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

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

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

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

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

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

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

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

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

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

Let’s nail down some specifics:

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

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

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

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

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

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

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

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

Addendum:

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


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