Provide feedback on a proposed ordinance that would establish a tobacco sales license, enact fees to ensure compliance, and raise the minimum age of tobacco purchase to 21 years old.
Do you support establishing a tobacco sales license in the City of Tempe?
No
Why or why not?
In 2019, The Journal of the American Heart Association published a study suggesting that nicotine vaping doubles the risk of a heart attack. The authors claimed e-cigarette use is "independently" associated with a heightened risk of myocardial infarction, which is "similar" to the risk among cigarette smokers.
Three years later, the World Journal of Oncology published a study that claimed vapers face about the same cancer risk as smokers. The authors said "prospective studies should be planned to mitigate the risk."
Both studies were later retracted, largely because they shared the same glaring weakness: The researchers failed to consider whether the medical problems that survey respondents reported were diagnosed before or after they began vaping, a minimum requirement for inferring a causal relationship. As University of Louisville researchers Brad Rodu and Nantaporn Plurphanswat showed in a 2022 Internal and Emergency Medicine article, that failure is characteristic of studies that allege a link between vaping and smoking-related diseases, including several articles that so far have not been retracted.
In all of these cases, the researchers seemed so eager to discredit vaping as a harm-reducing alternative to smoking that they overlooked a fundamental methodological flaw. So did the peer reviewers and journal editors.
This sort of tendentiously sloppy research compounds a problem that harm reduction advocates have been decrying for years: Although the evidence indicates that vaping is far less dangerous than smoking, most Americans think vaping is just as dangerous, if not more so. And while public health officials could help correct that misconception, which undermines the lifesaving potential of e-cigarettes, they frequently contribute to the confusion by obscuring the difference between these two modes of nicotine consumption.
The heart attack study was based on data from the Population Assessment of Tobacco and Health (PATH) Study, which includes questions about when respondents began vaping and when they were diagnosed. Amazingly, the researchers did not use that information, even though it was crucial in testing the hypothesis that vaping causes heart attacks.
Even more remarkably, the journal's editors recognized that problem before publication and asked the authors to address it. Although they failed to do so, the Journal of the American Heart Association published the study anyway.
A month after publication, Rodu and Plurphanswat pointed out that most of the e-cigarette users who reported heart attacks actually had them before they started vaping, making a causal inference logically impossible. Sixteen prominent tobacco researchers amplified that point in a letter to the American Heart Association, which finally retracted the study eight months after it was published.
In their Internal and Emergency Medicine article, Rodu and Plurphanswat analyzed PATH data on four conditions "strongly associated with smoking" that previous research had suggested are also associated with vaping: myocardial infarction, stroke, emphysema, and chronic obstructive pulmonary disease. They again found that the diagnoses generally preceded e-cigarette use.
The World Journal of Oncology study, which was based on the National Health and Nutrition Examination Survey, included information about the timing of cancer diagnoses but not the timing of e-cigarette use. As the authors conceded, that meant "causal or temporal association could not be established."
The editors and peer reviewers apparently were unfazed by that difficulty. They also missed writing errors, non sequiturs, failures of reasoning, contradictions, and a blatant inconsistency in the way researchers reported their main results. Perhaps reviewers were reassured by the fact that the article was attributed to no fewer than 13 authors affiliated with reputable institutions such as the University of Illinois, Temple University Hospital, the Mayo Clinic, and the Icahn School of Medicine at Mount Sinai.
In addition to glossing over the timing of e-cigarette use, the researchers classified participants as "e-cigarette users" if they had ever vaped and were not current smokers. The study did not take into account whether the respondents in that group had a history of smoking, which is problematic when you are trying to distinguish between correlation and causation.
Even while implying that vaping poses about the same cancer risk as smoking, the study cited evidence showing that can't possibly be true. The authors noted that the carcinogenic potency of e-cigarette aerosol is more than 99 percent lower than the carcinogenic potency of cigarette smoke. They added that "mean lifetime cancer risks decline from traditional smoking to e-cigarettes."
The researchers said the "exponential increase in the use of e-cigarettes due to their widespread promotion as safer alternatives to traditional smoking" is a "dangerous threat" and a "public health risk." But they also described e-cigarettes as a promising harm reduction tool that "could dramatically decrease the risk of serious disease in nicotine users and other high-risk groups."
Ten months after publication, the journal printed a retraction notice. "Concerns have been raised regarding the article's methodology, source data processing including statistical analysis, and reliability of conclusions," the editors said. But "the authors failed to provide justified explanations and evidence" in response to those concerns.
Publication of such a "grossly flawed" study, Rodu notes, raises an obvious question: "How could it get through peer review?" Respiratory specialist Riccardo Polosa and smoking researcher Konstantinos Farsalinos suggest an answer in a commentary that accompanied Rodu and Plurphanswat's Internal and Emergency Medicine article.
