September 26th, 2014

Falsely exaggerating risks scares people off things – new study finds

Let’s put this on e-cigarettes! That’ll teach ’em…

A promising contender has emerged for the coveted Worst Published Paper of All Time award…  

Popova L, Ling P. Nonsmokers’ responses to new warning labels on smokeless tobacco and electronic cigarettes: an experimental study, BMC Public Health 2014, 14:997  doi:10.1186/1471-2458-14-997 

Researchers from UCSF (where else?) exposed non-smokers to different types of warnings on smokeless tobacco and e-cigarettes to see if their perceptions of risk changed. Funnily enough they did – especially when e-cigarette users were shown graphic warnings suggesting that e-cigarettes cause mouth cancer – using the graphic above.  The graphic below shows the design of the experiment: non-smokers were randomised into 6 groups and shown a message related to smokeless tobacco or e-cigarettes – their change in perception of risk was recorded before and after exposure to the warning message.

Click to enlarge

No doubt the e-cigs cause mouth cancer warning was shocking news to the subjects of the experiment: and they duly modified their assessment of the risk of these products. The graphic below uses an index of perceived harm (actually a very poorly designed index, but that’s another story) and the lines below show how perception change before and after exposure to different warnings – broadly classed as ‘warnings’ and ‘endorsements’. Upward slope means they found it more scary after seeing the warning.

Screen Shot 2014-09-26 at 08.51.18

The problem is that the warning statement that has the biggest reaction (a graphic showing e-cigarettes causing mouth cancer) is simply not true, and other statements are just more subtle ways of misleading about risk [discussed in Kozlowski & O’Connor 2003].  However, the effect the researchers were looking for was not the impact of truthful communication, but a deterrence effect that is unconcerned by deception.  On the basis of this, they thought they had enough to recommend policy to regulatory agencies like the FDA.

Regulatory agencies should not allow “lower risk” warning labels, which have similar effects to the “FDA Approved” label, which is prohibited, and should consider implementing graphic warning labels for smokeless tobacco products and e-cigarettes.

There’s so much wrong with this, I hardly know where to start:

  • Concealment. Saying something is lower risk when that is true is not an ‘endorsement’, it is fact and it is unethical to conceal it
  • Deception. Exaggerating or inventing risks, or communicating them in a way that is likely to be perceived incorrectly is deception. It may change risk perceptions adversely and may cause behaviour change that is harmful to individuals
  • Harm-induction. The authors appear unconcerned by potential adverse changes in tobacco use that might arise from the changed perceptions: smokers who might have switched to lower risk products may remain as smokers; users of lower risk tobacco products may become indifferent to risks and start to smoke; young people may initiated nicotine use through smoking rather than less risky approaches; smokers will reject these products as ways of quitting
  • Non-sequitur. The FDA does not allow products to claim they are FDA approved if they are not – that is not the same as prohibiting truthful risk communication
  • Narrow population focus. The target population here can loosely be counted as: “non-smokers considering trying smokeless tobacco or e-cigarettes, who go as far as reading what is on the pack“.  It assumes that the warning intervention will work for this very small group at this point
  • Unexamined objective. The unstated assumption that a deterrent to non-smokers trumps all other concerns – including truthfulness and the welfare of tobacco users
  • Real world impact. No consideration of whether (wrong) perceptions created in the artificial test translate to real life perceptions, and whether such perceptions change behaviour
  • Credibility haemorrhage. No consideration of the general weakening of trust in warning messages (and all communication by public health authorities) when examples can be pointed out with demonstrably false information.
  • Hubris. Nothing at all in the experiment justifies the policy proposal to regulatory agencies – it is based on a flawed experiment using misleading messages focussed on a narrow subset of the at-risk population with no consideration of unintended harmful impacts on tobacco users
  • Unethical experiment. The authors should not have been given ethical clearance to mislead their subjects in this way – deception in experimentation is a serious matter and requires a substantial justification
  • Incompetent journal. It’s astonishing that this passed through editorial scrutiny and peer review process without these themes being raised in criticism

I left a comment on the BMC web site – here it is.

