Dangerous nonsense about vaping

If you thought you already had a good contender for “most dangerous, irresponsible, and ill-informed piece of health journalism of 2015”, then I’m sorry to tell you that it has been beaten into second place at the last minute.

With less than 36 hours left of 2015, I am confident that this article by Sarah Knapton in the Telegraph will win the title.

The article is titled “E-cigarettes are no safer than smoking tobacco, scientists warn”. The first paragraph is

“Vaping is no safer that [sic] smoking, scientists have warned after finding that e-cigarette vapour damages DNA in ways that could lead to cancer.”

There are such crushing levels of stupid in this article it’s hard to know where to start. But perhaps I’ll start by pointing out that a detailed review of the evidence on vaping by Public Health England, published earlier this year, concluded that e-cigarettes are about 95% less harmful than smoking.

If you dig into the detail of that review, you find that most of the residual 5% is the harm of nicotine addiction. It’s debatable whether that can really be called a harm, given that most people who vape are already addicted to nicotine as a result of years of smoking cigarettes.

But either way, the evidence shows that vaping, while it may not be 100% safe (though let’s remember that nothing is 100% safe: even teddy bears kill people), is considerably safer than smoking. This should not be a surprise. We have a pretty good understanding of what the toxic components of cigarette smoke are that cause all the damage, and most of those are either absent from e-cigarette vapour or present at much lower concentrations.

So the question of whether vaping is 100% safe is not the most relevant thing here. The question is whether it is safer than smoking. Nicotine addiction is hard to beat, and if a smoker finds it impossible to stop using nicotine, but can switch from smoking to vaping, then that is a good thing for that person’s health.

Now, nothing is ever set in stone in science. If new evidence comes along, we should always be prepared to revise our beliefs.

But obviously to go from a conclusion that vaping is 95% safer than smoking to concluding they are both equally harmful would require some pretty robust evidence, wouldn’t it?

So let’s look at the evidence Knapton uses as proof that all the previous estimates were wrong and vaping is in fact as harmful as smoking.

The paper it was based on is this one, published in the journal Oral Oncology.  (Many thanks to @CaeruleanSea for finding the link for me, which had defeated me after Knapton gave the wrong journal name in her article.)

The first thing to notice about this is that it is all lab based, using cell cultures, and so tells us little about what might actually happen in real humans. But the real kicker is that if we are going to compare vaping and smoking and conclude that they are as harmful as each other, then the cell cultures should have been exposed to equivalent amounts of e-cigarette vapour and cigarette smoke.

The paper describes how solutions were made by drawing either the vapour or smoke through cell media. We are then told that the cells were treated with the vaping medium every 3 days for up to 8 weeks. So presumably the cigarette medium was also applied every 3 days, right?

Well, no. Not exactly. This is what the paper says:

“Because of the high toxicity of cigarette smoke extract, cigarette-treated samples of each cell line could only be treated for 24 h.”

Yes, that’s right. The cigarette smoke was applied at a much lower intensity, because otherwise it killed the cells altogether. So how can you possibly conclude that vaping is no worse than smoking, when smoking is so harmful it kills the cells altogether and makes it impossible to do the experiment?

And yet despite that, the cigarettes still had a larger effect than the vaping. It is also odd that the results for cigarettes are not presented at all for some of the assays. I wonder if that’s because it had killed the cells and made the assays impossible? As primarily a clinical researcher, I’m not an expert in lab science, but not showing the results of your positive control seems odd to me.

But the paper still shows that the e-cigarette extract was harming cells, so that’s still a worry, right?