Polosa and Farsalinos note that the failure to consider the temporal relationship between vaping and disease is a "fatal" flaw that should be obvious to reviewers. "The unopposed acceptance of these (low-quality) papers by prestigious journals is symptomatic of a significant dysfunction in scientific publishing, which is distorting the practice of science," they write. "In the context of highly polarized scientific debates (as in e-cigarette research) the peer review process becomes strongly biased for or against a certain narrative."
In this case, the favored narrative says vaping products should be viewed with suspicion, despite their potential to reduce smoking-related disease and death. Statements from the Centers for Disease Control and Prevention (CDC) reinforce that narrative by inaccurately describing vaping as "tobacco use" and portraying it as a grave threat to public health.
The result of such obfuscation is apparent in opinion surveys. According to a 2020 survey, less than 3 percent of Americans recognize that e-cigarettes are "much less harmful than combustible cigarettes."
Brian King, director of the Center for Tobacco Products at the Food and Drug Administration (FDA), acknowledges the gap between what the evidence shows and what Americans commonly think. "I'm fully aware of the misperceptions that are out there and aren't consistent with the known science," he told the Associated Press in September 2022. "We do know that e-cigarettes, as a general class, have markedly less risk than a combustible cigarette product."
King did not acknowledge the role that his own agency, which sponsors hyperbolic propaganda aimed at deterring adolescent vaping, has played in creating those "misperceptions." Nor did he reflect on the damage done by discouraging smokers from switching to vaping. The upshot will be more tobacco-related deaths, exactly the opposite of what the CDC and the FDA claim they are trying to accomplish.
If a tobacco sales license is established, do you support the proposed fees to ensure compliance?
No
Why or why not?
No response.
Do you support increasing the minimum age for purchase of tobacco products to age 21?
No
Why or why not?
The war on drugs is winding down, and the war on tobacco is ramping up. E-cigarettes, a safer nicotine-delivery alternative, have contributed to plummeting use of traditional cigarette smoking. Yet the Food and Drug Administration (FDA) has effectively made it harder for cigarette smokers to switch by limiting vapes from the market. The agency also recently announced a ban on menthol cigarettes and flavored cigars, which will push more products onto the black market, with all sorts of unintended consequences.
"As tobacco, e-cigarettes, and e-liquids transition from legal to illicit, law enforcement agencies will more aggressively interfere with production, distribution, retail sales, and in some cases even individual use," wrote Jacob Grier, author of The Rediscovery of Tobacco: Smoking, Vaping, and the Creative Destruction of the Cigarette, in a recent issue of Reason. And there's no way to know how far police will go when black market purveyors inadvertently break the law by selling banned smoking products.
There's overwhelming evidence that vaping is safer than smoking regular cigarettes, and that policymakers should be making it easier for Americans to switch. "Vaping isn't completely risk-free but is far less harmful than smoking tobacco," according to the British Royal College of Physicians.
"Laboratory tests of e-cigarette ingredients, in vitro toxicological tests, and short-term human studies suggest that e-cigarettes are likely to be far less harmful than combustible tobacco cigarettes," according to the National Academies of Sciences, Engineering, and Medicine.
"We are in this kind of collective hysterical mindset that really resembles what happened with the war on drugs, back in the late eighties and nineties," says Ethan Nadelmann, the founder and former director of the Drug Policy Alliance and a central figure in the unwinding of America's longest war.
By banning options that smokers overwhelmingly prefer, and leaving the traditional cigarette untouched, the FDA is repeating the mistakes of the drug war, says Nadelmann.
"Every society needs a boogeyman."
Do you currently use tobacco products?
No
Do you currently own, manage or work at an establishment that sells tobacco products?
No response.
Do you have any other comments?
The World Journal of Oncology recently retracted a February 2022 article claiming that nicotine vapers face about the same cancer risk as cigarette smokers. "After publication of this article," the editors explain, "concerns have been raised regarding the article's methodology, source data processing including statistical analysis, and reliability of conclusions." Because "the authors failed to provide justified explanations and evidence for the inquires [sic], subsequently this article has been retracted at the request of Editor-in-Chief."
Some of the concerns raised by this article are similar to the problems with other studies that have linked vaping to smoking-related diseases. Most conspicuously, this study failed to address the question of whether diagnoses were made before or after people started vaping, a minimum requirement for inferring causation. In 2020, the same problem led to the retraction of a Journal of the American Heart Association article that reported an association between vaping and heart attacks.
