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Corporate Sponsorships May Have Gone Too Far

Posted By Jonathan Noel, Monday, February 17, 2014

According to a report on, McDonald's is supplying free food to athletes who are staying in the Olympic village...

Wait, what?

Corporations, particularly those who try to sell us products known to cause harm, buy sponsorship deals for sporting events all the time.

Coca-cola and McDonald's are sponsors for the Winter Olympics.

Anheuser-Busch, Taco Bell and Pepsi are sponsors for Major League Baseball.

Bud Light is the official beer of the NFL.  Coors Light used to be.

And it took massive lawsuits and federal law to ban Winston cigarettes from sponsoring NASCAR.

That's a lot of exposure for food and drink which aren't good for you.  Anyone else hear of the countless success stories of people on the Taco Bell diet? Neither have I.  And it is disingenious to say that it is entirely personal choice to eat, drink, or, formerly, smoke a product that is advertised.  It can't be entirely a personal choice because we, the consumer, don't have all the facts to actually make an informed decision.

The Coca-cola ad where God Bless America was sung in multiple languages was intended to both link Coca-cola with patriotism and Coca-cola with all of those linguistic communities.  Those languages and  images were picked for a reason, and were likely very effective.

All of the major beer producers plaster the airwaves during the NCAA basketball tournaments and the Bowl games with countless ads and in-stadium advertisements, all during games played primarily by underage people.

Now we have pictues of Olympic athletes with a dozen Big Macs on a tray during the Olymipcs.  Not afterwards, when people can relax and/or celebrate.  During.

To me, that's a problem.  The fact that more people don't see that as a problem, is also a problem.


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No More Refills on Cigarette Prescriptions

Posted By Jonathan Noel, Wednesday, February 5, 2014

Today was a good day for public health, even if it wasn't for most town's snowplowing budgets.  CVS announced that it will no longer sell tobacco products in any of its stores, and it's about time.

Tobacco and pharmacies always seemed like the ultimate contradiction.  How is it that the same store can sell you a product that is a leading cause of death and disease while also selling you a separate product that is supposed to treat those caused by the first product?  The classic example is someone buying a pack of cigarettes in the front of the store while waiting for the emphysema prescription to be filled at the back end of the store.  It just seems wrong.

But, sadly, tobacco in pharmacies is widespread.  I was lucky enough to play a small role in a project studying just this thing while at the Harvard School of Public Health.  Not only did a majority of pharmacies have a tobacco license, nearly all that had a license sold cigarettes and many sold other types of tobacco as well.  Of course, they also sold nicotine replacement therapy.  Talk about double-dipping.

This move by CVS is very promising for a couple of reasons. They did it voluntarily, which seems rare in the public health world, and they are large.  This isn't your Mom and Pop place trying to set an example for their kids.  This is a billion dollar decision.  Hopefully, this will pressure other pharmacy chains to follow suit. 

 All pharmacies are pretty much the same to me, but if given a choice, I'll probably choose CVS now, for no other reason that to support a business that doesn't support a dangerous habit.

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The Most In-Depth Analysis of the SOTU Out There

Posted By Jonathan Noel, Wednesday, January 29, 2014
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Griping About Social Media...Through Social Media

Posted By Jonathan Noel, Tuesday, January 28, 2014

We, like a lot of other non-profit, professional, or otherwise low budget organizations have seized the opportunity that is social media, particularly Facebook, to spread our message far and wide and reach people who were seemingly unreachable just a few short years ago.

Or so we thought.

For Facebook, instead of our messages getting out to everyone who Likes the page, I'm lucky if a dozen people see it, and I think that is pitiful.

But why you ask?  Shouldn't a post go out to all the followers? Isn't that the point of posting after all?

Well, it should be, but it's not.  It may be due to the time when things get posted versus when people log in and it could be that people who follow our page simply don't log in very often.  But I'm skeptical of those reasons.  I see plenty of professionals online all the time, day and night.  Simply put, if you have a Facebook account, you are going to check it.

