Thanks, Lincoln. Thanks, Darlene. Our next speaker is Dr. Teitelbach. He is going to be, his title is Breathing in the Kitchen, and has to do with the issues that are going on right now with guest stoves. Dr. Teitelbach is a professor emeritus at both Michigan State University and Lincoln Memorial University. He received his Doctor of Osteopathic Medicine from Michigan State University, College of Osteopathic Medicine, holds a Master's of Public Health degree from Harvard, and an MA from Michigan State University, and a BS in Mathematics from California State Polytechnic College in Pomona, California. He has published numerous articles, and he obviously is a distinguished fellow, I think, with our college as well as a fellow. He told me today, and I think we need to give him a lot of kudos. He said that his students in the matching program had let him know that they had all matched, and that is a big deal. Thank you, Helen. Thank you. Good job. Man, as we all know, times have changed a bit, and I'm just really pleased to say that I've been very, very fortunate to have excellent students. Anyway, hello there, and thank you for sticking around for this. I'm going to talk about a controversy in two ways. One, I'm going to look at it from a statistical point of view, and then I'll look at it a little bit from a policy and public health point of view as well. I'm titled Breathing in the Kitchen, and some of you may know that, first of all, I have no financial interest in the outcome. So let's think about this just a little bit. Question for you. Yes, sir. Do you have gas in your electric stove before you go further? Once more? Not to my knowledge. Anyway, here we go. Let's take a look at this. Here's Ronnie Jackson from Texas. I'll never give up my gas stove, Jackson wrote. If the maniacs in the White House come to my stove, they can pry it from my cold, dead hands. Now, this is national news. I'm not making this up. And the real question that comes up, particularly in PrevMed and public health, is very simple. How do you make a message clear that now doesn't alienate and essentially set up countermeasures to the measure you're trying to impart, whether it's wear a mask, whether it's get inoculations, vaccinations, whether it's to wear your seatbelt in the car, whether it's whether or not this... Whatever issue is, it tends to be more divisive. And how one do you complete a message? And it's anytime something is said, it's going to be taken differently. We have to remember that. And therefore, it's not the truth of the message. It's how the message is delivered that we must actually pay attention to. Now, what I'd like to do is... I don't know if I... I want to try to make sure and only advance this just to prove the point. Um... Federal officials may be considering a ban on gas stoves because of health concerns to children. But one West Michigan congressman is hoping to block the ban. 13 On Your Side's Carla Byron is here now to break down that proposed legislation. Carla? Guys, Congressman Bill Huizenga says his Stove Act will stop bureaucrats from telling the American people which appliance they can have in their homes. Representative Bill Huizenga introduced the Stove Act, which stands for Stop Trying to Obsessively Vilify Energy. The proposed bill... Okay, that's a state of Michigan, and it's the truth. And we certainly don't want to have a problem on that. And then, of course, we have this gentleman. And this is gonna... Seems like this is just a ploy to get you to buy more stuff the Democrats are selling. Now, I'm not sure about you, but this story lit a fire... ...under you-know-what. Chef and restaurateur Andrew Brewer joins me now. So the Democrats... Sure. ...say we want to stay out of the bedroom, get the government out of the bedroom, and just every other room in the house. Well... I'm trying to see whether I can just take the speaker... You have to take the microphone and put it next to the speaker. Okay. Thank you very much. Yeah, but I'm not sure on this machine where the speaker is. Seems like this is just a ploy to get you to buy more stuff the Democrats are selling. Now, I'm not sure about you, but this story lit a fire... ...under you-know-what. Chef and restaurateur Andrew Brewer joins me now. So the Democrats say we want to stay out of the bedroom, get the government out of the bedroom, and just every other room in the house they want to be involved in, like the kitchen. What I want to do is get up to... If I can't do it, I'm not going to waste any more time with it. But the notion is, is here's a gentleman who essentially has tied himself to a gas stove. Well, no, I'm not going to. And I should mention, actually, my stove is in my bedroom. So I'm kind of, you know, I got a little bit of safety there. Good for you. And look, you know, the reality is, is that I am so livid about this. And like the protests that we've seen as of late, I actually threw tomato soup all over my stove. And I have actually taped myself to my stove. I've been here for 24 hours now. I haven't moved once. I was 6 foot 9 yesterday. I'm 5 foot 11 right now. Sounds like me. And I'm going to stay here until this is just completely abolished from anybody's mind. I mean, we're living in an upside down world. This is a comedy. Actually, it's a tragedy is really what it is. But let me throw out there, because you and I have talked about this before. If you recall, the microwave generation that three years ago was, okay, we're going to move from electric. And there was nothing mentioned about. This is where I wanted to be. If not, this is it. I'm not going to work. The issue is very simple or any of that didn't work. And then a couple of years after that, they tried throwing a new alarmist piece into it. That didn't work. Well, what have they been doing for the past year? Using our kids as fodder and bait for their insanity. And now they're throwing the kids in there with this new study, which I should mention was written by an environmental think tank, whatever the heck that is. An environmental think