Well, there is the question of dose. It’s hard for me to know from the paper how realistic the doses were, as this is not my area of expertise, but the press release accompanying this paper (which may well be the only thing that Knapton actually read before writing her article) tells us the following:

“In this particular study, it was similar to someone smoking continuously for hours on end, so it’s a higher amount than would normally be delivered,”

Well, most things probably damage cells in culture if used at a high enough dose, so I don’t think this study really tells us much. All it tells us is that cigarettes do far more damage to cell cultures than e-cigarette vapour does. Because, and I can’t emphasise this point enough, THEY COULDN’T DO THE STUDY WITH EQUIVALENT DOSES OF CIGARETTE SMOKE BECAUSE IT KILLED ALL THE CELLS.

A charitable explanation of how Knapton could write such nonsense might be that she simply took the press release on trust (to be clear, the press release also makes the claim that vaping is as dangerous as smoking) and didn’t have time to check it. But leaving aside the question of whether a journalist on a major national newspaper should be regurgitating press releases without any kind of fact checking, I note that many people (myself included) have been pointing out to Knapton on Twitter that there are flaws in the article, and her response has been not to engage with such criticism, but to insist she is right and to block anyone who disagrees: the Twitter equivalent of the “la la la I’m not listening” argument.

It seems hard to come up with any explanation other than that Knapton likes to write a sensational headline and simply doesn’t care whether it’s true, or, more importantly, what harm the article may do.

And make no mistake: articles like this do have the potential to cause harm. It is perfectly clear that, whether or not vaping is completely safe, it is vastly safer than smoking. It would be a really bad outcome if smokers who were planning to switch to vaping read Knapton’s article and thought “oh, well if vaping is just as bad as smoking, maybe I won’t bother”. Maybe some of those smokers will then go on to die a horrible death of lung cancer, which could have been avoided had they switched to vaping.

Is Knapton really so ignorant that she doesn’t realise that is a possible consequence of her article, or does she not care?

And in case you doubt that anyone would really be foolish enough to believe such nonsense, I’m afraid there is evidence that people do believe it. According to a survey by Action on Smoking and Health (ASH), the proportion of people who believe that vaping is as harmful or more harmful than smoking increased from 14% in 2014 to 22% in 2015. And in the USA, the figures may be even worse: this study found 38% of respondents thought e-cigarettes were as harmful or more harmful than smoking. (Thanks again to @CaeruleanSea for finding the links to the surveys.)

I’ll leave the last word to Deborah Arnott, Chief Executive of ASH:

“The number of ex-smokers who are staying off tobacco by using electronic cigarettes is growing, showing just what value they can have. But the number of people who wrongly believe that vaping is as harmful as smoking is worrying. The growth of this false perception risks discouraging many smokers from using electronic cigarettes to quit and keep them smoking instead which would be bad for their health and the health of those around them.”

37 thoughts on “Dangerous nonsense about vaping”

  1. It seems that she can’t even keep internal consistency in her own article. She claims that the study was done just with vapor and that it was done with extract made from vapor. She switches back and forth between calling it “smoke” and “vapor” even though they are VERY different things.

    She claims at various points that nicotine is causing some of the damage, and that the dosage of nicotine received from e-cigs is too small to cause the damage:

    “The San Diego team found that the nicotine versions caused worse damage” followed farther down by “but it looks like the amount of nicotine that the cells are exposed to by e-cigarettes is not sufficient by itself to cause these changes.” Did the nicotine actually cause more damage? One can’t even tell what the author is reporting about that. It does but it doesn’t… and good luck making an informed decision!

    Of course the mitigating information isn’t contained in the headline, the lead paragraphs, or any photo caption. In every case, the conflicting information (i.e. the stuff that looks good for vaping) is either omitted entirely or buried farther down in the article. Typical anti-vaping bias.

  2. The underlying problem here is yet another failure of peer review. How could such a flawed study be published at all? What about asking it to be withdrawn?

    1. The paper itself is not actually that bad, Les. Nowhere does it make the claim that vaping is as dangerous as smoking. That’s just something that was added for the press release.

      Mind you, it does say in the discussion that the harmful effects of vaping are seen at “biologically relevant doses”, which is perhaps questionable.