No, there is something far more annoying afoot...profit. 

And I get it.  Facebook is a publicly traded company and to appease the stockholders (I am not one of them), they need to generate revenue.  They do that primarily through ads.

What does this mean for our posts?  If I want it to reach more people, I need to pay for ad space.  They even put a hypothetical ad on the side of the screen for me to see what a potential could possibly look like.

But we can't afford that.  There are likely 100's of similar organizations around the state (1,000's around the country) in the same position.  So our messages, no matter how relevant or interesting they may be, get seen by only a select few, chosen by some hidden algorithm.

Annoying. Frustrating. A bunch of other words I can't say in a public forum.

Social media? Nah, I'm going back to a tried and true method...Smoke Signals.  Or maybe a skywriter.  Everyone will see a skywriter.

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E-Cigarettes Part 3: Regulations

Posted By Jonathan Noel, Wednesday, January 8, 2014

For our last installment on e-cigarettes, let’s cover what existing regulations may apply to these products (Warning: this will have a bit more opinion and less objectivity than the previous posts).

Is it even tobacco?

First, e-cigarettes are a tobacco product, not a drug/delivery device, not a food/drink product, just a tobacco product. Whether you believe it or not, that’s what the courts have said and the FDA has not appealed that ruling.

The FDA has the ability to label any tobacco product as a modified risk product, which is any tobacco product sold that is known to reduce harm. It requires a formal application and decision by the FDA, and seems fairly onerous. E-cigarettes may qualify…someday, but as far as I can tell, e-cigarettes are still in the same category as all the other high risk tobacco products out there.

No Smoking Sections

The biggest issue at the moment is whether or not e-cigarettes should be included in indoor smoking bans. Proponents will argue that e-cigarettes are safer than cigarettes, users are just trying to quit smoking and if you send them outdoors, they’ll just smoke regular cigarettes. I think this argument misses the point of indoor smoking bans. The bans having nothing to do with the smoker and everything to do with the people who are around the smoker. In this instance, I think the question to be asked is really, has e-cigarette vapor been proven safe to non-users? (I don’t think it’s appropriate to assume it is safe until someone proves it is dangerous.)

So is e-cigarette vapor safe for non-users? I have no idea. There hasn’t been nearly enough reports published or nearly enough data collected to even answer that question. It’s still very much in a theoretical world without much ground for either side to stand on. That said, because of this unknown, I believe e-cigarettes should be included in smoking bans, although that is subject to change pending new research.


If e-cigarettes are a tobacco product and all tobacco products are taxed, e-cigarettes should be taxed, right? (Thank you transitive property) Yes, e-cigarettes should be taxed. The better question is how should they be taxed? They really aren’t like cigarettes, even though some look like it, but they REALLY aren’t like smokeless tobacco. If the absence of a separate tax status, I think a compromise would be to tax them similar to cigars. Cigars are taxed at a lower rate than cigarettes but may be high enough to dissuade non-smokers from trying them.


If e-cigarettes are a tobacco product and tobacco advertising is banned (from most media), e-cigarette advertising should be banned too, right? (Thank you again transitive property). I believe the answer is yes, at least for TV and radio. These products are still considered tobacco products and tobacco ads have been banned from TV and radio for 40 years. I don’t understand why people think there is an exception to the rule for e-cigarettes. All of that could change in the future, but with the current way e-cigarettes are classified, I don’t see how broadcasting a e-cigarette TV commercial is legal.

(As an aside, I’ve seen e-cigarette commercials on more than 1 channel, from science shows to Red Sox programming. They are out there. No doubt about it.)