tank whose financial incentive is to reduce greenhouse emissions. And the study they put together is not a study on children. All this is a meta analysis, which is basically them going out and trying to cherry pick as much statistical. Now, that's the point I want to emphasize. His claim is they use a meta analysis. And that cherry pick studies. And therefore, it's not really an unbiased way of making your point. I'm really now going to suggest that he is totally wrong on this. And we talked about a meta analysis last year at a meeting. Pardon me, not last year at the OMED, only because there was a meta analysis done on overtime and its effect on the workplace. So I want to criticize it. I want to take his point that it's a meta analysis, not a real one. It's a cherry picking. And that's one of the things we're going to talk about. I'm going to say a couple of things about that right now, and then we're going to get into the guts of the study. But again, this is the one thing I need you to take away. If there's only one point, it's this. It's a basic theorem in statistics and epidemiology, which is to say cause correlation does not prove causation. You really have to understand what that means. Look, we've got a tremendous increase in gunshot violence in the United States. We also have a rise in Baptist minister salaries. Therefore, to cut down on gun attacks, what we do is lower the cost of the Baptist minister salaries. Does that make sense to you? That's ridiculous. And the point I want to make is that's just a correlation. And we can correlate anything that can be measured. We can standardize the variables and correlate them, and we can get you a value. The question is, what's the intervening stuff? We've got to think about that. Just remember, correlation is the first step in causation, but it doesn't go any further. Now, the other thing that we have to worry about is they made the claim that they're throwing the children at us. Why is that? And the answer is, in the NHANES study in 2003, gas stoves and respiratory health didn't really relate. In other words, it only seems to affect children. Adults seem to avoid the exposure. Pardon me, when the exposure comes into methane and the NOs, noxious NO subsection X, then essentially nothing seems to happen. So it's children that are affected, not adults. That's why the guy chained to his flat plate in his kitchen or his restaurant isn't showing any results, because as an adult, it's not going to. And that means each of you, or also as adults, are not going to be as affected by this. It's the children that really are. And to that standpoint, we have to be kind of careful. So let's take a look a little bit about this. Among adults with asthma, there's no apparent impact of gas stoves on the pulmonary function. These results should be reassuring to adults with asthma and their health care providers. So only children, and the history of establishing the relationship started from Teitelbaum's point of view with these two studies. The Hasselblad study, which occurred in 1992. And Brunkief is going to come up in just a couple of slides here, because he did, in 2013, a meta-analysis on the effect of indoor nitrogen dioxide in gas cooking and wheezing in children. And then another one, again, you see Brunkief starting again. And what essentially is this took place in, it should be 2013, not 1013. And the notion is that he did find the cooking fuels and the prevalence of asthma, a global analysis in phase three of the study of asthma and allergies in childhood. Now, Brunkief, I say, has published on this and very respectful and done it as recently as 2013. Now, the major article that started all of this is the one that appeared by Taylor Grunewald. And it's called A Tributable Fraction of Gas Stoves and Childhood Asthma in the United States. That was published in 2023. And that's what the first two slides I showed you really took off on. Now, the people who criticized that study as soon as it came out was really the American Gas Association and the American Public Gas Association. One might look at that with the same argument that the gentleman chaining himself to the stove use and the environmentalists wanted to tout it because it was a problem with the global, with the whole idea of climate. And now the people who have a vested interest in the gas stove industry said it's all bunk. They want to claim that the other articles dispute the finding, particularly those by Grunkief themselves. His work in 2013 disputed the association. And Grunkief's remark was his article is not really good use of our study. His articles were used by opponents of the association to show nothing happened. But a proponent of the association said, no, something really did. And he was the one who started to lay claim that gas stoves were really a problem. However, this guy, Trumka, who is your one U.S. Consumer Protective Safety Commission gentleman, basically says there's no plans to ban gas stoves. So let's be real clear about that. How many of you use gas stoves to cook on? And you love them, right? God, they heat directly. They heat quickly. I can moderate it. Nothing has to move. Everything is perfect. Why in the hell would you want to take my gas stove? I also will prostrate myself on that stove and you can take it out of my cold, dead hands. Well, the point is it's not really. All this is is just like a warning on certain things that you have to be careful of. And I'm going to cover that towards the end of my remark. Now, then, there lies in the problems they're using. The problem is that the people who use one creed that says one article does it, one article doesn't. They forget they're talking about the same article in their interviews, but they're using two different articles. One creaser and one run crease later once. So Trump could use the meta analysis to show an association. American Gas Association use a later paper that showed there was no association. And Burn Creek says you misinterpreted my remarks. So that although his meta analysis didn't include the