Wednesday, January 18, 2017

New WHO/NCI Report Falsely Conflates Smoking & Tobacco

The World Health Organization and the U.S. National Cancer Institute recently published a 700-page report on the economic consequences of smoking, tobacco use, or both (here).  The dozens of tobacco experts who contributed failed to distinguish between tobacco and smoke.  This is especially disappointing, since one of the two editors, University of Illinois at Chicago professor Frank Chaloupka, previously acknowledged the difference (here).

The report’s summary conclusions, which are mainly about smoking and not tobacco, follow, with smoke highlighted in red and tobacco highlighted in green.

1.  There are about 1.1 billion smokers in the world, and about 4 in 5 smokers live in low- and middle-income countries. Nearly two-thirds of the world’s smokers live in 13 countries.

2.  Substantial progress has been made in reducing tobacco smoking in most regions, especially in high-income countries. Overall smoking prevalence is decreasing at the global level, but the total number of smokers worldwide is still not declining, largely due to population growth. Unless stronger action is taken, it is unlikely the world will reach the WHO Member States’ 30% global reduction target by 2025.

3.  Globally, more than 80% of the world’s smokers are men.  Differences in prevalence between male and female smokers are particularly high in the South-East Asia and Western Pacific Regions and in low- and middle-income countries.

4.  Globalization and population migration are contributing to a changing tobacco landscape, and non-traditional products are beginning to emerge within regions and populations where their use had not previously been a concern.

5.  An estimated 25 million youth currently smoke cigarettes.  Although cigarette smoking rates are higher among boys than girls, the difference in smoking rates between boys and girls is narrower than that between men and women. Smoking rates among girls approach or even surpass rates among women in all world regions.

6.  Worldwide, an estimated 13 million youth and 346 million adults use smokeless tobacco products.  The large majority of smokeless tobacco users live in the WHO South-East Asia Region.  Smokeless tobacco use may be undercounted globally due to scarcity of data.

7.  Secondhand smoke exposure remains a major problem. In most countries, an estimated 15%–50% of the population is exposed to secondhand smoke; in some countries secondhand smoke exposure affects as much as 70% of the population.

8.  Annually, around 6 million people die from diseases caused by tobacco use, including about 600,000 from secondhand smoke exposure. The burden of disease from tobacco is increasingly concentrated in low- and middle-income countries.

In the last item, the substitution of tobacco for smoke is obvious.  In fact, most of the report is distorted by this bogus substitution.
The sham synonym tactic reflects the anti-tobacco posture of the report’s sponsors, NCI and WHO.  Officials at those organizations supplied two prefaces, totaling 2,700 words. “Tobacco” appears 128 times, while “smoke” is used only 14 times.

Decades of scientific studies document that tobacco is not synonymous with smoke (here and here).  The deliberate conflation of terms by anti-tobacco forces would not be tolerated in any other serious scientific or medical debate. 

Thursday, January 12, 2017

CDC Omitted Important Findings in Report on 2015 National Youth Tobacco Survey

The U.S. Centers for Disease Control and Prevention released selected information from the 2015 National Youth Tobacco Survey in April 2016 (here).  The agency cherry-picked numbers from previous surveys to portray e-cigarettes as a threat to teens, while ignoring sharp declines in teen smoking (here, here and here).

Last month, the CDC released the underlying 2015 NYTS data, ending an eight-month embargo that prevented analysis by independent investigators. 

The agency traditionally reports current smoking and vaping numbers separately, ignoring dual use and wrongly suggesting that the numbers are independent.  In contrast, here I report exclusive users of these products as well as dual users.  I also add important findings that the CDC omitted.

The chart shows current use (that is, on one or more days in the past 30) of cigarettes and e-cigarettes among middle and high school students over the four-year period.  The CDC emphasized the large increase in e-cig use from 2011 to 2015.  As I noted earlier (here), the large spike from 2013 to 2014 was likely due to a change in the NYTS questions.  It is clear that the increase slowed during the last year, but prevalence of exclusive e-cig use among high schoolers still  increased from 8.2 to 10.6%; dual use declined marginally from 5.2 to 5.0%.  The prevalence of exclusive smoking among high school students was flat at 4.0%. 

Given that the CDC has relentlessly asserted that e-cigarettes are a gateway to smoking, it is unsurprising that the agency did not publicize responses to two questions in the 2015 survey that focused on which products students used first.  I report here for the first time how high school students answered these questions, comparing two groups of current smokers: those who only smoked cigarettes and dual users of cigarettes and e-cigs.

