Stanton Glantz – Expert, or Extremist?

Glantz is a professor of medicine in the cardiology division at the University of California, San Francisco, and one of the most influential anti-tobacco activists in the world.

It’s hard to overstate how influential Glantz has been in the campaign against e-cigarettes. He’s one of the most prolific authors of anti-vaping papers. He regularly appears in the media to complain about vaping – more so than any other activist. His work is the most commonly cited by the full range of vaping opponents, from Wikipedia to the Campaign for Tobacco-Free Kids. So who is he, really, and what does he want?

The Background

Glantz was born in Cleveland, Ohio, in 1946, and seems to have had a fairly conventional childhood. He was an Eagle Scout, an achievement he seems very proud of – he’s still using it to pad his list of awards more than 50 years later. After leaving school in 1965 he went to the University of Cincinnati, and graduated from there in 1969 with a degree in aerospace engineering. At the same time he was also signed up as a student trainee at NASA’s Manned Spacecraft Center in Houston, Texas.

After graduating, Glantz worked briefly at the Manned Spacecraft Center before moving to California, where he studied mechanics and engineering economic systems at Stanford University. He picked up a Masters in 1970 and a PhD in 1973; his PhD topic was computer modelling of heart tissue. This is where his career starts to get interesting.

The chances are that, as you read the last two paragraphs, you’ve taken a puzzled look back at the first one. Glantz is a professor of medicine, so surely he’s also done a medical degree of some sort as well as his engineering qualifications? No. He hasn’t.

Although you wouldn’t guess it from his UCSF faculty page, which makes no mention of his education, Glantz has no medical or scientific qualifications at all. It’s often reported that he did post-doctoral work in cardiology but this isn’t entirely true. He did do post-doctoral work on the human heart, but it was in Stanford’s Department of Applied Mechanics. This is part of the Department of Mechanical Engineering; they don’t study medicine there.

Academia or Activism?

So, if Glantz doesn’t have any medical qualifications, how come he’s a professor of medicine? It turns out that titles like this, “Professor of whatever”, depend on where you work, not what you’re qualified in. He works in the cardiology department of a medical school, so he’s a professor of medicine despite never having studied the subject in his life.

It’s hard to say why Glantz chose this unusual path to working in a medical school. His early work focused on the mechanics of heart tissue. This is medical research, but looked at from an engineering perspective. It already hints at the direction he would go in though. His very first piece of work was on ventricular stiffness, one of the ways smoking harms the heart.

Within months of completing his PhD Glantz was already shifting his focus to activism, which suggests this was his real goal all along. In 1974 he helped found the organisation that became Americans for Nonsmokers’ Rights, which despite the name is more focused on denying rights to smokers and harassing the tobacco industry.

In 1977 Glantz started work at UCSF, where he’s now worked for 40 years. His research there continued to focus on the mechanics of heart tissue, especially ventricular stiffness, but he was beginning to link his research more openly to smoking. In 1978 he tried to have a widespread smoking ban imposed in California, but was defeated by a popular vote. He had more success in 1983 when he helped block a challenge to San Francisco’s workplace smoking ban.

In 1984 Glantz published his first explicitly anti-tobacco paper, the incoherently named What to do because evidence links involuntary (passive) smoking with lung cancer. The paper itself, like the title, was written in Glantz’s trademark clunky and ungrammatical English, and it established him as a leading campaigner against second-hand smoke.

By the mid-1980s Glantz’s name was appearing more and more frequently on anti-smoking research. His own papers still focused on cardiac mechanics, but they were becoming less frequent; more often, he appeared as a co-author on someone else’s paper, and usually that paper was about second-hand smoke. He was also stepping up his activism; in 1982 he obtained a copy of a British TV documentary on smoking which had been withdrawn after a court case launched by Philip Morris. He also started producing anti-smoking courses for schools, and helped produce two films on the risks of secondhand smoking. By 1990 he was controversially claiming that heart attacks caused by secondhand smoke killed 53,000 Americans every year.

The Helena Miracle

At this point Glantz was just another minor academic in a growing field of research, but in May 1994 his career got a major boost. Two boxes of documents, containing around 4,000 stolen documents belonging to tobacco firm Brown & Williamson, were delivered anonymously to his office at UCSF. These became the core of UCSF’s tobacco industry library, which has now grown to around ten million pages of industry documents. This library is a useful tool for historians interested in the industry’s unethical behaviour in the 1950s and 1960s; it’s been even more useful for those who argue that it still can’t be trusted 60 years later.

The study that really pushed Glantz to prominence was the so-called “Helena miracle”. In June 2002 the city of Helena, Montana, introduced a smokefree law that covered all workplaces and shared public places. In November the same year the law was suspended by a judge. Glantz, along with two local doctors who had agitated for the ban, carried out a statistical analysis of heart attacks in the city between December 1997 and November 2003. When they’d crunched all the numbers they made a truly remarkable claim: While the smoking ban was in place, heart attacks in Helena had fallen sharply by a massive 60%. When the ban was suspended they returned to their previous level. By the time they released an academic paper the figures had been revised down, to a 40% reduction in heart attacks, but it was still impressive.

All around the world, campaigners seized on this evidence to support smoking bans – and why not? This was dramatic evidence in favour of smokefree regulations, showing that they could save millions of lives.

Smoke and Scepticism

However, before long some doubts began to surface. Various medical organisations had tried to put a number on the percentage of heart attacks caused by secondhand smoke, and they’d come up with numbers that ranged from 20% all the way down to zero. Nobody was claiming that it caused 40% of heart attacks, never mind 60% – especially when the law had only eliminated exposure to smoke in public places, not in the home. As scepticism grew other researchers started to look at the data. What they found blew a huge hole in Glantz’s scientific credibility.