The World Journal of Oncology article—which was attributed to no fewer than 13 researchers at institutions such as the University of Missouri, Temple University Hospital, the Mayo Clinic, and the Icahn School of Medicine at Mount Sinai—has other obvious problems that should have been apparent before publication. It features enough inconsistencies, writing errors, non sequiturs, and failures of reasoning to make you wonder whether peer reviewers and editors actually read it, let alone carefully evaluated its strengths and weaknesses.
As critics have noted, the publication of such studies suggests that the peer review process is biased against vaping, favoring articles that highlight its potential hazards even when the science underlying them is weak. In an email, Brad Rodu, a University of Louisville professor of medicine who has been studying tobacco harm reduction for decades, says the "grossly flawed" study of vaping and cancer raises a troubling question: "How could it get through peer review?"
In the retracted study, University of Illinois internist Anusha Chidharla and her 12 co-authors analyzed data from the National Health and Nutrition Examination Survey. The sample included 154,856 respondents surveyed from 2015 through 2018, of whom 5 percent reported that they had ever used e-cigarettes, 31.4 percent said they were current smokers, and 63.6 percent said they did not smoke and had never used e-cigarettes. The survey also asked whether participants had ever been diagnosed with cancer.
Crucially, the study does not include information on when the e-cigarette users began vaping. But the authors note that "e-cigarettes [were] used as a strategy to quit smoking in most cancer respondents," which suggests that their diagnoses generally preceded their e-cigarette use. If so, that would be consistent with what Rodu and University of Louisville research economist Nantaporn Plurphanswat found when they analyzed data on other smoking-related diseases from the Population Assessment of Tobacco and Health Survey, which includes information on the timing of both diagnoses and e-cigarette use.
Chidharla et al. classified participants as "e-cigarette users" if they had ever vaped and were not current smokers. The researchers did not take into account whether the respondents in that group had a history of smoking, which is obviously problematic when you are trying to distinguish between correlation and causation.
"The authors reclassified former smokers as nonsmokers, thereby obscuring the effects of 'former,'" Rodu notes. "That also raised the cancers in their reference group, which was inappropriate."
Keeping those points in mind, what did the researchers find? They seemed confused about that.
According to the abstract, "the e-cigarette users [had] lower prevalence of cancer compared to traditional smoking (2.3% vs. 16.8%; P < 0.0001)." That is consistent with the numbers reported in Table 2. But according to the "Results" section of the article, "respondents with cancer [had] a lower prevalence of e-cigarette [use] compared to traditional smoking (2.3% vs. 16.8%; P < 0.0001)." The "Discussion" section reiterates that "cancer respondents had a lower prevalence of e-cigarette use than traditional smoking (2.3% vs. 16.8%)."
All those passages cite exactly the same numbers, but they are talking about two different things: prevalence of cancer among e-cigarette users and smokers (the study's "secondary aim") vs. prevalence of e-cigarette use and smoking among people diagnosed with cancer (the study's "primary aim"). "I have made a serious attempt," Rodu says, "but I cannot figure out how the authors switched from cancer prevalence among e-cig users to e-cig prevalence among participants with cancer." It seems neither the peer reviewers nor the journal's editors noticed that inconsistency prior to publication.
Assuming the version of the results presented in the abstract and Table 2 is the correct one, 2.3 percent of e-cigarette users reported cancer diagnoses, compared to 16.8 percent of current smokers and 9.5 percent of the nonsmokers. But when the researchers ran a regression analysis that included several demographic variables and "comorbidities" (including other diagnoses and use of other drugs), they calculated that e-cigarette users "had 2.2 times higher risk and traditional smokers had 1.96 times higher risk of having cancer compared to non-smokers."
In other words, the prevalence of cancer among the e-cigarette users was about one-quarter the prevalence among nonsmokers and one-seventh the prevalence among current smokers. But after the regression analysis, the risk for e-cigarette users was about the same as the risk for smokers—i.e., roughly twice the risk for nonsmokers.
Since the retraction mentions "concerns" about "source data processing including statistical analysis," we can surmise that the editors, after taking a closer look at the study, questioned that calculation. In any event, the lack of information about the timing of e-cigarette use makes it impossible to draw causal conclusions from whatever correlations these survey data do support. Or as Chidharla et al. put it, "causal or temporal association could not be established."
Despite that concession, the authors' conclusion assumes a risk they have not proven. "Our study found e-cigarette users had an early age of cancer onset as well as higher odds of having cancer compared to non-smokers," they write. "Prospective studies should be planned to mitigate the risk."
In light of the study's fundamental weaknesses, what value would it have had even if the "source data processing including statistical analysis" had been sound? "Despite the limitations," the authors say, "to our knowledge, this is the first large population-based study to find [a] potential association between e-cigarette use and cancer in humans." So there's that.