Warning Labels

I’m going to play this game 1 last time. If e-cigarettes are a tobacco product and all tobacco products have warning labels, e-cigarettes should have warning labels too, right? Just as before, I believe the answer is yes.  There's just not enough data to conclude they are safe enough to not need warning labels and the FDA still classifies them with other tobacco products.  There are 2 possible sets of warning labels that could be used: the warning labels for smoked tobacco and the warning labels for smokeless tobacco. Since e-cigarettes more closely resemble smoked tobacco products (inhalation of the product versus ingestion), I would favor using cigarettes warning labels. Our current warning labels really aren’t that bad, or all that effective, anyway. Nothing like the graphic warning labels of Canada or Brazil.

The Wrap-Up

So there you have it. These are the basic pieces of information I think anyone needs to talk about e-cigarettes. As for the products themselves? I’m not convinced they are a magic bullet that will make all of our cigarette problems go away. I think as more evidence comes out, the data will show they are not safe, just safer than cigarettes. I also think hazards to non-e-cigarette users will also be characterized.

There is just a lot of unknowns right now and it’ll be a few more years before the science has had a chance to catch up.

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E-Cigarettes Part 2: The Science

Posted By Jonathan Noel, Tuesday, January 7, 2014

Yesterday, I mentioned some questions that I think need to be answered before you even begin a debate on e-cigarettes. I’m sure there are more but that should be a good start. For this part, I wanted to see what the science has actually told us about e-cigarettes. To do that, I went to and did a search for "electronic cigarette" OR "e-cigarette." I’m purposefully excluding any reports that haven’t gone through a peer-review process for all those reasons why you really should trust any research that hasn’t gone through the peer-review process, but will mention them if there really isn’t in the published literature.

As far as I can tell, there are 3 main e-cigarette parts to be concerned about: the battery, the cartridge/liquid and the vapor. There’s also that whole smoking cessation thing to review as well.

The Battery

There are no reports on PubMed that I could find relating to the battery component of e-cigarettes. That doesn’t mean they are safe or not safe. It just means no one has published about it yet. But there have been reports in the media on e-cigarette batteries that have exploded. Some are attributable to users modifying the devices whereas others may have just been faulty construction. In the worse cast scenario, there is a systematic problem with e-cigarettes (Too much current for the wiring? Poorly constructed batteries?) and a regulatory agency needs to issue warnings or recalls. In the best case scenario, the problems are a long the lines of the brake problems Toyotas had a couple years ago. You doubt it’ll ever happen to you, but your trust in the product drops just a little bit. 

The Cartridge/Liquid

The liquid used in e-cigarettes is made up of a solvent (propylene glycol, glycerin, etc.), flavorings, and nicotine. There is no water in the cartridge (meaning there can’t be any water in the vapor either!). The heating elements of e-cigarettes are about 50% efficient at converting the liquid into a vapor, which leaves 50% of the nicotine and other chemicals that are supposed to be inhaled still in the cartridge. Levels of which can be toxic. Exposure of any kind to e-cigarettes caused 29 poisonings at the California Poison Control Center between 2010-12. Is this a small number? Absolutely, but there are also a small number of e-cigarette users, particularly 3-4 years ago. The point is there is a risk, and cases will likely increase with an increased numbers of users.

The Vapor

The single most important thing I can tell you about the e-cigarette vapor is that it is NOT water vapor. Nope. Nada. Not a drop of water in the thing. It is one of the few things I will say with any definitiveness. If you hear anyone, particularly an e-cigarette company, say it is just water, they either don’t know what they are talking about or are lying.

That said, everything in the liquid will appear in the vapor, well half of everything anyway, meaning the vapor is composed of a solvent (not water!), flavorings, and nicotine.

The main solvent is propylene glycol, which is used for the delivery of some pharmaceuticals into the lungs and appears safe in low doses, but there is a BIG but here. The dose of propylene glycol from a pharmaceutical product used a few times a day may be much less than from an e-cigarette which may be puffed hundreds of times a day. Could it be safe? Sure, but we can’t make the assumption that high levels of exposure are safe just because lower levels of exposure are. That would be some kind of strange logic.