Firstly, the numbers of heart attacks in the study were tiny. There had been an average of seven a month before and after the ban, and four a month while it was in place. In other words, recommendations for global health policies were being based on just eighteen heart attacks that had supposedly been prevented.

Next, it turned out that only 33% of the heart attack patients in the study were lifelong non-smokers – the people who could be expected to benefit. Another 29% were ex-smokers, who may already have had cardiac damage, and 38% – the largest group – were smokers. If a smoker has a heart attack it seems unlikely that passive smoking was to blame.

It then turned out that the reduction in smoke exposure which the study credited for the reduction was questionable, to say the least. After all this is Montana we’re talking about – a state that’s famously resistant to government regulation. Some investigation found that three of the city’s five casinos, and an unknown but probably large percentage of its bars, had simply refused to implement the ban. Additionally, many people were going out of town to visit bars that weren’t covered. It’s likely that the actual reduction in smoke exposure was very small.

Closer examination of the statistics showed a similar drop in heart attacks in 1998. Although this fell inside the period studied by Glantz and his associates they had ignored it, despite it seriously undermining their claims. There was no smoking ban in 1998, but heart attacks had still dipped. Of course random fluctuations are to be expected when dealing with such small numbers.

Finally, people wondered why this effect only seemed to show up in Helena. After all Glantz’s own city, San Francisco, also had a public smoking ban – and there had been no drop in heart attacks there. Sceptics suspected that this was because San Francisco has fifteen times the population of Helena, so random fluctuations are less likely to distort the figures. It almost looked as if data had been cherry-picked to make a point, with Helena selected for the study precisely because the numbers moved in the right direction.

Moving to the Fringes

With many articles questioning the Helena study, Glantz’s reputation took a knock. However, his prominence as a tobacco control activist meant most people ignored the fallout from Helena. This meant that, when vaping reached the USA in around 2007, he was one of the experts the media spoke to about the new technology.

Glantz formed his opinions about e-cigarettes early, and has stuck firmly to them ever since. His approach to tobacco use is an abolitionist one and harm reduction doesn’t seem to play a part in it – in 2010 he co-authored a paper attacking snus as a harm reduction tool, although it’s responsible for Sweden having the lowest male smoking rate in the developed world. While he admits that snus (and e-cigarettes) are much safer than tobacco, he doesn’t think this matters. As a result he has become a ferocious opponent of vaping.

In the last three years alone Glantz has been a named author on no less than fourteen papers that took a negative view of vaping. He has two main lines of argument: One is that vaping is just as bad for the heart as smoking, and the other is that using an e-cigarette makes it less likely that a smoker will quit. Both of these arguments are unconventional and contradicted by the bulk of the current science.

Dr Michael Siegel is a tobacco control expert at Boston University’s school of public health. A former protégé of Glantz, he has become extremely critical of his mentor’s stance on vapour products. Some of his harshest criticism is aimed at Glantz’s insistence that vaping is causing more smoking. When Glantz publicly backed a 2014 paper that claimed e-cigs were aggravating the tobacco epidemic among youth, Siegel publicly accused him of “no longer playing by the rules of science” and “essentially lying”.

The authors of the study were the source of the dishonesty. Their data was cross-sectional – it gave a snapshot of smoking and vaping rates at one point in time – and, as they admitted in the paper, you can’t detect cause and effect from cross-sectional data. Then they went on to claim they’d done exactly that. Glantz either didn’t know what the problem was or chose to join in the deception; either way, it was another blow to his scientific reputation.

The Road to Irrelevance?

Glantz’s other hobby horse, that e-cigarettes are as bad for the heart as smoking, will probably do him even more damage in the long run. He’s been speculating about this for a while, but recently he’s stepped it up by claiming that a new study supports him. The problem is, as Siegel points out, that this paper isn’t a study at all; it’s just a poster done by some medical students for a presentation.

This research also uses cross-sectional data, so can’t make any conclusions about cause and effect. Glantz has done exactly this, though, suggesting that he really doesn’t understand the difference between cross-sectional and longitudinal data. He’s also grabbed the wrong end of the stick. The data shows that vapers are 42% more likely to have had a heart attack than non-vapers. This is entirely believable; if a smoker suffers a heart attack, switching to vaping is a sensible thing to do (I did that myself).

By jumping on such a flimsy piece of “evidence” Glantz has completely abandoned any pretence of science; it’s now obvious that he’s simply an activist. Instead of studying the evidence to see what conclusions it leads to, he’s arrived at a conclusion and is looking for evidence that agrees with it.

It isn’t going unnoticed. Organisations that used to support him are becoming increasingly critical of his work. The Truth Initiative, which funds his chair at UCSF, has openly disagreed with Glanz’s statements on e-cigs leading to more smoking, while the American Cancer Society said, “The data in this study do not allow many of the broad conclusions that it draws.” That’s very close to an accusation of either incompetence or dishonesty.

In closing, it’s worth noting that Glantz has linked himself to scientifically dubious causes before. He has argued that radiation from mobile phones can cause cancer and sterility, although the evidence is very strongly against these claims (and Glantz has no training in radiation, cancer or sterility…) More recently he’s jumped on the anti-sugar bandwagon. Naturally, Glantz claims that both the phone and sugar industries are using the same tactics as cigarette companies did in the 1950s. It’s almost as if he’s obsessed.

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