Monday 12 September 2022

'Problematic information' about nicotine and COVID-19

A study titled 'The influence of pro-vaping "gatewatchers" on the dissemination of COVID-19 misinformation on Twitter' has been published in something called the Journal of Medical Internet Research. It's paywalled but the pre-print version is here. It is yet another whinge about people retweeting things that 'public health' academics don't agree with. 

The authors lament the lack of gatekeepers on Twitter to control what scientific information people have access to. They then invent the meaningless term 'gatewatchers' to describe anyone who has built up a following and puts out interesting tweets. After the usual dredging of Twitter, they conclude that quite a few of the people who mentioned the evidence that smokers are less likely to get COVID-19 in 2020 had a 'pro-vaping bias'.

A review of early clinical data in Wuhan province found that smokers were less likely to be admitted to the ICU due to COVID-19 complications, compared to non-smokers [10]. Although the study itself did not provide any evidence of a causal relationship between smoking and COVID-19 infection or progression, the authors posited that the anti-inflammatory properties of nicotine might be responsible for the unexpectedly low prevalence of COVID-19 infected smokers in countries with high smoking rates [12, 13].

Indeed they did. This was sparked by evidence in an NEJM study showing surprisingly few smokers in hospital with Covid in China and a study by Dr Konstaninos Farsilinos published in May 2020.

While no subsequent evidence has been found to support a protective role of nicotine, the notion that smoking, vaping, or nicotine use would prevent COVID-19 circulated, leading researchers to document misinformation about smoking, vaping, and nicotine as protective against COVID-19 across communication channels, particularly on Twitter [14-16].

If you're going to write a study about misinformation, it's best not to put a big fat lie in your introduction. No subsequent evidence?!? I have so far found 98 studies looking at this question and the vast majority of them find that smokers are significantly less likely to get COVID-19. A less expansive meta-analysis published in Addiction last year found the same thing. Nicotine is the obvious explanation and there are biological reasons why nicotine would make a difference. It could be something else, but a study published only last week found that smokers given nicotine in hospital had better outcomes than those who weren't.
No amount of evidence will satisfy the authors (one of whom works for the USA's risible Truth Initiative), but to say that there is no evidence at all is just a lie. 

Such counterintuitive findings are not misinformation in a direct sense, in that they do not present demonstrably false information [21].

You can say that again.

Rather, the extrapolation of the study’s findings out of context or with overreaching implications exemplifies the sort of claims that are not egregiously false, but rather represent unsubstantiated and misleading implications that run counter to the best available scientific evidence [11, 22].

In other words, people on Twitter read about the research and discussed what it might mean.

The 'unsubstantiated and misleading implications' that people were tweeting about, according to the authors of this study, included articles in the Economist ('Smokers seem less likely than non smokers to fall ill with Covid-19'), the Telegraph ('Smokers 'four times less likely' to contract Covid-19, prompting nicotine patch trials on patients') and the Guardian ('French study suggests smokers at lower risk of getting coronavirus'). All were perfectly factual, even if the evidence displeased anti-vaping academics in America.

The authors quote the top 10 posts by the 'top users'. They don't give their names but typing the text into Twitter shows that they were the scientists Konstantinos Farsalinos and Eli Rubashkyn, the journalist Alex Norcia, a South African radio station, occasional commenter on this blog Klaus K., the news website News24, a lawyer who tweeted the News24 article and someone who can't be traced because the tweet has disappeared.

Several tweets by Farsalinos are in the top 10. You may recall that he wrote one of the studies. So a scientist tweeting about his own research falls under the umbrella of not-misinformation-as-such-but-we-don't-like-it as far as the authors are concerned, as does any Twitter user linking to a respectable news source.

This research demonstrates the utility of the gatewatching framework for examining the dissemination of problematic information on Twitter. More than half of our sample of top users and 22 of the 25 most prolific users producing and disseminating content about COVID-19 and tobacco in the first nine months of the pandemic were pro-vaping “harm reduction” advocates. 

Anti-vaping harm reduction opponents obviously saw nothing to be gained from mentioning it. So what? Perhaps the fault lies with them.