Stanton Glantz, the American Legacy Foundation Distinguished Professor of Tobacco Control at the University of California, San Francisco, thought that was good enough. In a blog post, he hailed the "first epidemiological evidence linking e-cigs to cancer in people." Glantz, who co-authored the retracted Journal of the American Heart Association article alleging a connection between vaping and heart attacks, said Chidharla et al.'s study provided "direct evidence that people who use e-cigarettes are at increased risk of some cancers" (emphasis his). He added that "e-cigarette use was associated with higher risks of some cancers than smoking cigarettes, including cervical cancer, leukemia, skin cancer (non-melanoma), skin (other) and thyroid cancers" (again, emphasis his).
For those of us who are less eager to undermine the case for vaping as a harm-reducing alternative to smoking, what would this study have meant if it had not been retracted? Chidharla et al. were not sure.
If you ignore the glaring methodological weaknesses, the study suggests that vapers and smokers face similar cancer risks. Yet the authors note that "vaporized nicotine emissions from e-cigarettes contain carcinogens generally in lower concentrations with cancer potencies < 1% that of tobacco smoke." In other words, the carcinogenic potency of e-cigarette aerosol is more than 99 percent lower than the carcinogenic potency of cigarette smoke. The researchers add that "mean lifetime cancer risks decline from traditional smoking to e-cigarettes."
Chidharla et al. say the "exponential increase in the use of e-cigarettes due to their widespread promotion as safer alternatives to traditional smoking" is a "dangerous threat" and a "public health risk." But they also describe e-cigarettes as a promising harm reduction tool.
"Although smoking in any form is never safe, e-cigarettes can be recommended by clinicians as an alternative to traditional smoking in populations with a history of cancer who would otherwise continue to smoke or those who want to start smoking at all cost," the authors write. "This could dramatically decrease the risk of serious disease in nicotine users and other high-risk groups."
That is exactly the point of harm reduction. A dramatic decrease in health risks among people who otherwise would be smoking is unambiguously an improvement. So why do Chidharla et al. seem ambivalent at best about products that help people achieve that outcome?
"Due to higher prevalence of certain types of cancers in e-cigarette [users] and
unknown consequences of e-cigarette use, more guidelines are needed regarding the use of e-cigarettes and their association with cancer," the authors write. "E-cigarette[s] should not be considered as a safe alternative to dual or traditional smoking without stronger clinical evidence on [their] safety." But to reduce health risks, e-cigarettes do not have to be "a safe alternative"; they need only be a safer alternative, which Chidharla et al. concede they are.
The authors sometimes seem desperate to obscure that point. "The recent outbreak of e-cigarette vaping-associated lung injury (EVALI) in the USA suggests caution," they write. "EVALI is primarily attributable to vitamin E acetate in cannabis oils distributed through illicit channels [emphasis added]." What does that have to do with the risks posed by the legally distributed nicotine products the article is ostensibly discussing?
Chidharla et al. worry that e-cigarettes are "gaining popularity" among "never-smokers and adolescents." They add that "the potential for negative health effects from exposure to nicotine or other chemicals in e-cigarettes among non-smokers is concerning."
Adolescent vaping actually has been falling in recent years. And according to a survey the researchers cite, never-smokers account for less than 9 percent of Americans who report that they have tried e-cigarettes. A more recent survey found that less than 3 percent of Minnesota never-smokers reported "current" e-cigarette use, meaning they used e-cigarettes "every day or some days."
Chidharla et al. also worry that vaping products "are commonly marketed as a safe alternative" when "the long-term effect of e-cigarettes is not known yet." But as they concede, the evidence indicates that vaping, even if it may pose some long-term risks, is far less hazardous than smoking.
Surveys suggest that Americans generally do not understand that, thanks largely to deliberate obfuscation by anti-smoking activists and public health officials. When it comes to public perceptions, the problem is not that people mistakenly think vaping is completely risk-free; the problem is that less than 3 percent of Americans recognize that e-cigarettes are "much less harmful than combustible cigarettes."
Brian King, director of the Food and Drug Administration's Center for Tobacco Products, acknowledges the gap between what the evidence shows and what Americans commonly think. "I'm fully aware of the misperceptions that are out there and aren't consistent with the known science," he told the Associated Press in September. "We do know that e-cigarettes, as a general class, have markedly less risk than a combustible cigarette product."
Since those "misperceptions" discourage smokers from switching to vaping, they are a significant obstacle to reducing smoking-related disease and death. Ill-conceived, poorly reasoned studies like this one compound that problem.
