Hold the Mayo

Once again the Mayo Clinic indulges in unethical and misleading risk communications in the form of a new article on e-cigarettes,  promoting fear and confusion and dissuading smokers from trying them.

Mayo clinic: Electronic cigarettes: Not a safe way to light up 

Update: Mayo Clinic subsequently (probably in June 2016) amended and shortened this document – though much of the original remain and the criticisms below still apply.

This seems like a good moment to mention the recent Kozlowski-Sweanor theme on ethics of risk communication in a series of excellent papers:

• Kozlowski LT, Sweanor DT. Young or adult users of multiple tobacco/nicotine products urgently need to be informed of meaningful differences in product risks. Addict Behav. 2017 Jan; [link]
• Kozlowski LT, Sweanor DT. Withholding differential risk information on legal consumer nicotine/tobacco products: The public health ethics of health information quarantines. Int J Drug Policy. Elsevier; [link]
• Kozlowski LT, Sweanor DT. “Not harmless” messages without comparisons disserve consumers, potential consumers, and public health approaches to tobacco/nicotine products. Addict Behav. 2017 Jan 25; [link]

And Mayo Clinic has form…   recall my posting: Mayo Clinic progresses from blatantly wrong to deeply misleading

I have annotated the Mayo Clinic article below in red. Hopefully, the authors, academics and governors of the Mayo Clinic will think more carefully about what the are doing and stop doing this sort of thing in future.

Healthy Lifestyle

Quit smoking

Electronic cigarettes: Not a safe way to light up
[there is no ‘lighting up’, that’s the point]

E-cigarettes are popular alternatives to regular cigarettes, but are they safe? [see Kozlowski & Sweanor above about framing a question like this]

By Mayo Clinic Staff 

Electronic cigarettes, often called e-cigarettes, are battery-operated devices that heat a liquid (usually but not always containing nicotine), turning it into a vapor that can be inhaled. Using e-cigarettes is often referred to as vaping.

Electronic cigarettes come in a variety of designs. Some are sold with filled cartridges, while others are designed so that users can add a solution that’s purchased separately. The solutions typically contain vegetable glycerin or propylene glycol as the main ingredients, varying amounts of nicotine, flavorings and other additives.

Are e-cigarettes safe?
[an unethical non-sequitur]

There’s no scientific evidence that using e-cigarettes is safe. [nor can there ever be.  There is, however, a large body of evidence that they are much safer. There is no scientific evidence that eating bananas is safe.]

Because e-cigarettes don’t burn tobacco, most experts agree that they’re likely to cause fewer harmful effects than traditional cigarettes. [not ‘most’, ‘all‘… if they don’t agree this, they are not experts in any meaningful sense – reduced risk isn’t in doubt. How much safer (approx 5%, 25%, 70% or 99% safer?) is what matters and is the source of controversy in the range 70% to 99+% safer.  All evidence so far points to the lower-risk end of this range: i.e. likely to be at least 95% lower risk and probably substantially lower than that. The figure of 70% is used by some activists but has no basis in reality. There is currently no credible evidence suggesting any material risk to life expectacy, so all the estimates are allowances for unknowns]

Most e-cigarette manufacturers claim that their products are a safe alternative to conventional cigarettes. However, the Food and Drug Administration (FDA) has questioned the safety of these products. [no they don’t make this claim.  Almost always they claim, rightly, that they are safer and they have good scientific support for this claim]

Researchers have found that some e-cigarettes have nicotine amounts that are very different from what’s on the label. [this is consumer protection issue, not a source of much complaint from users, and not a health issue] In addition, some flavoring agents and other additives have been shown to be toxic [not at the relevant exposures.  Many agents are hazardous at high exposures but easily tolerated at low exposures – to reiterate the absolute basics idea of toxicology: “the dose make the poison”].

The long-term health effects of inhaling vegetable glycerin, propylene glycol and other additives are not known [but no material risks have so far been identified, and potential risks can be monitored and mitigated – and they are sure to be lower than long term exposure to cigarette smoke]. The FDA and many health care organizations, including the American Heart Association, have issued warnings about the health risks of e-cigarettes. [Yes, other irresponsible organisations have also chosen to mislead the American public – which, as a result, has highly distorted perceptions of relative risk – see the HINTS data (table below).  This data should shame everyone involved in shaping these risk perceptions: only 5.3% of Americans correctly think e-cigarettes are much less harmful than cigarettes – but 37% think they are the same or more harmful. That’s the real problem and one that Mayo Clinic bears some responsibility for]

Studies to test whether e-cigarettes can help people stop using tobacco have had inconsistent results. At best, e-cigarettes are no more effective than nicotine replacement medications in helping people quit. [the main problem is that researchers have been studing these products as if they are medical devices, which they are not – they are rapidly evolving consumer products and form part of a complex web of behavioural influences that determine whether people smoke, quit or switch.  They do not lend themselves to study in the way medicines are studied. It is both way too confident, and completely wrong, to say “at best” they are no more effective than nicotine medications. For example, see this study People using e-cigarettes to quit smoking 60 percent more likely to succeed than those using NRT sold over the counter.] 

The U.S. Preventive Services Task Force has concluded that the current evidence is insufficient to recommend electronic nicotine delivery systems for tobacco cessation in adults. [the Cochrane review says otherwise – but the issue is whether this type of analysis is the appropriate way to understand these products and the randomised controlled trials that are used to evaluate medicines are the appropriate way to measure the impact of e-cigarettes – the product of many behavioural influences, not a feature of a device. See my discussion of this in a separate posting Or you could simply ask people: Millions of European users report quitting smoking with them. 

If you’re looking for help to stop smoking, there are seven FDA-approved medications that have been shown to be safe and effective for this purpose. A combination of medication and counseling has been shown to work best. [many will find they have tried these and find them ineffective. Yet Mayo Clinic says they should not try something that has worked for thousands of people. Why?]

Because of the unresolved safety concerns and because the research on e-cigarettes as a stop-smoking aid is inconclusive, Mayo Clinic does not recommend e-cigarettes as a way to quit smoking. [but e-cigarettes have clearly helped many millions of Americans – 2.5 million vapers are ex-smokers].

If you want to stop smoking, call 800-QUIT-NOW (800-784-8669) to connect to your state’s quit line or call the Mayo Clinic Nicotine Dependence Center at 800-344-5984. [please disclose funding or sponsorhip partners and any competing interests if you are going to provide science-like advice to smokers]

Better sources

If you are smoker or work in smoking cessation and you are wondering what to make of this advice, listen to what vapers who are now ex-smokers have to say about their experience in a short film produced by the UK National Centre for Smoking Cessation and Training (also see its briefing on e-cigarettes for quit smoking services).