      1. I’m wondering what is the point of publishing a paper that doesn’t compare like with like, and doesn’t explain why some data were excluded.

        I was told years ago that a press release has to be written such that a journalist can drop it into the publication more or less as is. In this case though a poor release has been mangled even further. Conversely, I have recently been told by certain academics that fact-checking by investigative journalists is much more rigorous that a lot of academic research. Some tension between these surely?

        1. Yes, it’s also very poor science that they don’t explain why the positive control data were excluded. It’s not a great paper, that’s for sure. Though probably no worse than thousands of other papers that get published every week.

          I still think the real blame here lies with the people who wrote the dreadful press release and with the journalists who regurgitated it so uncritically.

    2. Peer review, in the normal sense of the term, largely doesn’t exist in “public health” literature, and especially not for tobacco-related subjects. This phenomenon has now even started to creep into the pages of previously reputable journals like the NEJM.

      If you write a paper concluding that smoking is the most horrible thing in the universe, and it kills basically everyone, it gets published. There probably is some pay-for-play involved, because it’s hard to conceive of the entire editorial board of any medical journal passing around a study like this (which makes gradeschool-level errors like mistaking correlation for causation, and which states conclusions that, to any living human with a functioning intellect, simply do not follow from the data) and declaring “Yup, looks good to me.”

      Tobacco controllers have monopolized the conversation for so long that their claims just aren’t scrutinized by anyone, including people in government and science whose job it is to scrutinize such claims.

      Of course, on the other side of the coin, if you write a paper that calls into question the claims made by tobacco controllers, and your qualifications, data, and methodology are all above reproach, the same journals will be extremely hesitant to publish it, or they may just refuse altogether.

  3. I haven’t gone through the original paper, but I agree with the substance of your critique of both Knapton’s report and her strange lack of ethical journalistic conduct, Adam.

    There is, however, one point I’d like to make. I’m of the opinion that pro-active disclaimers, in form of COI statements, as encouraged by the PLOS journals and many others, are a good thing when it comes to science communication. And that goes for both Knapton and you (even if your – in plural – media/platforms are different).

    A lay reader may well want to consider the following questions:
    1. Does Knapton have a pre-existing bias against vaping which has influenced the slant of her essay?
    2. Do you, Adam, have a pre-existing bias towards vaping which would incapacitate you from judging the research paper and/or Knapton’s take on it?

    A statement explaining the lack of bias/COI or why the report/critique may be valid even if there exists some bias would go a long way; blocking people who question a hypothesis on Twitter is not quite a reasonable response to said questions. :)

    And I present this humbly, because of a personal realization. Having lost people early on to cancers which are strongly associated with cigarette smoking, I have a very strong anti-tobacco bias and have been advocating against smoking all my life in an evidence-based manner (since I am a working, bench-scientist after all). When that anti-tobacco bias turned into anti-smoking bias (encompassing all manner of smoking including vaping and pot-smoking) in my mind, I don’t know – but the recent realization of the presence of that latter bias has made me take a step back, reevaluate my stance, and reeducate myself on the concepts of harm reduction and risk mitigation. This is the reason why this blogpost of yours – which advocates for scrupulousness in science communication – has resonated with me strongly.

    1. That’s an entirely fair question, Kausik, and one I shall try to do my best to answer. I am strongly of the opinion that we are never free of conflicts of interest.

      That said, I first came to the question of vaping with very little skin in the game. I have never smoked nor vaped. I have no financial relationships with any of the relevant players. For my day job, I am a salaried employee of a contract research organisation that runs clinical trials on behalf of pharmaceutical companies and medical device manufacturers. In theory, we could run trials of smoking cessation products, though to the best of my knowledge we have not done so. Certainly I’ve not been involved in any such trials if we have.

      Of course, non-financial conflicts of interest are often more powerful than financial ones. This article mentions very strong COI effects for the “allegiance effect”, where you are biased towards an intellectual position you have taken previously.