Tempe Forum is not a certified voting system or ballot box. As with any public comment process, participation in Tempe Forum is voluntary. The responses in this record are not necessarily representative of the whole population, nor do they reflect the opinions of any government agency or elected officials.
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Do you support establishing a tobacco sales license in the City of Tempe?
Why or why not?
In 2019, The Journal of the American Heart Association published a study suggesting that nicotine vaping doubles the risk of a heart attack. The authors claimed e-cigarette use is "independently" associated with a heightened risk of myocardial infarction, which is "similar" to the risk among cigarette smokers.
Three years later, the World Journal of Oncology published a study that claimed vapers face about the same cancer risk as smokers. The authors said "prospective studies should be planned to mitigate the risk."
Both studies were later retracted, largely because they shared the same glaring weakness: The researchers failed to consider whether the medical problems that survey respondents reported were diagnosed before or after they began vaping, a minimum requirement for inferring a causal relationship. As University of Louisville researchers Brad Rodu and Nantaporn Plurphanswat showed in a 2022 Internal and Emergency Medicine article, that failure is characteristic of studies that allege a link between vaping and smoking-related diseases, including several articles that so far have not been retracted.
In all of these cases, the researchers seemed so eager to discredit vaping as a harm-reducing alternative to smoking that they overlooked a fundamental methodological flaw. So did the peer reviewers and journal editors.
This sort of tendentiously sloppy research compounds a problem that harm reduction advocates have been decrying for years: Although the evidence indicates that vaping is far less dangerous than smoking, most Americans think vaping is just as dangerous, if not more so. And while public health officials could help correct that misconception, which undermines the lifesaving potential of e-cigarettes, they frequently contribute to the confusion by obscuring the difference between these two modes of nicotine consumption.
The heart attack study was based on data from the Population Assessment of Tobacco and Health (PATH) Study, which includes questions about when respondents began vaping and when they were diagnosed. Amazingly, the researchers did not use that information, even though it was crucial in testing the hypothesis that vaping causes heart attacks.
Even more remarkably, the journal's editors recognized that problem before publication and asked the authors to address it. Although they failed to do so, the Journal of the American Heart Association published the study anyway.
A month after publication, Rodu and Plurphanswat pointed out that most of the e-cigarette users who reported heart attacks actually had them before they started vaping, making a causal inference logically impossible. Sixteen prominent tobacco researchers amplified that point in a letter to the American Heart Association, which finally retracted the study eight months after it was published.
In their Internal and Emergency Medicine article, Rodu and Plurphanswat analyzed PATH data on four conditions "strongly associated with smoking" that previous research had suggested are also associated with vaping: myocardial infarction, stroke, emphysema, and chronic obstructive pulmonary disease. They again found that the diagnoses generally preceded e-cigarette use.
The World Journal of Oncology study, which was based on the National Health and Nutrition Examination Survey, included information about the timing of cancer diagnoses but not the timing of e-cigarette use. As the authors conceded, that meant "causal or temporal association could not be established."
The editors and peer reviewers apparently were unfazed by that difficulty. They also missed writing errors, non sequiturs, failures of reasoning, contradictions, and a blatant inconsistency in the way researchers reported their main results. Perhaps reviewers were reassured by the fact that the article was attributed to no fewer than 13 authors affiliated with reputable institutions such as the University of Illinois, Temple University Hospital, the Mayo Clinic, and the Icahn School of Medicine at Mount Sinai.
In addition to glossing over the timing of e-cigarette use, the researchers classified participants as "e-cigarette users" if they had ever vaped and were not current smokers. The study did not take into account whether the respondents in that group had a history of smoking, which is problematic when you are trying to distinguish between correlation and causation.
Even while implying that vaping poses about the same cancer risk as smoking, the study cited evidence showing that can't possibly be true. The authors noted that the carcinogenic potency of e-cigarette aerosol is more than 99 percent lower than the carcinogenic potency of cigarette smoke. They added that "mean lifetime cancer risks decline from traditional smoking to e-cigarettes."
The researchers said the "exponential increase in the use of e-cigarettes due to their widespread promotion as safer alternatives to traditional smoking" is a "dangerous threat" and a "public health risk." But they also described e-cigarettes as a promising harm reduction tool that "could dramatically decrease the risk of serious disease in nicotine users and other high-risk groups."
Ten months after publication, the journal printed a retraction notice. "Concerns have been raised regarding the article's methodology, source data processing including statistical analysis, and reliability of conclusions," the editors said. But "the authors failed to provide justified explanations and evidence" in response to those concerns.
