Monthly Archives: February 2014

Some follow-up questions for Richard Carmona

My regular readers and anyone expert in tobacco harm reduction (THR) will know that former U.S. Surgeon General Richard Carmona, who now works for the major e-cigarette company NJOY, is arguably the worst anti-THR liar in history.  His “worst” rating comes from a combination of how blatant the lies were and how much influence they had on the world.  The low point was the disinformation he presented in 2003 Congressional hearings on THR, claiming that smokeless tobacco is as harmful as cigarettes.  This was used in basically every anti-THR lie campaign for years.  This preeminence faded when anti-THR lying shifted some focus from smokeless tobacco to e-cigarettes, but the quotes are still aggressively used in many anti-THR efforts.

He could have told the truth, to the great benefit of the public’s health, or at least stayed silent if he genuinely did not know the truth, but instead he chose to lie (about what he knew and/or by claiming he had sufficient expertise to offer an opinion) and thus massively set back the progress of THR.  While switching to smokeless tobacco was never hugely popular in the USA, it was far from rare.  The modest decline in smoking prevalence in the 2000s pretty much matched the increase in smokeless use, and switching was a usually-successful method for quitting smoking.  But its potential was strangled.  Carmona probably killed tens of thousands smokers with his lies.  He has never issued a correction, let alone apologized for the harm that he has done.

As part of NJOY’s publicity efforts, Carmona recently gave an interview to Science magazine (paywalled, but Snowdon was kind enough to reprint it for the masses).  Sadly, health reporters — even those at Science, who are better than average — are not good at asking probing questions, even when they know they are talking to flacks.  So I have suggested some follow-up questions.  To make it easy when Carmona posts a comment here to reply (haha), I have made them multiple choice.  The italicized material are selected bits of the original interview where a follow-up was desperately needed (for the rest of it, follow the Snowdon link).  My questions are identified as “F.U.” to follow the format of the original (that is for “follow-up” — what else could it mean?).

Note to pre-answer a couple of inevitable follow-up questions for me:

1. Of course I believe that people should be allowed to change their mind, correct past mistakes, and start making positive contributions, and should be praised for doing so.  And, yes, it is a good thing that Carmona is now partially on the right side of the issue (partially because someone is not truly a supporter of THR if he is just flogging one product and not embracing the entire concept in all its variations).  But trying to memory-hole past mistakes without so much as an admission of error, let alone an apology, is not acceptable.  It is not as if his 2003 statements were a random blog post by a 25-year-old kid that his 36-year-old future self should be allowed to quietly forget — it was Congressional testimony by a supposed expert.  In politics and personal dealings, apologies are considered necessary.  In science, it is explicit statements of correction or even retractions.  In some religions it is confession.  In 12-step programs it is making amends (which is confession+apology+more).  This is not a radical expectation.

2. No, I do not think it is better tactics to just embrace Carmona and quietly forget about the harm he caused because he is now doing and saying some things that are good for the cause.  That is the strategy of tobacco control — to embrace anyone and any claim that seems to be supporting their cause — and this makes them fundamentally unethical, to say nothing of frequently self-contradictory.  It also tends to perpetuate anti-scientific beliefs and frequently backfires (until Carmona mans-up and corrects his previous disinformation, it is not difficult to imagine settings in which a follow-up question could cause enormous damage to THR all over again).

3. No I am not trying to pick on NJOY this week (or ever).  NJOY is doing great work.  But their statements and actions make for interesting analysis.  The smaller e-cigarette companies and their various trade groups say and do enough incorrect, damaging, or downright nutty things that I could write about that full time, but they just do not matter that much, unlike NJOY.  The established tobacco companies tend to keep tighter control on communications (e.g., they tend to be more subtle when they hire a former tobacco controller), so there is less to say about them, though I certainly criticize them when they make anti-consumer moves.  (Note that exceptions to this are some of Lorillard/Blu’s nuttier moves, which I do comment on, such as using Jenny McCarthy as a spokesman — remarkably parallel to using Carmona in many ways — or calling for a twitter bombing of a member of Congress.)

So, on to the interview questions:

Q: How can you be sure [e-cigarettes are] safe?

R.C.: As research priorities, we’re asking about cons from long-term nicotine use, and we’re examining the different components in side-stream vapor to make sure they’re not unsafe. So far we don’t see any problems. And we’re also looking into long-term efficacy: How many people who use e-cigarettes quit and for how long? We just have to craft the right questions and then report back to the public.

F.U.: Isn’t it the case that the evidence that smokeless tobacco was low risk was, in 2003 when you claimed there was no such evidence, far stronger than the current evidence that e-cigarettes are low risk?  Wasn’t there overwhelming affirmative evidence there are no major problems, in contrast with your mere “so far we don’t see any problems”?  And, indeed, isn’t the main reason we can be confident that e-cigarettes are low risk the fact that we know smokeless tobacco is low risk?