Building on previous research both identifying and quantifying the extent of a specific piece of misinformation that nicotine can prevent COVID-19, we show the disproportionately broad reach of this claim across the most retweeted content during this time period [16, 47, 48]. Even in May 2020, when the original study by Farsalinos et al was published, the preponderance of scientific evidence, including multiple meta-analyses, still opposed the notion that nicotine, and especially smoking, would protect people from COVID-19 [10].

This is untrue and reference 10 is Farsilinos's study so it provides zero support for the authors' claim.

Still, in our sample of the top 1000 retweets, propagation of this claim was more than 20 times more common than the five tweets trying to debunk the claim and was retweeted nearly 17 times as often.

One can only assume that Twitter users found the attempts to debunk the claim unconvincing.

This research highlights the growing challenge of addressing scientific distortions that while not themselves misinformation can nonetheless drive false beliefs. There is no reason to believe that the study finding fewer smokers than expected was falsified. In fact, this “smoker’s paradox” drove significant research interest and calls to pre-register hypotheses towards the goal of rigorously investigating the effects of nicotine on COVID-19 [53]. A substantial body of literature has provided strong evidence that smoking during a respiratory pandemic increases the risk of severe illness and death [5-8].

References 5-8, which include a hastily written junk meta-analysis from Stanton Glantz, looked at the health outcomes of smokers who have contracted COVID-19. They did not look at the relevant question of whether smokers are less likely to get COVID-19 in the first place.

Our study does not address this complicated body of literature.

There is a good reason for that.

Opinion leaders on Twitter do not have control over the content posted on the platform. However, they have outsized influence over the dissemination of certain perspectives over others.

Because people are interested in what they have to say.

Although more research is needed, we contribute strong evidence that the ideological lean of the most prolific tweeters on a given subject (pro-vape users discussing COVID-19 and nicotine) directly influenced the spread of problematic information (that nicotine could prevent COVID-19) through retweeting much of the most broadly disseminated posts.

Now do anti-vapers and see what they've been saying. You wouldn't believe the amount of 'problematic information' those guys pump out.

These findings are reminiscent of previous research showing the majority of disinformation in another context, anti-vaccination, emanated from only twelve users [56].

Anti-vaxxers are an interesting comparison, but not for the reasons the authors think. Anti-vaxxers say that there is not enough evidence that COVID-19 vaccines are safe in the long-term despite them having been in use for a considerable length of time and despite there being ample evidence from beyond observational epidemiology that they do not pose any significant long-term health risks. Anti-vaxxers focus on rare examples of harm while ignoring the major benefits they provide to the vast majority. And they claim that there is no evidence of efficacy despite the death rate from COVID-19 falling dramatically as soon as the population is immunised.

Similarly, anti-vapers claim there is no evidence of long-term safety despite ample evidence to the contrary, focus on very rare examples of harm (batteries exploding, etc.) while ignoring the broader benefits, and claim that e-cigarettes do not help smokers quit despite smoking prevalence falling noticeably wherever they have become popular.

However, in contrast to the “Disinformation Dozen,” pro-vaping gate watchers on Twitter are not producing and disseminating overtly false information.

So you keep (rightly) saying. So what exactly is the problem? 

Rather they serve as mediators between the scientific community and the broader, Twitter-using public, and privilege scientific findings that support a pro-vaping narrative while dismissing, ignoring, and countering a preponderance of evidence that does not.

The preponderance of evidence on this issue is all on their side. Even if it weren't, the US anti-vaping racket is vastly better resourced to counter it.

The broader implication of this process of dissemination is that the proverbial deck is stacked against effective public health communication on Twitter. 

If 'effective public health communication' means telling people that smokers are more likely to get COVID-19 and that vaping is very dangerous, then it would be a good thing if the proverbial deck was stacked against it. However, growing public ignorance about the risks of vaping suggests that it is not.

The observable pro-vaping bias of the most outspoken users discussing COVID-19 and nicotine inevitably meant that even attempts to debunk such information on the platform did not receive nearly the same amount of traffic. 

Boo hoo. Go ask Mike Bloomberg for some more money.

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