The question, “Which of the following tobacco products did you try first?” produced these results:

Table 1. Percentage of High School Current Exclusive Smokers and Dual Users Who Tried Various Tobacco Products First, NYTS 2015
ProductExclusive SmokersDual Users

Smokeless tobacco9.17.6
Other products1.12.6
Not sure2.91.3
Never tried any product4.40.3

Percentages in bold: Exclusive smokers significantly different than dual users.

The table shows that there were no significant differences between exclusive smokers and dual users in the product first used.  Most had tried cigarettes first (60% and 67% respectively); the rest had chosen cigars, smokeless, e-cigs and other products.  There is little evidence here for the CDC’s claim that e-cigarettes are a gateway to smoking.

A question about initiation further exposed the relationship between cigarette and e-cigarette use.  Here is how current exclusive smokers and current dual users responded:

Table 2. Relationship of Cigarette and E-Cigarette Use Among High School Current Exclusive Smokers and Dual Users, NYTS 2015
ResponseExclusive SmokersDual Users

Never tried cigs or e-cigs16.4%1.8%
Only tried cigs19.82.7
Only tried e-cigs0.51.9
Tried cigs before ever tried e-cigs48.777.2
Tried e-cigs before ever tried cigs 14.616.4

Percentages in bold: Exclusive smokers significantly different than dual users.

This table shows that large majorities of high school current exclusive smokers and dual users started with cigarettes.  Only 15-16% of these students are even eligible to be considered gateway cases, in which users moved from vaping to smoking.

There are troubling inconsistencies in these tables.  For example, 16% of current exclusive smokers – who only used cigarettes in the past 30 days – responded that they never tried cigarettes (Table 2).  Four percent of exclusive smokers responded that they had never used any tobacco product (Table 1).

The “Y” in NYTS stands for youth, and responses from these surveys are known to be inconsistent.  In working with the data, if one eliminates participants who gave inconsistent responses, there would be considerably fewer valid participants.  I discussed this problem in 2015 (here), when I called on the CDC to “issue a comprehensive report on the internal consistency and relative validity of the NYTS data.” The agency appears to have ignored that issue.

Wednesday, January 4, 2017

Confirmed: Snus Use Protective for Parkinson’s Disease

Investigators in Sweden, Italy and the United States report that “non-smoking men who used snus had a substantially reduced risk of Parkinson’s disease…”

The research, published in the International Journal of Epidemiology (abstract here), combined data from seven Swedish cohort studies involving nearly 350,000 men.  Subjects were classified according to tobacco use and diagnosis of Parkinson’s disease (an illness of the nervous system affecting movement) over an average 16 years of follow-up.

The principal results are impressive:

“Among never-tobacco smokers, Parkinson’s disease risk in ever-snus users was lower than in never-users (pooled [hazard ratio, similar to relative risk] HR = 0.41, 95% [confidence interval] CI 0.28-0.61, for the fully-adjusted model).  Current-snus use was associated with a lower Parkinson’s disease risk than former use.  In addition, there was evidence of dose-response relationships such that moderate-heavy amount (pooled HR 0.41, 95% CI 0.19-0.90) and long-term current-snus users (pooled HR 0.44, 95% CI 0.24-0.83) had the lowest Parkinson’s disease risks.”

The bottom line: Current snus use, not former use, was strongly protective against Parkinson’s disease, with more protection from heavier and long-term use.

This is not the first such finding.  In 2009, I discussed (here) research from the American Cancer Society showing a similar strong protective effect (Relative risk, RR = 0.22, CI = 0.07 – 0.67) (abstract here).  Further, Parkinson’s may not be the only nerve illness for which smokeless tobacco and/or nicotine use is protective.  Snus users have a significantly lower risk for multiple sclerosis than nonusers of tobacco (here).  Nicotine has been found to improve performance in people with mild cognitive impairment, and it may also benefit those with Alzheimer’s disease (discussed here).

The current study represents a new era in Swedish snus research.  It was conducted by the Swedish Collaboration on Health Effects of Snus Use, “which brought together Swedish prospective cohort studies with detailed information on tobacco smoking and snus use.”

In the past, the snus research field was dominated by investigators at the Karolinska Institute; they published a series of studies that featured obvious technical problems and contradictions, and routinely found significant, small risks.  I documented these flawed studies in professional journals and in my blog (here, here, here, and here).

It is my hope that the Swedish Collaboration, with investigators from multiple universities in Sweden and beyond, will produce valuable, unbiased research on the health impact of snus use.