  1. You are right, and I would hereby like to apologize for misleading people about smokeless tobacco in 2003.  I have learned a lot since then and realize that what I said then caused a lot of damage.
  2. In 2003 I was being paid to claim that smokeless tobacco was high risk.  Now I am being paid to claim that e-cigarettes are low risk.  So I don’t see any problem.
  3. Other __________

Q: E-cigarettes are touted as a way to stop tobacco smoking. But would you advocate that people who do that successfully then also try to wean themselves off e-cigarettes?

R.C.: Yes, but the urgency isn’t as great because people who use them aren’t inhaling large amounts of carcinogens and cardiovascular disease–causing agents.

F.U.:  Are you aware that basically everything is a carcinogen or cardiovascular-disease-causing agent in the right quantities and situations, so claims like this are scientific nonsense that are used to trick people into believing all sorts of falsehoods?

  1. Yes, and I use lines like this because they are a good way to trick people into believing a claim is scientific.
  2. No, they do not teach things like that in medical school, and despite presenting myself as a scientific expert for decades, I never took the time to learn the science.
  3. Other ____________

Q: Won’t e-cigarettes just lead to more people getting hooked on nicotine?

R.C.: That same question came up decades ago when nicotine gum, patches, and sprays came on the market. People said they would create new nicotine addicts and that never happened. But e-cigarettes are a different kind of nicotine delivery device, so they raise unanswered questions that we’re looking into.

F.U.: Are you aware that roughly half of all NRT sold is to long-term users, most of whom are practicing THR but some of whom never smoked?  Are you aware that using the term “addicts” to describe (any) tobacco product users is derogatory and highly misleading, but even setting that aside, clearly seldom applies to uses of tobacco other than smoking cigarettes?

  1. No.

Q: On what basis do you think e-cigarettes can help people quit smoking?

R.C.: There is evidence that gums, patches, and sprays work, but they don’t work well enough. And early evidence suggests that because e-cigarettes reinforce the physical movement of smoking, they can enhance tobacco cessation, but we don’t have all the information yet. We have to continue doing the research and publishing data to demonstrate that they’re helpful.

F.U.:  How does the evidence about the effectiveness of e-cigarettes compare to the evidence — from 2003 or currently — that smokeless tobacco use is quite effective at replacing smoking, and indeed as of now has replaced far more smoking than have e-cigarettes?

  1. It is basically the same evidence.  We have observed a lot of people replacing smoking with each of these product categories, and the evidence is clear that it makes people happier to replace smoking rather than just quitting.
  2. I would like to repeat my apology for playing a role in slowing the replacement of smoking with smokeless tobacco, and thus dooming thousands more people to die from smoking.
  3. Both of the above.
  4. Other __________

Q: How would you respond to [tobacco control industry] critics who say you shouldn’t be doing this?

R.C.: ….

F.U.: How would you respond to critics who say you have no intellectual or moral authority to do this — and indeed, see your role as some kind of sick joke — until you recant about smokeless tobacco?

  1. __________________

We await your reply.

Random rant about denominator-free statistics

Not particularly relevant to anything, but offering a chance for a random science lesson, I got really annoyed at a couple of items in my twitter feed over the last few minutes.

The first (in which the tweet was ridiculing the claims) linked to this article about a new journal paper which claimed:

Cat bites to the hand are so dangerous, 1 in 3 patients with such wounds had to be hospitalized, a Mayo Clinic study covering three years showed. Two-third of those hospitalized needed surgery.

Regular readers will know my lack of respect for Mayo’s attempts at research on anything other than medical treatments. But this is worse than usual. Contrary to the headlines that this claim is designed to generate, obviously only a tiny fraction of cat bites result in hospitalization. Their error, of course, is using “patients” as the denominator, a completely useless population to base the statistic on. Who becomes a “patient”? Obviously it is people who are suffering serious medical problems. In the case of cat bites, this consists of people who, after being bitten by their cat many times before, and suffering no serious problems from it, develop an infection that will not go away. Does this represent 1/1000th of all cat bites? 1/10,000th? Fewer? We have no way of knowing, so the statistic is worthless. More important, we do not know what degree of seriousness typically makes someone a patient. Someone with a non-trivial cat bite injury has no way of guessing her chance of needing hospitalization or surgery because there is no way of knowing how serious the condition of the average patient was in comparison.

(Note: People bitten by stray cats of unknown rabies status might also end up as patients and be hospitalized on spec, which further biases the number away from how it is being interpreted.)

Note that this is exactly the same error that infection disease “experts” always make when there is an exciting disease like bird flu.  They claim things like “half of those who get it die.” Um, no. Half of those who get it and get so sick from it that they are willing to go to the almost-certainly-low-quality hospital that they cannot afford (think about the populations in question) end up dying. A bit different.

(If you are particularly interested in that observation, I have written about it at some length in this blog, but I am feeling too lazy to go look for the link.)

The other version of denominator-challenged innumeracy was this tweet from a group calling itself the Center for Priority Based Budgeting, which was naively retweeted by the Robert Wood Johnson Foundation’s public health feed.  It included a coded map of the USA and the observation “Half of the nation’s uninsured live in just 116 counties”.  I am not going to go check this, but eyeballing the map, I would guess that half of the nation’s people live in those 116 counties, so this is not exactly exciting news.

