- Sunday, 28 September 2014 15:30
Response letter by Dave Bareham to my critique of his critique
In response to my previous critique of his comments, David Bareham wanted to upload his views as a comment. Unfortunately, the character limit of comments made this impossible. Therefore, I will present his response herein as a guest post. After his letter, I will provide my short response.
BEGINNING OF LETTER
Dear Dr Farsalinos
Many thanks for your critique of my critique. However, there are a few issues and errors in your piece that I would respectfully like to draw your attention to.
1. You state that “there are only 2 studies mentioned”. This is significantly erroneous. The studies mentioned that you miss are:
· Hutzler et al, June 3rd 2014 here http://link.springer.com/article/10.1007%2Fs00204-014-1294-7 which as you know confirmed the presence of ethylene glycol in samples. As you stated in our email correspondence in June: “I was also shocked to see the presence of ethylene glycol in many samples. It is a disgrace for these manufacturers to use this chemical, which is not supposed to be used for human consumption.” We also discussed the presence of the carcinogen coumarin in samples, which was utilised by the tobacco industry as an “impact booster”, as you know. Clearly, the scientists also confirmed the presence of high levels of carbonyls, especially in the range of 150oC. Your You Tube “experiments” demonstrate temperatures in this range and above, as evidenced.
· This cited Trading Standards link http://www.tradingstandards.gov.uk/policy/policy-pressitem.cfm/newsid/1551 takes the reader to a study commissioned by Public Health England that “seeks to explore the ease with which young people may currently purchase e cigarettes and similar products” and found that “Of 574 visits made by young people in March 2014, successful purchases were made on 227 occasions (40%). The highest proportion of purchases to visits made was from market stalls (80%) followed by independent pharmacies (74%).” Kevin Fenton of Public health England subsequently states that: “The report finds that, despite age of sale warnings, many retailers are selling e-cigarette products to young people. This is unacceptable.”
· This Lorillard study http://legacy.library.ucsf.edu/tid/otl76b00/pdf from 1978 is formed from focus groups and looks at the attraction of flavours in tobacco
· This ASH England survey study http://www.ash.org.uk/files/documents/ASH_891.pdf is currently pivotal in assessing the prevalence of electronic cigarette use in the UK currently. However, as stated, the data for under-16s (n=1428) dates to March 2013, and is therefore clearly outdated.
· This paper http://pubs.rsc.org/en/content/articlelanding/2014/em/c4em00415a#!divAbstract was provided to Professor McNeill in full in the original email to her. I am sure you will be able to obtain this very recent study of particulate metals etc in full also.
· The paper Hajek P, Etter J-F, Benowitz N, McRobbie H (2014) Electronic cigarettes: review of use, content, safety, effects on smokers, and potential for harm and benefit is also cited, as the cut-off point for reviewing research in this study was February 2014, and so several key papers including Kosmider et al and Hutzler et al were not reviewed in it.
· I cite this abstract, which you comment on, but initially you fail to count it https://www.ersnetsecure.org/public/prg_congres.abstract?ww_i_presentation=70441
· Moreover, the Policy Statements proposed by the AHA and the AACR/ASCO are all clearly cited in evidence, and so when I cite these documents (as you have) we are also thereby citing the evidence that forms the foundations of those Statements.
· I am therefore really surprised that you state that I only cite two studies. In this circumstance it is apparent that, to this point in your “critique” at least, there is an absence of even face validity in what you write.
2. Moreover, your statement “The paper by Goniewicz and Lee, finding nicotine (but not TSNAs as stated in the response)” is misleading, as what I stated was the authors discussed the “potential dangers of third hand nicotine from Electronic Cigarettes, and their potential to form carcinogens – TSNAs - in the presence of other chemicals” (my changed emphasis). The Goniewicz and Lee paper does actually state in their abstract that “Nicotine from tobacco smoke has been shown to react with oxidizing chemicals in the air to form secondary pollutants, such as carcinogenic nitrosamines” and they cite a key paper entitled “Formation of carcinogens indoors by surface-mediated reactions of nicotine with nitrous acid, leading to potential thirdhand smoke hazards (Sleimana et al) which I attached in the original email to Professor McNeill. Clearly, Goniewicz and Lee found no TSNAs, but part of their reasoning for justifying this preliminary piece of work was to point out this potential risk: which was my point.