This paper uses an inappropriate and unethical experiment to advocate misleading people about risk in order to modify their behaviour in ways that the authors favour.  The authors appear untroubled by the fact that smokeless tobacco and e-cigarettes actually are of the order 95-100% less risky than smoking [1][2].  If you smoke this is important health-sensitive information. If you don’t smoke, this information is merely true.

Yet the authors advocate removing any communications of the truthful relative risk and replacing these with a text warning [not a safer alternative to cigarettes] that is misleading, or, even worse, graphic warnings suggesting that smokeless tobacco and e-cigarettes cause oral cancer. There is not one single piece of evidence from anywhere that e-cigarettes cause oral cancer, and there is not even a speculative mechanism that has been identified by which it would be plausible. The communication is pure fabrication. Likewise, the most recent assessments of modern American and Scandinavian smokeless tobacco also suggest zero or minimal risk of oral cancer [2][3] – yet the risks of smoking are well understood and orders of magnitude greater than either use of smokeless tobacco or e-cigarettes.

The authors appear oblivious to the potential harms that may arise from misleading people about the risk of alternatives to cigarettes – namely that they will continue to smoke or start using cigarettes unaware that there are much lower risk alternatives that they could choose instead. It appears that the authors approach is to mislead subjects of the experiment in order to increase the subjects’ aversion to using these products. On the basis of results showing that they are ‘successful’ in creating false perceptions of risk, they make a policy proposal to generalise this to a regulatory intervention.

The ethics of deceiving people with false or misleading information deserves greater scrutiny given the harm it can cause, and the individuals and institutions that engage in this disreputable practice should face professional sanctions [4].

I am surprised that this paper is published without some challenge on these themes from peer reviewers.

[1] Hajek P, Etter J-F, Benowitz N, et al. Electronic cigarettes: review of use, content, safety, effects on smokers and potential for harm and benefit. Addiction 2014 [link]

[2] Lee PN. Summary of the epidemiological evidence relating snus to health. Regul Toxicol Pharmacol2011;59:197–214. doi:10.1016/j.yrtph.2010.12.002 [link][update]

[3] Lee PN, Hamling J. Systematic review of the relation between smokeless tobacco and cancer in Europe and North America. BMC Med 2009;7:36. [link]

[4] Kozlowski LT, O’Connor RJ. Apply federal research rules on deception to misleading health information: an example on smokeless tobacco and cigarettes. Public Health Rep;118:187–92. [PDF]

Carl Phillips has added more insights on this: New public health research: lying to people can affect them (as if they didn’t already know) and has done his own peer review as a case study.

33 comments to Falsely exaggerating risks scares people off things – new study finds

  • Many countries are making tighter rules and looks like they will make it tighter. Giving people open choice is quite important. E Cigarette and nicotine scare is probably the reason why so many people still smoke and will continue. Info should be factual and not biased.

    Big pharma are the sponsors of anti-ecigarette research either directly or indirectly. It may not be totally unbiased.

  • […] Letter to delegates to FCTC COP-6    Falsely exaggerating risks scares people off things – new study finds » September 28th, […]

  • […] travesty, and he covered the breadth of it well, so I am not going to reinvent the wheel here.  Go read what he wrote first. Then come back to this, wherein I go deeper into a few specific […]

  • […] Bates, author of the Counterfactual, wrote a detailed point-by-point criticism of this paper.  He began by saying, “A promising contender has emerged for the coveted Worst […]

  • Anja M.

    Aha. False and misleading warnings frighten people off from safer alternatives.

    Let me tell you a true story:
    When my former husband and I were in our twenties and both smokers, he wanted to switch to chewing tobacco. I had read all the warnings about chewing tobacco causing mouth cancer – and believed them at that time. That was in the 1980s, long before I started vaping and thus reading up on the subject.

    So I told the guy “Do not do that! It can give you mouth cancer!”
    He replied “But smoking can give you lung cancer”
    And I said “So what? Would you rather die of lung cancer and be dead or live with half your face cut away?”
    – He saw my point and continued smoking.

    No, I am not making this up. This was the result of the misleading propaganda. The desired result, I may add.

  • Allen

    How difficult would it be to find out what this farce cost us taxpayers?