results of his own paper by A.G.A., they were too fine. It was finalized too late to be part of the literature review. It's very unlikely that it would change the bigger picture. So. Let's just I'm going to skip a few slides and I want to summarize this this way. Think about this. If I have seven studies all kind of wrapped around the same topic, is there a way of combining these results? Now, they're each a little different from each other. And how can I get them together? That's the purpose of a meta analysis. The meta analysis uses statistics to combine the same idea in different studies into one omnibus summary figure. And there are rules to doing that. I discussed it earlier. I'm going to show you the summary article to do that or summary way to do that. But the notion is think of it as combining everything into a single value. Very, very powerful technique to do. And so usually and that's what we call a meta analysis is an analysis of previous analyses. OK, it's a combined thing. Now. What we have to do is to be very, very careful about how we do it and a few things that we have to worry about in each article. So now the paper. Is it a good study? Statistically speaking. Well, what I'm going to do is to ask you to start thinking about if you had to design a study, what would you look for if you wanted to see if there was a relationship between exposure and the outcome of aggravation of asthma? Would you? Goodness gracious me. Would you want to use. A randomized control trial. Let's take a few kids, put them in this house, gas it up, take some other kids, put them in that house. No gas. Let's see who breathes hard. Anybody want to do that? Depends. Yeah, yeah, yeah, yeah. That's right. If I could choose the kids, I'm all in favor of. Which one are you going to start with? Right. Your own. That's science. No, that's where you're wrong. That's where I must correct you on their randomized control trials. No doubt about it has its use, but there are several things which is not good. One of the things of good science is that it is ethical. I would, I would submit to you studies, studies, you know, with the Zipf studies that we all keep hearing about from time to time. And you just can't do that. Yes, sir. He did not do RCTs to develop. Yeah, well, there's example. You can't do. How about this? Let's do a randomized control trial to see if parachutes really work. Oh, sure. Sure. You want to do good. It's publishing. The notion is you don't want to do that. It's unethical to do it. And just because it's available doesn't mean it should be used. I really am glad you brought that up, Carl, because that is a very, very, very big problem. People think it's not randomized control. You can't do it. It's the best. No, it's not the best. It's the best as long as ethically sound and you can measure the variables. Exactly. Without it, you're screwed. That's a medical term. What the hell is going on with this thing? Okay, let's take a look. How about prospective trials? Now, we'll just take people. Let's say kids, for example, and we'll just put them in and we'll just see how they progress along. We're not doing it. We're just kind of letting the natural course kind of take over here. How about retrospective trials, which is to say, let's see if those people already have the disease, then back them up and see if they were exposed. I haven't done anything to them. I'm just taking them the way they are. And then we'll see what the hell goes on. A retrospective cohort study. Retrospective cohort studies are really, really powerful when it comes to occupational medicine. You know why? Because you did pre-placement physicals. And so we know what they were when they started. So I can take them where they are in the shot and then back them up to square one and essentially treat it prospectively from there. Excellent opportunity to do that. And they're the ones who made prospective cohort trials very, very popular. How about just a cohort study? Just take a group of children, see what happens as they age and see what goes down. We could do a case study. Problem with a case study is when you've seen one, you've seen one. Remember, all Italians eat spaghetti on Wednesday, at least the one I know did. So you've got to be real careful about that. And so we're really kind of stuck into certain sorts of things. What do we want to do? Each study has its advantages. Each study doesn't. So we have to be careful. And what about the independent variables? How the hell do you want to measure them? And how precise do you want to do it? How about just a gas stove? Okay. Are all gas stoves designed the same? No, not really. They have the same mechanism. You put gas through a filter and off it goes. But is presence or absence of a gas stove enough? Or do we have to somehow stratify the type of gas stove you use? Is it a four burner? Is it a flat plate? Is it a six burner kitchen stove? How do you want to look at that and how you want to control for it? How about does age make a difference relative to the effect of what's going on? How about the gender? Are female children affected more than male children? How about the idea of with or without asthma? Well, depends on the type of study that we talk about in the preceding cohort study. You got two groups. Retrofictive cohort, I could do with one group and back them up to the beginning and kind of go forward from there. And who's going to determine whether or not asthma is present? How about other sorts of things which exacerbate asthma in a household? Dust mites, pests, smoking, mice, mold. Sir? Methamphetamines. Absolutely right. Particularly when they chew them. Okay. So now what we have to worry about are all of these variables as if they didn't matter. And so how we want to control for that statistically, I, as a clinical epidemiologist, we can kind of do some of that, but there's some things we're not. And this author has made some assumptions, which I'm going to point out in a moment, which might be questionable. Now, what about your independent variable? Again, are you