Publication of such a "grossly flawed" study, Rodu notes, raises an obvious question: "How could it get through peer review?" Respiratory specialist Riccardo Polosa and smoking researcher Konstantinos Farsalinos suggest an answer in a commentary that accompanied Rodu and Plurphanswat's Internal and Emergency Medicine article.
Polosa and Farsalinos note that the failure to consider the temporal relationship between vaping and disease is a "fatal" flaw that should be obvious to reviewers. "The unopposed acceptance of these (low-quality) papers by prestigious journals is symptomatic of a significant dysfunction in scientific publishing, which is distorting the practice of science," they write. "In the context of highly polarized scientific debates (as in e-cigarette research) the peer review process becomes strongly biased for or against a certain narrative."
In this case, the favored narrative says vaping products should be viewed with suspicion, despite their potential to reduce smoking-related disease and death. Statements from the Centers for Disease Control and Prevention (CDC) reinforce that narrative by inaccurately describing vaping as "tobacco use" and portraying it as a grave threat to public health.
The result of such obfuscation is apparent in opinion surveys. According to a 2020 survey, less than 3 percent of Americans recognize that e-cigarettes are "much less harmful than combustible cigarettes."
Brian King, director of the Center for Tobacco Products at the Food and Drug Administration (FDA), acknowledges the gap between what the evidence shows and what Americans commonly think. "I'm fully aware of the misperceptions that are out there and aren't consistent with the known science," he told the Associated Press in September 2022. "We do know that e-cigarettes, as a general class, have markedly less risk than a combustible cigarette product."
King did not acknowledge the role that his own agency, which sponsors hyperbolic propaganda aimed at deterring adolescent vaping, has played in creating those "misperceptions." Nor did he reflect on the damage done by discouraging smokers from switching to vaping. The upshot will be more tobacco-related deaths, exactly the opposite of what the CDC and the FDA claim they are trying to accomplish.
If a tobacco sales license is established, do you support the proposed fees to ensure compliance?
Why or why not?
No response.Do you support increasing the minimum age for purchase of tobacco products to age 21?
Why or why not?
The war on drugs is winding down, and the war on tobacco is ramping up. E-cigarettes, a safer nicotine-delivery alternative, have contributed to plummeting use of traditional cigarette smoking. Yet the Food and Drug Administration (FDA) has effectively made it harder for cigarette smokers to switch by limiting vapes from the market. The agency also recently announced a ban on menthol cigarettes and flavored cigars, which will push more products onto the black market, with all sorts of unintended consequences.
"As tobacco, e-cigarettes, and e-liquids transition from legal to illicit, law enforcement agencies will more aggressively interfere with production, distribution, retail sales, and in some cases even individual use," wrote Jacob Grier, author of The Rediscovery of Tobacco: Smoking, Vaping, and the Creative Destruction of the Cigarette, in a recent issue of Reason. And there's no way to know how far police will go when black market purveyors inadvertently break the law by selling banned smoking products.
There's overwhelming evidence that vaping is safer than smoking regular cigarettes, and that policymakers should be making it easier for Americans to switch. "Vaping isn't completely risk-free but is far less harmful than smoking tobacco," according to the British Royal College of Physicians.
"Laboratory tests of e-cigarette ingredients, in vitro toxicological tests, and short-term human studies suggest that e-cigarettes are likely to be far less harmful than combustible tobacco cigarettes," according to the National Academies of Sciences, Engineering, and Medicine.
"We are in this kind of collective hysterical mindset that really resembles what happened with the war on drugs, back in the late eighties and nineties," says Ethan Nadelmann, the founder and former director of the Drug Policy Alliance and a central figure in the unwinding of America's longest war.
By banning options that smokers overwhelmingly prefer, and leaving the traditional cigarette untouched, the FDA is repeating the mistakes of the drug war, says Nadelmann.
"Every society needs a boogeyman."
Do you currently use tobacco products?
Do you currently own, manage or work at an establishment that sells tobacco products?
No response.Do you have any other comments?
The World Journal of Oncology recently retracted a February 2022 article claiming that nicotine vapers face about the same cancer risk as cigarette smokers. "After publication of this article," the editors explain, "concerns have been raised regarding the article's methodology, source data processing including statistical analysis, and reliability of conclusions." Because "the authors failed to provide justified explanations and evidence for the inquires [sic], subsequently this article has been retracted at the request of Editor-in-Chief."
Some of the concerns raised by this article are similar to the problems with other studies that have linked vaping to smoking-related diseases. Most conspicuously, this study failed to address the question of whether diagnoses were made before or after people started vaping, a minimum requirement for inferring causation. In 2020, the same problem led to the retraction of a Journal of the American Heart Association article that reported an association between vaping and heart attacks.