3. You then state that “The rest of the presentation is based on newspaper or electronic news-media articles”, which of course were included to demonstrate and evidence some of the language that has been used publically by some pro-harm reduction advocates. The TIME news media article, if read in full, is highly enlightening, being a report based on the transcript of two top CEOs being questioned by two Senators/former lawyers. One of the CEOs contradicts themselves, for example, in drawing a distinction between adult and child flavours of e-juice, which is wonderfully picked up on by the questioners. I recommend all to read this piece in full.
4. You continue “letters by attorney generals (as if they have the knowledge or expertise to judge the harmful potential of e-cigarettes compared to tobacco)”, which again I found a little surprising, and somewhat condescending. It was Attorney Generals that finally managed to “nail” the Tobacco Industry to the Master Settlement Agreement and to successfully sue them for approximately $246Bn. They certainly recognized the pivotal importance in this achievement of key expert scientific “whistleblowers”, for example, Dr J.S.Wigand. Specifically, you also miss the point again, however, as I cited their specific statement made in evidence to the FDA with regard to electronic cigarette flavourings. This was not, therefore, their stance on the relative potential harms of electronic cigarettes to tobacco: this was their evidence and stance on the risk of children being preferentially drawn to certain flavours more than adults. Their opinions on this issue, as stated, significantly coincide with other independent organisations e.g. AACR/ASCO, as cited.
5. You state that “we were very careful in our expressions: “…e-cigarettes potentially offer a much less harmful form of nicotine delivery . . . “. However, in this response by yourself and Riccardo Polosahttp://www.bmj.com/content/349/bmj.g4597/rapid-responses you stated that: “Evidence that inhalation of e-cigarette aerosols may be of concern for the lung is non-existent”. I will again, therefore, strongly argue that there are times when there is significant incongruity between the statements that you and others make, and again confirm my significant concern that some of these statements, by understating what we currently know, could be misinterpreted by any potential user that these devices emit no potentially harmful substances.
6. You state that: “. . . but in almost every report which has been constructed with the purpose of misleading the public. Why? Because it is easy to create confusion, by selectively presenting the potential adverse effects of a product without mentioning any potential benefits.” I take that you do not mean my report, as I clearly state what I believe and what my clinical practice is at the very start of my “critique”. Interestingly, this is the side that you choose to focus on, but, as per the critique above, your “analysis” appears seriously lacking in many other aspects.
7. You state: “Is it appropriate to inform smokers that the levels of carbonyls emitted from e-cigarettes can (under certain conditions) be similar to or higher than smoking, but to hide from them that exposure to nitrosamines is at levels similar to NRTs (>1000 times less than smoking) and that carbon monoxide and polycyclic aromatic hydrocarbons are infinitely lower (i.e. absent)? “ I tell them all of this, both positive and potentially negative, and more e.g. potential cytotoxic profiles of some flavourings (e.g. Bahl et al, 2012), because I believe people need to be able to make an informed choice. However, this is still true for all populations, current- and non-smokers, especially youth. I believe you concur with this when you state: “Obviously, every non-smoker also deserves to know that the e-cigarette is not a safe new habit for everyone to adopt but a tobacco harm reduction product.”
8. Finally, you state that “Policy makers and the public require scientists to present evidence objectively . . . “. Your Group cite Clive Bates, again. Is this your definition of presenting “evidence “objectively, here: http://www.clivebates.com/?p=2073 where Mr Bates “critical analysis” involves accusations of “slurry gusher” science? Or here http://www.clivebates.com/?p=2011 where the graphic removed at the request of the Legal Counsel of The WHO was a WHO icon, with a scull and cross-bones put in it? It seemed to me to be a curious citation, when the second letter to Dr Chan by electronic cigarette advocates utilised one of Mr Bates’ Counterfactual Website postings, as this would have actually led readers at the WHO to these very postings.
END OF LETTER
My response will be very short. WHO has proven his empathy against e-cigarettes repeatedly, even in the social media. Such a campaign is not science-based, and is damaging the reputation and credibility of the WHO.
Concerning the statement by me and Polosa that “Evidence that inhalation of e-cigarette aerosols may be of concern for the lung is non-existent”, it is true that no single study has ever found that the respiratory function is compromised when switching from smoking to e-cigarette use. This is the response to people who present the THEORY that e-cigarettes impair lung function as already proven. Our statement was a reminder to them that no such study exists. Obviously, we must wait for research evidence (and there is some evidence for beneficial effects when switching; but we need more), but we will continue to criticize anyone who mis-presents his reservations and theories as already established evidence.