  • […] is here and Carl V Phillips’s and Clive Bates’s devastating critiques of it are here, here, here, and in comments attached to the article at the journal here. People who manage to publish […]

  • […] points better than any abstract principles can. As I discussed in the previous post, which built on what Clive Bates had already written, a newly published article by Popova and Ling was unethical and misleading, fraught with anti-THR […]

  • roger that

    The last time I smoked a cigarette was 2 weeks ago. My close family is thrilled, changed their casual perception of vaping as dangerous, and agree that vaping is a great thing. Other people around me are noticing Ihaven’t smoked and asking about it. The impression I get from them is they are a bit uneasy, conflicted about my accomplishment. What happens if millions of people quit? Does it create a more competitive world for the non smokers? I think this is an influence on the vaping debate.

  • Brian

    Basic psychology explains why this work exists and persists. This is a group of people who believe down to their souls that all tobacco is evil, no one should ever use it, and it (and all its forms) should be banned from the planet. They acquired this unshakeable belief during the heady days of cigarette smoking when they were mostly correct on the science and generally admired for their commitment to public health. Along comes smokeless tobacco and e-cigarettes, with proof that they are dramatically less risky than smoking, and now they’re buried in an avalanche of cognitive dissonance. As Carol Tavris explains in “Mistakes Were Made (but not by me),” people are highly motivated to resolve this dissonance. But there’s only a few ways out. First, you could admit your beliefs are wrong and adjust them accordingly. Tobacco control (along with myriad governmental organizations, NGOs, journal editors and reviewers) have careers, reputations, and millions of research dollars at stake with the “all tobacco is evil” belief. So the first option is out. Second, you can declare the new information (and those that bring it) wrong, misguided, or worse, tools of the evil tobacco empire. And finally, you can engage in confirmation bias as a way of continuing to support your beliefs. This involves looking at (or reporting) only evidence that supports your view while ignoring or discarding everything else. You can find elements of these final two approaches in almost every tobacco control research report. This also explains why so many in tobacco control are such lousy scientists. Why bother with such details when you’re already convinced you know the truth?

  • Bill Godshall

    This study is so pathetic that I expect the FDA will invite (and pay for) Pam Ling and/or Lucy Popova to present this study at the FDA’s Public Workshop on e-cigs on December 10 & 11.
    http://www.fda.gov/TobaccoProducts/NewsEvents/ucm414814.htm?

    I also expect that FDA will not allow many of us to present the truthful scientific and empirical evidence about e-cigs at that same Public Workshop (just as FDA did at the Modified Risk Tobacco Product workshop it held several years ago, and just as FDA’s TPSAC has done at its meetings).

    • Clive Bates

      Hi Bill,

      Hmmm… not if they are tied up in an ethics violation inquiry or if BMC withdraws it first. But it is the lowest form of garbage. Well apart from the next one on third hand vapour exposure.

      How does this work exist and persist?

  • Yvonne

    This, surely, is yet another classic case of “follow the money”?

  • Mark Magenis

    When you start with an assumption and conclude with conjecture you should loose the right to
    Claim science is involved.
    Sadly the political world is happy to operate under such conditions, because it’s expediant to be unfettered by reality.

  • Michael Barton

    I have often wondered what happened to Muhammad Saeed al-Sahhaf after the Iraq war. Now we know. Comical Ali is back and as brazen as ever.

  • spinster

    Oh good heavens, why don’t they just put ‘WARNING: This product is full of dog poo, bogies and syphilis and will make your willy drop off’? That’d work :-)

    Thanks once again for the clarity and sense of your writing Clive.

  • The National Cancer Institute’s URL is http://www.cancer.gov — so this is in the same regime as the FDA and CDC.

  • Spazmelda

    Didn’t Andrew Wakefield already demonstrate this?

  • Robert Jones

    You know the worst thing about all this misinformation about vaping is that the writers of it are actually killing people.

  • Chris Price

    Although it seems a little excessive to say that cancer organisations may on occasion promote and protect cancer, in the tobacco control area it appears more likely than not. It may at first seem inappropriate to bring up the fact that such orgs receive a great deal of funding from the pharmaceutical industry, who have more reasons than most to protect cancer. Unfortunately the topic area of smoking and health is a free-fire zone where normal rules don’t apply – hate speech, abuse of minorities, and ignoring preventable deaths is not just allowable but seems official policy.