The World Journal of Oncology article—which was attributed to no fewer than 13 researchers at institutions such as the University of Missouri, Temple University Hospital, the Mayo Clinic, and the Icahn School of Medicine at Mount Sinai—has other obvious problems that should have been apparent before publication. It features enough inconsistencies, writing errors, non sequiturs, and failures of reasoning to make you wonder whether peer reviewers and editors actually read it, let alone carefully evaluated its strengths and weaknesses.
As critics have noted, the publication of such studies suggests that the peer review process is biased against vaping, favoring articles that highlight its potential hazards even when the science underlying them is weak. In an email, Brad Rodu, a University of Louisville professor of medicine who has been studying tobacco harm reduction for decades, says the "grossly flawed" study of vaping and cancer raises a troubling question: "How could it get through peer review?"
In the retracted study, University of Illinois internist Anusha Chidharla and her 12 co-authors analyzed data from the National Health and Nutrition Examination Survey. The sample included 154,856 respondents surveyed from 2015 through 2018, of whom 5 percent reported that they had ever used e-cigarettes, 31.4 percent said they were current smokers, and 63.6 percent said they did not smoke and had never used e-cigarettes. The survey also asked whether participants had ever been diagnosed with cancer.
Crucially, the study does not include information on when the e-cigarette users began vaping. But the authors note that "e-cigarettes [were] used as a strategy to quit smoking in most cancer respondents," which suggests that their diagnoses generally preceded their e-cigarette use. If so, that would be consistent with what Rodu and University of Louisville research economist Nantaporn Plurphanswat found when they analyzed data on other smoking-related diseases from the Population Assessment of Tobacco and Health Survey, which includes information on the timing of both diagnoses and e-cigarette use.
Chidharla et al. classified participants as "e-cigarette users" if they had ever vaped and were not current smokers. The researchers did not take into account whether the respondents in that group had a history of smoking, which is obviously problematic when you are trying to distinguish between correlation and causation.
"The authors reclassified former smokers as nonsmokers, thereby obscuring the effects of 'former,'" Rodu notes. "That also raised the cancers in their reference group, which was inappropriate."
Keeping those points in mind, what did the researchers find? They seemed confused about that.
According to the abstract, "the e-cigarette users [had] lower prevalence of cancer compared to traditional smoking (2.3% vs. 16.8%; P < 0.0001)." That is consistent with the numbers reported in Table 2. But according to the "Results" section of the article, "respondents with cancer [had] a lower prevalence of e-cigarette [use] compared to traditional smoking (2.3% vs. 16.8%; P < 0.0001)." The "Discussion" section reiterates that "cancer respondents had a lower prevalence of e-cigarette use than traditional smoking (2.3% vs. 16.8%)."
All those passages cite exactly the same numbers, but they are talking about two different things: prevalence of cancer among e-cigarette users and smokers (the study's "secondary aim") vs. prevalence of e-cigarette use and smoking among people diagnosed with cancer (the study's "primary aim"). "I have made a serious attempt," Rodu says, "but I cannot figure out how the authors switched from cancer prevalence among e-cig users to e-cig prevalence among participants with cancer." It seems neither the peer reviewers nor the journal's editors noticed that inconsistency prior to publication.
Assuming the version of the results presented in the abstract and Table 2 is the correct one, 2.3 percent of e-cigarette users reported cancer diagnoses, compared to 16.8 percent of current smokers and 9.5 percent of the nonsmokers. But when the researchers ran a regression analysis that included several demographic variables and "comorbidities" (including other diagnoses and use of other drugs), they calculated that e-cigarette users "had 2.2 times higher risk and traditional smokers had 1.96 times higher risk of having cancer compared to non-smokers."
In other words, the prevalence of cancer among the e-cigarette users was about one-quarter the prevalence among nonsmokers and one-seventh the prevalence among current smokers. But after the regression analysis, the risk for e-cigarette users was about the same as the risk for smokers—i.e., roughly twice the risk for nonsmokers.
Since the retraction mentions "concerns" about "source data processing including statistical analysis," we can surmise that the editors, after taking a closer look at the study, questioned that calculation. In any event, the lack of information about the timing of e-cigarette use makes it impossible to draw causal conclusions from whatever correlations these survey data do support. Or as Chidharla et al. put it, "causal or temporal association could not be established."
Despite that concession, the authors' conclusion assumes a risk they have not proven. "Our study found e-cigarette users had an early age of cancer onset as well as higher odds of having cancer compared to non-smokers," they write. "Prospective studies should be planned to mitigate the risk."
In light of the study's fundamental weaknesses, what value would it have had even if the "source data processing including statistical analysis" had been sound? "Despite the limitations," the authors say, "to our knowledge, this is the first large population-based study to find [a] potential association between e-cigarette use and cancer in humans." So there's that.