There have been some lung function studies of e-cigarette vapor showing increase inflammation and decrease lung function, but they did not isolate the solvent from the other components so it’s not possible to associate the changes with any 1 component. There is also evidence of increase NO release when exposed to e-cigarette vapor, a sign of oxidative stress.

Findings on the flavorings that are being used are somewhat surprising. In lab settings, some of the flavorings have been shown to be cytotoxic (i.e. they kill cells), particularly embryonic cells, indicating there may be increased risk of exposure to neonates.

As for the nicotine…As I said yesterday, I’m not convinced that nicotine is a safe chemical. Somewhere between seeing researchers use full hazmat gear in the lab when using it to talking with drug users who quit every drug under the sun except nicotine, I said to myself this isn’t a good thing. There are some positive consequences of nicotine use, such as increased alertness, but I just think the negative consequences out-weigh the positives. Nicotine’s effects are concentrated in the cardiovascular system where exposure can lead to increases in heart rate, blood pressure, and breathing rates, and is known to increase the risk of heart attacks. There’s a reason this stuff was used as a pesticide instead of caffeine.

A few other things have been found in the vapor as well, including nitrosamines, which are known to cause cancer, and carbonyl compounds, which induce oxidative stress in the body. I’m sure there are more, but regardless, they occur at much smaller concentrations than those found in cigarette smoke. More troubling is the presence of metal particulates. Metal particulates don’t originate from the liquid but actually come from the heating element. Apparently, the heating elements get so hot as to slowly break off. I don’t know if the concentrations are physiologically significant, but it may be a sign of poor manufacturing standards.

Smoking Cessation

The good news is that e-cigarettes appear to help people stop smoking or at least cut down on the number of cigarettes per day. There are also cases studies where they were effective in some very extreme cases involving schizophrenia and/or dementia. But there are still high numbers of dual users, indicating full cessation hasn't been achieved. There may also be large numbers of e-cigarette users who never used cigarettes. A report out of South Korea showed that 23% of e-cigarette users never smoked cigarettes, indicating that e-cigarettes may be effective at smoking cessation but ineffective at nicotine cessation.


What I think is the most dangerous thing about e-cigarettes is that when children see someone using them, children think the user is smoking a real cigarette. This is potentially the most dangerous aspect of the product. The legacy of the tobacco control movement is the denormalization of smoking. That’s what all the regulations are meant to do, from increased taxes, indoor and outdoor smoking bans, and warning label. By accepting a product that looks like smoking, there is a real threat that the efforts to denormalized smoking will begin to be unraveled and the act of smoking with be re-normalized.

Finally, if you end up doing you own research of e-cigarette science, always check who funded or supported the study. Some studies have been done with government funding, others with funding from public health foundations, and others have been done with industry support.

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E-Cigarettes Part 1: The Debate

Posted By Jonathan Noel, Monday, January 6, 2014

The debate over electronic cigarettes is fascinating. On one hand, you have New York City trying to ban them, while on the other, I've seen the hosts of MSNBC's Morning Joe subtly promoting them.  People trained in public health are all over the map on this issue as well, and I think it is time to leave the anecdotes, politicking, and marketing aside and try to figure out what this debate is really about and what the science says about this fascinating little devices.

As I started to put this together, it got pretty long so I’ll break it up into 3 parts: 1) the important questions to ask, in my opinion, 2) the science, which has been published, and 3) the regulations that can be enforced. I’ll try to keep this as objective as possible, but let’s face it, it’s nearly impossible to be completely neutral on a subject and it wouldn't be a good blog if I didn't say at least a couple of things to get a reaction.

Part 1. Questions

There are a handful of important questions that I think need to be personally answered before a debate on e-cigarettes get started.  Too often I've been in an e-cigarette debate where we can't agree because we are arguing two completely things.

1) What is the reference point?

Are you going to compare e-cigarettes against cigarettes, approved smoking cessation products, or no nicotine or tobacco use at all? Each comparison offers support for very different conclusions. I’ll address the exact science briefly in the next post, but here’s the quick overview.