Seriously, did everyone who understands numbers from the last couple of generations go to Wall Street, Google, and the NSA, leaving the rest of the world innumerate?

22% of Australian tobacco controlers support genital mutilation

Ok, as you might have guessed, that is not true.  (Presumably.)  But I did get your attention to make the point that they favor something that is equivalent to genital mutilation.  That is not some hyperbolic Godwin-esque comparison.  There really is a pretty exact analogy, even if the harm caused differs quantitatively.

I have been meaning to search my archives for important posts that have not been read as many times as they deserve.  The great tweeter, @TobaccoTacticss — whose readership has doubled in the last week and a half (you’re welcome :-), helped me choose where to start by posting this table from this survey of Australian tobacco controllers.  It shows that 22% expressed support or strong support for “Vaccinating children and/or adolescents against the effects of nicotine to prevent the uptake of tobacco use.”

My archive post in question is here, in which I observed:

Most of the discussion about the topic is not about the rational adult making an informed decision, but about involuntarily inflicting the vaccine [a drug that would — theoretically permanently — eliminate the body’s ability to respond to nicotine] on kids.  Those proposing it tend to gloss over that “involuntary” bit, and failure to even address this is a serious ethical problem in itself.  But, of course, unless we are talking about a current user who is wanting to quit, this is the only interpretation.  Either the kid is already choosing to not use nicotine, in which case he would see no reason to accept the side effects, or he is currently choosing to use nicotine, in which case he would prefer to avoid the vaccine. 

Of course, we take actions that restrict kids’ choices all the time.  But there is something rather different when the method involves altering their bodies to make it impossible to enjoy a particular choice (and that choice is not “inflict violence on others” or “commit suicide” or something of that nature).  If the effect were permanent, I think this would be an ethical no-brainer.  I suspect that a permanent effect is the goal of those pursuing research on this vaccine, and inflicting that on someone would clearly be unethical.  No, that is too mild — it would be utterly appalling.   

Consider the other example (the only other one I can think of) in which adults permanently alter the body of a child to prevent the child from engaging in a behavior that entails some costs, and where they (the adults) do not approve of the kids enjoying the benefits:  the mutilation of girls’ genitals practiced in some African communities, which you have no doubt read about.  Before anyone who cannot follow a logical argument flips out, I will point out that I am not claiming that either the damage done or the loss of benefits from the vaccine is as great as that from genital mutilation.  But the motivation and implications are otherwise similar:  enjoyment of sex/nicotine by youth is considered evil by those in power for some reason; the benefits of sex/nicotine result in temptation that can be removed by altering someone’s body to diminish the benefits; yes, the behaviors that are thus prevented can increase risks of disease, but this does not appear to be the genuine motivation (e.g., because there are other ways to avoid disease that the proponents oppose).  I suspect that never in my life have I had a conversation with someone who thinks that genital mutilation is anything other than appalling, so why is there no hint of such ethical concern directed at the nicotine vaccine?

Frankly, I think I understated it a bit there because I was writing primarily for a group of young students and not my usual more hardened readers.  It is really pretty much impossible for me to see any ethical distinction between the two practices.  Presumably “vaccinating” children would only be done with the consent of the parents, but that is also true of genital mutilation as I understand.  In both cases, doing whatever it takes to stop the disliked behavior in question is strongly supported in some communities, so no difference there.  They are both about limiting the behavior of the adult that the child will become also.  And so on.  The only tiny bit of light I can see shining between them is the fact that for most (though not all) people the loss of much of the physical pleasure of sex is a larger cost than the loss of the benefits of nicotine — but that is only a quantitative difference, not a fundamental one.

The survey also found 38% support for “Vaccinating smokers against the effects of nicotine as a cessation method”.  This would not be as troubling if this were “making a vaccine available to smokers who wanted it”, but it is actually phrased in terms of inflicting the vaccine, not merely providing the option.  Perhaps most respondents interpreted it as the latter.  But if not, it is arguably even worse.  Not only do nearly half support it, but there is no hiding behind “we have to protect the children” because it is trying to deprive adults of free choice by maiming them.  (You can decide for yourself whether this is even worse depending on your personal trade-offs about issues of freedom, children, etc.)

Finally, notice that “as” I emphasized.  Read the original post to see why merely offering a vaccine to interested adults is — to borrow a favorite phrase of the tobacco controllers — a wolf in sheep’s clothing.  The pitch, like the promise that accompanies the marketing of NRT and other stop smoking methods, would inevitably be that if you take the drug you will not want to smoke.  The reality is that it would permanently (unlike other drugs) trap someone who wants to smoke or otherwise use nicotine in a body that could not use nicotine.

I wish I could take some consolation in the fact that Australia seems to have the most evil tobacco control people in the world.  But I am afraid that the portion of those people who are willing to maim children and adults to control their behavior is not much lower elsewhere.