      So with that in mind, probably my most relevant COI is that I have previously written blogposts that could be described as taking a pro-vaping position, such as this one.

      I should point out that I previously took that position simply because I looked at the debate from the perspective of a disinterested outsider and decided that the science was on the side of the pro-vaping argument. But nonetheless, having taking a pro-vaping position once, that becomes a COI when I write about vaping subsequently.

      I hope that answers your question.

      1. Oh, absolutely, and thank you, Adam. I wish Sarah Knapton would also do the same and be transparent. I’m, too, of the opinion that we are almost entirely – as you put it – never free of conflicts of interest, and that is precisely why I feel that COI declarations, especially for non-financial ones, are essential for good science communication.

    2. Thanks, Kausik for pointing out that the anti-tobacco bias has turned into an anti-smoking (anything at all) bias.

      I hadn’t appreciated this before and could not understand what appeared to me to be an emotional bias against vaping.

      Thanks for putting it so plainly.

  4. This article has been copy/pasted on numerous UK tabloids today.

    New regulations just around the corner and the media continue to publish blatant e-cig hate propaganda.

    Sad times

  5. Motivation for dissing ecigs = sell more cigarettes. Who would that benefit? I came across diacetyl used as a medium in ecigs and I know of popcorn lung caused by diacetyl so that seems a bad thing to use but is a tangent from the article which does a good job of slapping down a poor paper. But what do I know, I am mortal.

      1. And a bit of further computation on the amounts/concentrations involved also reveals that you’d usually have to vape several tens of thousands of puffs per day in order to even approach the “safe” boundary level for factory workers.

        – MJM

    1. I should really look up more about the popcorn lung/diacetyl thing, but one thing that was pointed out to me was that diacetyl is present in cigarettes in a far higher concentration than ecig liquid, but you never hear of smokers getting popcorn lung. Also, I looked at all the links I could find to see if I could determine which products still contain diacetyl, but lo and behold, the study apparently doesn’t mention which were tested, or this was wasn’t reported on in a way I could locate, which seems like extremely important information to me.

    2. Tobacco controllers are who it benefits. If everybody stops buying cigarettes, they make no money. Basically all their funding is directly tied to cigarette sales. If those sales evaporate, their entire industry (a hugely profitable one that wields massive political influence) ceases to exist.

      Tobacco control suffers from the worst of all conflicts of interest: an existential one. If your livelihood depends on the maintenance of something it is your ostensible mission to destroy, it is not possible to be objective or dispassionate. People reliably and consistently act in their own self-interest. People who have good-paying jobs generally want to keep them. People whose qualifications do not translate to any other field of endeavor generally try to avoid having to switch careers.

  6. Wrong information kills. I have posted 2 press releases from the US CDC and UK MHRA with a personal essay. http://www.drsusanna.org/mjotatalkshealth/cigarettesmoking.html

    Cigarette smoking is responsible for all sorts of horrible diseases that shorten life because the smoker is inhaling bits of matter filled with toxins.

    From the UK MHRA “Smoking is the biggest single cause of avoidable death – killing 80,000 people in England each year. Making safe and effective products available for people who smoke can help them cut down or quit.”

  7. Please note that the referenced study (whose conclusion misrepresented the study’s findings) was funded by the US Department of Veterans Affairs (VA) and the US National Institutes of Health (NIH), and the deceitfully misleading press release was issued by the US Department of Veterans Affairs.

    This is just the latest of hundreds of studies funded by the Obama administration whose conclusions and press releases misrepresent the study findings in order to demonize e-cigs, deceive and scare the public to lobby for US FDA’s proposed ban on the sale of all nicotine e-cigs to adults.

    While the reporter’s article was horrendous, she is just one of hundreds of useful idiots in the news media that has repeated the deceitful propaganda that is Obama’s War on Vaping.