In terms of safety, if you are comparing e-cigarettes with regular cigarettes, you’ll conclude e-cigarettes are safer. How could you not? I’m hard pressed to find any non-prescription consumer product meant to be eaten, inhaled, injected, or absorbed that is more dangerous than a cigarette. They are just that bad.  If you see e-cigarettes as a cessation device, then you may want to compare them to the nicotine patch, lozenge, or inhalator, products which similarly deliver nicotine in the absence of tobacco. Since there are no regulations on e-cigarette manufacture, they likely contain higher levels of chemicals known to be dangerous than FDA approved nicotine products. And compared to complete nicotine cessation? I’ve yet to be convinced nicotine is a safe chemical, so I’m going to say that e-cigarettes are less safe than nothing at all.

2) Which should come first, proving the e-cigarettes are effective at reducing smoking or proving that they are safe?

As a country, we have taken the approach that a product should be considered safe before we test its effectiveness. That's the model the FDA uses for approving new pharmaceuticals and thats that standard all agencies take when determining levels of food safety.  Everything is not 100% safe (there will always be exceptions, but they are just that, exceptions), but we do minimize or eliminate risk whenever possible.  Traditionally, we do not promote a product as effective before showing that it is safe to use.  The definition of safety you want to use is has already been answered in question 1 (see how I did that there?).

3) Where is the impact?

Are you only focusing on the impact to the consumer? Or are you including in the debate the impact of those around the consumer? My public health training has taught me to look beyond the individual and determine the effects of a product on the entire population, not just individual users. With e-cigarettes, there are 2 additional populations beyond the consumer to think of: those exposed to secondhand vapor, and those who can’t differentiate between e-cigarette use and regular cigarette use at a distance. I’ll get into the implication of each of these in tomorrow's post.

4) What is your impact time-frame?

Are you looking at short-term or long-term impact? How long is the long-term impact you are looking at? 6 months? 1 year? 10 years? And are you looking at the short or long-term impact on the user or the surrounding population? These types of questions mount quickly, but we should think about them now rather than after the fact when regulations are easier to implement.  Remember, it took 3 decades after we knew cigarettes caused cancer to determine that secondhand smoke can cause cancer too.

Hm, I guess that was slightly less than a handful.  Eh. Tomorrow, I’ll do a brief review of the data that has been published, and only the data that has been published.  None of these one-off, potentially biased reports that have appeared on websites ranging from e-cigarette companies to the FDA.

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Lockdowns, Lockdowns, and More Lockdowns

Posted By Jonathan Noel, Thursday, December 19, 2013

I'm not sure what to make of this:

CCSU on lockdown after reports of armed man spotted on campus

Yale on lockdown after report of gunman in area

Reports of gunman sends UNH into lockdown

Harvard on Lockdown: 4 Buildings Evacuated After Reports of Explosives

UMass Alert: University of Massachusetts Boston Evacuated, Reports of Gunman

Now, I'm no stranger to lock-downs or evacuations.  By the time I graduated high school, I was a pro.  There were gas leaks in 6th, 8th, and 9th grade.  Hit lists in 7th and 8th grade.  A PCB spill in 10th grade. A mercury spill in 11th grade. And dry ice bombs in 12th grade. (Wow, I never added it all up before, and in a "safe" suburb no less.)

But these seem strange.  5 lockdowns at 5 universities in 2 months in 2 states that are smaller than some of the counties out west. At the very least, the proximity of these events should have defied someone's odds. 

Which leads to a logical question, were the responses appropriate?  In hindsight, we know 4 were hoaxes (I think slightly less of Harvard students knowing it was done to miss a final), and 1 may have been caused by a halloween costume. But there's no way to know that when the email or call is received. 

(Isn't it a disturbing thought knowing anyone can alter the lives of thousands of people with a phone call, an email, or a text?  160 characters can make all the difference.)

