I just can't get over how batcrap crazy this graph is, and it is gnawing at me. So I am going to seek psychological salve by writing a...
Thread 1/22

(reading note: click through the quoted tweet and open the graph if a new tab to follow along) https://twitter.com/carlvphillips/status/1297136746392625152

(yes, 22. Just read it. You will be glad you did)

So there are the problems with this as a graph that I explore with an interlocutor in the original thread. Those are issues also. But now I am just thinking about the claims in the graph if you charitably interpret it as meaningful quantitative claims.
2/

Start on the right-hand side. Small cigars are cigarettes but with the rolling paper made of tobacco rather than wood pulp. How exactly does someone think that this substitution eliminates 33% of the risk???
3/

Back to the left-hand-side. There is literally not any evidence that would allow us to declare an ordering of the risk of the first seven entries (including "no use"). Nothing. It is very plausible using smoke-free products is better for your health than "no use".
4/

I mean if you had to guess, you should say that the one that involves the lungs (ecigs) is the worst of the bunch. But that is highly speculative.
5/

As for the eighth entry in the graph, "smokeless unrefined", WTF? Approximately nobody chews/dips unrefined tobacco leaves. This is not a thing.
6/

I would speculate that whoever wrote this is confusing tobacco use with coca or khat chewing. Except that I am pretty sure that whoever made this is so unfamiliar with drug use behavior that they would respond "cocakhat what?"
7/

As for the quantities, there is no possible way that smokeless products (the ones that exist in the real world) are 5 to 10% as harmful as smoking. Don't you think we would have noticed the harms from them if they were that bad (that is quite bad)? They're not exactly rare.
8/

Shifting back to the right-hand four entries, not only does changing the rolling paper eliminate 1/3 of the risk, but avoiding the rolling paper entirely eliminates 3/4 of the risk. Damn, who knew that the danger from smoking was mostly in the paper? Quite the breakthrough.
9/

Oh, and if instead of shredding the tobacco you leave it as cured sheets of leaf, you eliminate even more of the risk. It must be something about smaller bits of tobacco making more of those magical ultrafine particles or something.
10/

Of course, differences in average health outcomes among people smoking the different products do exist. But they have nothing to do with the products. They are behavioral. Take 200 lung hits a day off a pipe and the effect is the same as smoking a pack a day.
11/

Mouth puff three cigarettes a day and the effect is about that of someone who mouth puffs one (standard) cigar or bowl each evening. It is not about the hardware. Lung hits are a choice. Quantity is a choice.
12/

(Still having trouble coming up with any explanation for why "little cigar" cigarettes are different from paper rolled cigarettes. Presumably that is all about quantity -- more users of the former are chippers.)
13/

As for the other entry in combustibles, "water pipes": Yes, it is possible to use a water pipe to smoke combusted plant matter -- see: bongs. But approximately no one does that with tobacco. Again, we run into the problem of people writing about a behavior without...
14/

...ever having experienced it, nor even having talked to someone who does it.

Can you imagine a paper about "the gay lifestyle" or "native ceremonial rites" by someone who is not part of that community nor ever even set foot there? Yeah, I guess you can. But it is not ok.
15/

Presumably what they are referring to is hookah/shisha, which is NOT combusted. It is heat-not-burn (when done correctly). Yes, like IQOS. It is not as clean as IQOS, but it is in the same category. And so, ok, it is probably somewhere between the first 7 and the last 4.
16/

And maybe the graph's "14% as bad as smoking" is right. We don't really know and this is not implausible. But here's the thing: A lot of the harm from hookah use is being in a lounge full of burning charcoal. It is not about the drug, it is about the indoor cook fires.
17/

Bouncing back to entry 3, "oral products", we have another WTF? Nine of the other entries are oral products. Do they mean nicotine lozenges and gum? Perhaps. Do they count nicotine pouch dip? How do we know the risk from those compared to other smokeless products? We don't.
18/

One of the two entries that are not oral products is "nasal sprays". Seriously? I am not sure I know anyone who has even tried that. As for risks, I would put those at the bad end of the "appx harmless" list, along with ecigs. Squirting stuff into your sinuses can be bad.
19/

At least patches, the other non-oral product, get a nice low (tho probably still too high) score. Why? Presumably because it is hard to get a buzz off of them. Because obviously that is what this ordering really is: "how negatively I, the author, judge people who do X".
20/

FWIW, I know several experts on the relevant science who took up using some of these products in middle age, not to quit smoking but for the health BENEFITS. They all chose either pouched ST dip (often mistakenly called "snus") or patches if they wanted to avoid a buzz.
21/

In conclusion, WTAF?
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