    In the end, it is an unfortunate fact that cancer makes a lot of people a lot of money. A large number of jobs depend on it, and it may help to remember that tobacco and health is an area where the normal rules don’t apply: virtually anything seems allowable.

  • […] A promising contender has emerged for the coveted Worst Published Paper of All Time award… Popova L, Ling P. Nonsmokers' responses to new warning labels on smokeless tobacco and electronic ciga…  […]

  • Andrew Summerfield

    Your opening line is brilliant – ” A promising contender has emerged for the coveted Worst Published Paper of All Time award… ”

    I’d like to offer a new award for this study – “Do you think we were all born yesterday award”

  • Dragonmum

    Graduates of the Josef Goebbels Academy of Misinformation leading to a degree in subsidised Lying Propaganda and a chance of entering for the Josef Mengele Prize. This is so awful it’s almost amusing.

  • Alan Depauw

    What is saddest of all is that so many of our legislators are liable to fall for these Goebbels-sized lies. With elections looming, it will be vital for voters to question candidates closely on their policy towards ecigs, lest they find themselves with a government susceptible to such lethal propaganda.

  • Mark Magenis

    This is simply proving that propaganda works, even in its purest form and designed to deceive.
    I think we already knew that, just look at how totalitarian states have worked throughout history.
    Who funded and briefed this non research is the interesting issue.

    • Clive Bates

      Mark – amazingly the funder is the National Cancer Institute of the US – in theory a gilt-edged institution.

      Maybe one of its committees will take a look if prodded?

      • Cancer Research again.

        This seems to the primary target of the social engineering parasite FCTC spreading all over the world. WHO might be patient zero.

        It grows like a tumour and spreads metastases into other public health bodies. Always leaching on the formerly good name of its host.
        It emits critic suppressors and delusionary agents that befuddle the public. Most receptive seem to be “journalists” and politicians.
        It has developed a symbiotic connection to the pharmafia kraken which helps it feed and spread, while it cares to exterminate the kraken’s competition.

        We need a cure. Fast.

      • Bill Godshall

        Nothing amazing about NCI funding this junk science, as the NCI has been funding much/most of the junk science and THR opponents for the past 25 years to lie about the negligible risks of smokeless tobacco products, to demonize the products, and to lobby for counterproductive smokeless tobacco regulations (that protect cigarette markets).

  • prog

    ‘On the basis of results showing that they are ‘successful’ in creating false perceptions of risk, they make a policy proposal to generalise this to a regulatory intervention.’

    As also employed to force through smoke-free legislation in order to denormalise smokers.

  • Nigel Rudd

    I wish that I was as clever as some of these researchers.

    I think we need to know if graphic warnings of spontaneous human combustion on wine labels will put people off buying wine.
    These are scientists (supposedly), so maybe we should excuse their lack of common sense, and put it down to a sheltered life in academia. I’m not a fan of conspiracy theories, but you have to wonder if such futile and ridiculous research has been ‘encouraged’ by outside influences.

    • prog

      It’s not outside influences, simply run of the mill TC/Big Pharma backed junk designed to maintain revenue from, and control of, nicotine and NRT.

    • Bill Godshall

      This so-called research was funded by the National Cancer Institute, which has funded many so-called researchers to protect cigarette markets by grossly exaggerating the risks (and denying or greatly downplaying the benefits) of smokeless tobacco products, e-cigarettes, nicotine and flavorings, and who lobbied for the FSPTCA to require even larger intentionally false and misleading warnings on smokeless tobacco, to make it a federal felony for smokeless tobacco companies to truthfully claim that their smokeless tobacco products are less hazardous than cigarettes, and to impose the deeming regulation to ban >99.9% of e-cigs.

      Also note that the FDA has awarded the same UCSF junk scientists lots of money to conduct even more junk science, lie about the risks of e-cigs and nicotine, and lobby for more FDA regulations that protect cigarette markets and threaten public health.

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