So, were the responses appropriate?  Yes, in my opinion (and you can read here why it is just my opinion).  In today's climate, anything less than what occurred would have caused outcrys, but prevailing opinions on appropriate responses are never constant.  They will ebb and flow as opinions on most topics due. And someday, there may be 1 too many lockdowns caused by 1 too many students who didn't study for a final for people to take.  Then, the calls for more security will turn to calls for less, and the cycle will start anew.

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Student Centered: You Need a Research Topic, I Have a Data Source

Posted By Jonathan Noel, Thursday, December 12, 2013

Student Centered will be our periodic posts (you know, when the tests, papers, and presentations are completed and some semblance of a life has returned) that focuses on student interests, problems, or anything else school related. 

We are nearing that time again.  The fall semester is over, and we look forward to winter break.  Well, most of us that is, because in addition to the holiday season, it's also the season for students to finalize thesis or dissertation topics.  And oh yes, there are always some mad scrambles to the finish line for those who keep putting it off.

But there is a silver lining...secondary data analysis.  If you have an idea, someone else has already collected some data on it at some point in time.  They may not have realized it, but they did, and any of us can be the beneficiary of the costly, labor intensive work of our peers. 

All for the low, low price of...nothing.

Here are some free sources of data for all of your project needs.

Project Tycho: Data for Health

Project Tycho has completed the digitization of the entire history of weekly Nationally Notifiable Disease Surveillance System (NNDSS) reports for the United States (1888-2013) into a database in computable format

Inter-University Consortium for Political and Social Research

ICPSR maintains a data archive of more than 500,000 files of research in the social sciences. It hosts 16 specialized collections of data in education, aging, criminal justice, substance abuse, terrorism, and other fields.

The Cancer Genome Atlas

TCGA is a national research program of NIH's National Cancer Institute. The goal is to provide publicly available genomic sequence data from over 200 difference types of cancers to foster research in bioinformatics, biomarker development, and cancer treatment.

And if those aren't enough, check out CPHA's Public Database Resource page for more publicly available datasets.

(For those of you worried about any regulatory issues, don't.  Yes, they'll likely have to be an IRB submission, but the use of public data can be submitted as an "Exempt" application. That means less time you have to worry about the IRB telling you what to do and more time to actually complete the research.)

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You May Be Fit. You May Be Fat. But You Probably Aren't Both.

Posted By Jonathan Noel, Monday, December 2, 2013

Can you be fat and fit (or is it fit but fat, I can never remember)?  An article posted on NBCNews Health describes a meta-analysis which raises the question again, and I find this topic fascinating.  I think we could argue for hours about this because we have terrible definitions of "fat" and "fit."

Defining "fat" seems straightforward.  How could it not?  You see someone walking down the street with a beer belly, their fat.  But when you see someone coming out of the gym who is reasonably trim, they can be fat too.  It is the downfall of our reliance on BMI.  Muscle mass, which is good, is treated the same way as fat, which is bad.  And if you have a lot of either, you can be overweight or obese.  I'm technically overweight based on BMI alone, but I don't think many people would call me fat (they probably wouldn't call me fit either, but that's a different problem).

The meta-analysis analyzed studies which relied on BMI, and without providing incredibly detailed information on the study population, you just don't know if a handful of high muscle mass/low body fat individuals skewed the results of an individual study.    Waist/height ratio is probably the better measure of obesity if you could only pick 1, and yes, I've met people where that ratio is 1.  Sadly, they were in the healthcare field.

Defining "fit" can get a little trickier.  Is "fit" being able to run a mile or a marathon?  I recently read about a guy completing an ironman triathlon who openly admittedly he was fat, and he has a much higher athletic fitness level than me.  But that may not be the correct definition to use in the debate.  Instead, "fit" should mean inflammation, where the fitter you are, the lower state of inflammation your body is in.  Fat increases inflammation, and inflammation is linked with diabetes and cardiovascular disease.

 I think people can be fit and fat, but I haven't been convinced that they could be "fit" and fat.  And so the debate continues.  Now, where did I leave that donut...

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