    1. This is just about the stupidest thing I’ve heard today.
      I’m pro-vaping, and I don’t care if it’s Donald Trump or Barack Obama in the White House… the President does not control every single press release that comes out.
      Obama himself is a smoker, and has been criticized for “allowing” e-cigs at the White House dinner. I cannot find a single example of Obama saying anything at all about vaping or e-cigs/vaporizers. So how you can take that information and determine that there is some massive “War on Vaping” is beyond me.

  8. I’m curious what happened to the control cells during the eight weeks. In science experiments they always have a control. Cells that have nothing done to them to see the differences in the end. Wonder how much they broke down in eight weeks.

    1. There were 2 kinds of controls, Jim. There was a negative control which wasn’t treated with any kind of vapour or smoke, and there was a positive control treated with an extract of cigarette smoke.

      You can read all about the negative control in the paper (link above). As I mentioned in the post, you can only read partial results for the positive control. They did several different assays, and they only report the positive control results for some of them.

  9. The real reason that there have been so many bad articles on ecigs lately is purely down to one thing, money. Or more precicely, clicks.

    Whenever some moron like Knapton writes an article as bad as this the amount of interest (read: page views) it creates far outweighs anything that a balanced article would. The more controversial the more page views and, by definition, the more clicks on the ads that these outlets have on their web pages. You get loads of pro vapers linking to the article on Twitter, large e-cig forums get wind of it plus Facebook posts etc. all ironically give the BS article extra traction.

    It really is as simple as that, it’s 100% click-bait. The newspaper outlets don’t care about their reputation when print media is dying on its arse and sole revenue eventually will come from ads on web pages.

    The best thing to do would be to ignore the bastards (do not give them free traffic FFS!) but I know it is very difficult not to get angry when we continually see utter crap like this.

  10. “The cigarette smoke was applied at a much lower intensity, because otherwise it killed the cells altogether. So how can you possibly conclude that vaping is no worse than smoking, when smoking is so harmful it kills the cells altogether and makes it impossible to do the experiment?”

    PERFECTLY summarized! Very similar tricks and techniques are used to produce “scientific” results regarding secondary smoke or even “thirdhand” smoke. While most of my “TobakkoNacht” book fouses on smoking, I do have one fairly extensive chapter that examines a number of vaping studies. One of those studies touted a danger that could only be achieved if someone drank 15,000 gallons of e-liquid per day, every day, for fifty years straight. Seriously… that’s how the figures worked out. See:

    http://www.tobakkonacht.com/PDF/TNSite-SlabVIII-OfVaporsAndVapers.pdf

    for the details, and backtrack to the home page and “Book Selections” if you want to see the similarity of so many of their other tricks.

    Remember: almost every Antivaper was previously an Antismoker. They’ve simply carried the same tricks and lies with them over to the new campaign.

    – MJM

  11. Two glaring flaws in their charade:
    1. Cells that die don’t cause cancers.
    2. Their Comet assay has not been validated to predict cancer (and a similar one was demonstrated NOT to do so).

    In Epstein-Barr virus-transformed lymphoblastoid cell lines established from prospectively collected peripheral blood samples of 117 lung cancer patients with 117 matched controls, the alkaline Comet assay and the host cell reactivation (HCR) assay with the mutagen benzo[a]pyrene diol epoxide were unrelated to lung cancer risk. “The magnitude of the association between the bleomycin assay and lung cancer risk was modest compared with those reported in previous lung cancer studies but was strengthened when we included only incident cases diagnosed more than a year after blood collection (P(trend) = 0.02), supporting the notion the assay may be a measure of cancer susceptibility.” [However, infections by both Epstein-Barr virus and cytomegalovirus make cells more susceptible to damage by bleomycin.]

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3010173/

    And they note that “Our study is the first to prospectively evaluate three widely used mutagen sensitivity assays in relation to lung cancer risk.” So, the purveyors of mutagen assays are crassly deceiving the public when they pretend that those assays are relevant.

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