rattles off scary-sounding chemicals is slanted. We’re talking medicines-level exposure to toxins. We’re not in the ballpark of cigarettes. Hence, people assume they will save lives. It’s not the biggest logical leap, but I understand where you’re coming from. Newer devices also feature temperature control which probably tames the release of aldehydes and acrolein. I’ve yet to see a study touch on this.
    2. Smoking should be going up, but it isn’t. No evidence of a gateway. Not practical to assume there is one.
    3. RCTs aren’t necessarily appropriate to measure e-cig effectiveness in the real world, but still show a benefit.
    4. Worries about daily uptake by non-smokers have not materialized.
    5. A clear pattern of successful vaping has emerged. Do it every day with an open system (which delivers nicotine comparable to a cigarette) and you’re more likely to quit. PH could be much clearer on this. To treat vaping as a homogenous entity and say “we don’t know” ignores the more precise evidence we do have.
    6. Vaping seems to work for a lot of people.
    7. Again, I don’t think saying “we don’t know” here is appropriate. The evidence is emerging. This is in agreement with the population data showing smoking going down as vaping rises. The gateway hypothesis and the negative cessation hypothesis are not.

    Marc Beishon

    November 20, 2015 at 4:39 am

    Paul, the certainty about saving lives is embodied in the very quote you have from Nocera:

    “There is no doubt [e-cigarettes] could save lives if adult smokers could be encouraged to make the switch.”

    Note the qualification – “…if adult smokers could be encouraged to make the switch.” You are conflating two issues – the safety of e-cigs and the behaviour of smokers. We all know how hard it is to quit smoking and of course there will be questionable benefits to dual users in terms of harm reduction. But nicotine replacement therapy – which is essentially what e-cigs are – delivers a substance (nicotine) that has been extensively studied in humans. There may be long term health issues with vaping and the presence of other substances – we won’t know these for many years. The key issue is whether on the balance of evidence now it is better to vape than smoke tobacco cigarettes, given that for many quitting completely is too hard.

    Chris Hughes

    November 21, 2015 at 8:27 am

    Research? There has been plenty. Certainly enough to say that there is a scientific consensus forming that vapor products are 95% to 99% less harmful than combustible cigarettes. If you don’t think 95% is less significant, I suggest you run on 5% of your weekly salary for a month, then get back to us. Also, we know from recent data that never smokers are not typically initiating with these products, and the estimates on that are from .4% to a couple percent. But it really doesn’t take a giant step of logic to understand that that substituting inhaling vaporized eliquid, even if it contains nicotine, would be wildly less harmful than breathing in burning tobacco smoke repeatedly all day, that contains tar and carbon monoxide. I’m sure at some point since you’ve posted this article you’ve said “oh those vaping people again”? I would urge you to reflect for a second why it would possibly be that users of a product would so rapidly become such vocal supporters of a product. You suppose it could be because it’s had a tremendously positive impact on their lives? Maybe after considering that, you should reevaluate your position on these products. Almost 1400 people die prematurely every day from smoking. These products in 7 or 8 years on the market have had a vastly greater impact on that situation than decades of taxpayer funded tobacco control/public health nonsense, and they’ve done so with no assistance from the government. In fact they’ve made this tremendous impact while fighting off government, and pharmaceutical interests, and for a while even big tobacco interests. Consider how that fight against smoking related disease would be going if these small businesses were left alone to flourish, rather than continually attacked by people trying to protect their pile of cash.