Stanton Glantz, the American Legacy Foundation Distinguished Professor of Tobacco Control at the University of California, San Francisco, thought that was good enough. In a blog post, he hailed the "first epidemiological evidence linking e-cigs to cancer in people." Glantz, who co-authored the retracted Journal of the American Heart Association article alleging a connection between vaping and heart attacks, said Chidharla et al.'s study provided "direct evidence that people who use e-cigarettes are at increased risk of some cancers" (emphasis his). He added that "e-cigarette use was associated with higher risks of some cancers than smoking cigarettes, including cervical cancer, leukemia, skin cancer (non-melanoma), skin (other) and thyroid cancers" (again, emphasis his).
For those of us who are less eager to undermine the case for vaping as a harm-reducing alternative to smoking, what would this study have meant if it had not been retracted? Chidharla et al. were not sure.
If you ignore the glaring methodological weaknesses, the study suggests that vapers and smokers face similar cancer risks. Yet the authors note that "vaporized nicotine emissions from e-cigarettes contain carcinogens generally in lower concentrations with cancer potencies < 1% that of tobacco smoke." In other words, the carcinogenic potency of e-cigarette aerosol is more than 99 percent lower than the carcinogenic potency of cigarette smoke. The researchers add that "mean lifetime cancer risks decline from traditional smoking to e-cigarettes."
Chidharla et al. say the "exponential increase in the use of e-cigarettes due to their widespread promotion as safer alternatives to traditional smoking" is a "dangerous threat" and a "public health risk." But they also describe e-cigarettes as a promising harm reduction tool.
"Although smoking in any form is never safe, e-cigarettes can be recommended by clinicians as an alternative to traditional smoking in populations with a history of cancer who would otherwise continue to smoke or those who want to start smoking at all cost," the authors write. "This could dramatically decrease the risk of serious disease in nicotine users and other high-risk groups."
That is exactly the point of harm reduction. A dramatic decrease in health risks among people who otherwise would be smoking is unambiguously an improvement. So why do Chidharla et al. seem ambivalent at best about products that help people achieve that outcome?
"Due to higher prevalence of certain types of cancers in e-cigarette [users] and
unknown consequences of e-cigarette use, more guidelines are needed regarding the use of e-cigarettes and their association with cancer," the authors write. "E-cigarette[s] should not be considered as a safe alternative to dual or traditional smoking without stronger clinical evidence on [their] safety." But to reduce health risks, e-cigarettes do not have to be "a safe alternative"; they need only be a safer alternative, which Chidharla et al. concede they are.
The authors sometimes seem desperate to obscure that point. "The recent outbreak of e-cigarette vaping-associated lung injury (EVALI) in the USA suggests caution," they write. "EVALI is primarily attributable to vitamin E acetate in cannabis oils distributed through illicit channels [emphasis added]." What does that have to do with the risks posed by the legally distributed nicotine products the article is ostensibly discussing?
Chidharla et al. worry that e-cigarettes are "gaining popularity" among "never-smokers and adolescents." They add that "the potential for negative health effects from exposure to nicotine or other chemicals in e-cigarettes among non-smokers is concerning."
Adolescent vaping actually has been falling in recent years. And according to a survey the researchers cite, never-smokers account for less than 9 percent of Americans who report that they have tried e-cigarettes. A more recent survey found that less than 3 percent of Minnesota never-smokers reported "current" e-cigarette use, meaning they used e-cigarettes "every day or some days."
Chidharla et al. also worry that vaping products "are commonly marketed as a safe alternative" when "the long-term effect of e-cigarettes is not known yet." But as they concede, the evidence indicates that vaping, even if it may pose some long-term risks, is far less hazardous than smoking.
Surveys suggest that Americans generally do not understand that, thanks largely to deliberate obfuscation by anti-smoking activists and public health officials. When it comes to public perceptions, the problem is not that people mistakenly think vaping is completely risk-free; the problem is that less than 3 percent of Americans recognize that e-cigarettes are "much less harmful than combustible cigarettes."
Brian King, director of the Food and Drug Administration's Center for Tobacco Products, acknowledges the gap between what the evidence shows and what Americans commonly think. "I'm fully aware of the misperceptions that are out there and aren't consistent with the known science," he told the Associated Press in September. "We do know that e-cigarettes, as a general class, have markedly less risk than a combustible cigarette product."
Since those "misperceptions" discourage smokers from switching to vaping, they are a significant obstacle to reducing smoking-related disease and death. Ill-conceived, poorly reasoned studies like this one compound that problem.