using NO, NO2, others? And they usually put NO sub X, which is noxious. We heard noxious, they're talking about NO, NO2, NO3, and so forth. Now I'm going to take you back to medical school, remember, where you did your pharmacology course, where they had about a dose-response relationship. For example, is the exposure, does that come out? I don't know what the hell, why that overwrote, but the question is this, in a dose-response relationship, you want to describe the magnitude of the response of an organism as a function of the exposure to a stimulus. Remember, response equals concentration times the time. How long were you exposed? If we're talking about nuclear energy, it takes a very short time to get the result of the problem versus something which you need, it's a lower dose, you need a longer time to show the results. So how do you want to measure it? And I'm saying you want to take a look at it as minutes per day, how long were you exposed, or minutes per day times the number of days per week times the number of weeks, how do you want to measure that? What's more? There you go, whatever. But the question is, is how do you get the horse to stand still? Now the notion that we got to think about here is, these become problems to understand and appreciate the outcome that we're looking for. Now, the other big thing is time in the kitchen, so that's your length of exposure. Now look, we have any moms in the audience, okay? How long, did you have any children? How long did you keep your child in the kitchen? Yeah, per day, let's say. Depends on the age. A little while, even when they were young, okay. Yeah, a little time, not a long time, right? There's other times. Call it out yourself, anybody else who raised their hand? I'm not a mom, but as a dad, I know my wife kept the kids, the younger they were, usually in around the kitchen area longer, and then they became independent and played time in the living room. Understood, okay. Well, let's think about it. I wandered, and I asked a nimble bit, everybody knows Jeff LeBoeuf, remember Rhonda's wife? I called her up and said, how long did you keep your kids in the kitchen? She had five. Seems a pretty decent number. Well, I'm sorry, six. So the notion here is, and she said a very short time, because usually what happens, people busy themselves around. So they keep the kids there, they focus in the kitchen, and then what they do is they move their child out and do other things. Here you go. On average, infants spend approximately 12.3 hours per day in their bedrooms, 7.3 hours in the living room, 35 minutes in the kitchen, and 3.8 hours out of their home. Now that's on average. And now why would they? The answer is, well, because they're busy doing things, they don't want any accidents in the kitchen, like carrying hot water, this kind of stuff. They do it, they serve the stuff, then they get them out of there. Now, so as a condition of participation, none of the infants spent more than 20 hours per week in a daycare outside of the homes, okay? So this mean time infants spend in the kitchen during cooking was approximately nine minutes per day, okay? Now that was done by the, in 1993 when they were looking at that. So exposure to the concentration is really kind of short. Now, you want to take a look at your degree of asthma? Is it intermittent, mild persistent, moderate persistent, severe persistent? How are you going to measure that? Do you want to look at symptoms only? Do you want to look at FEV indices? Gradient across degrees of asthma, as the average is, is the effect more gone by that? And physician diagnosed, or you want parent judgment about, is the kid worse? This article doesn't address these things. From a statistical point of view, this has, as the article is presented in the journal, leaves a bit to be desired. Oh, any reason at that point to do a study with non-exposed, i.e. electrical stove tops? Yes, absolutely. That would be a wonderful situation. The people who are most enthused about this study are people who make convection ovens. They think that's going to replace all this stuff. Hold on, there's gas convection. What can I tell you? I don't know. If it's not at the Big Mac store, I don't know. All right, here we go. What I've done is I've just put up from an EPA chart just to refresh your memory. We'll spend a lot of time on that. All of you are kind of familiar with that to begin with. But now I want to talk about a systematic review for just a moment. Oh, yeah, sure. Go back to your list. It says air quality nitrogen dioxide. Nitrogen dioxide is not natural gas used in a household. That's correct. It's a byproduct of the methane. And so the notion is, is that we measure the byproduct and we want to find out what level is dangerous. That's the way this thing worked. So here we go. Process of conducting a systematic review. Did they formulate the question? Yes, they did. Did they find the eligibility criteria? Well, actually, they really did. Did they develop a priority hypothesis to explain heterogeneity? Heterogeneity is a technical term. Think about that as the variance between studies. One shows a big difference. One shows a small difference. Between these, we look over it, there's just lots of differences. And the idea in a meta-analysis is to combine these variances into one measure to get kind of like an average variance in each study. That's the whole purpose of it. Yes, sir. You say these are questions of the author of the meta-analysis he's asking? Yeah. No, these are the criteria you have to satisfy to render it a good meta-analysis. These are the steps you have to go through. Now, then you conduct your search for articles. And then you screen the titles in the abstracts to see if these articles meet your criteria. You review the full text for making sure they're okay. You assess the risk of bias. I put that in a different color because I'm going to comment on that in a moment. We get the data. And then when the analysis is performed, it generates summary estimates and confidence intervals. You look for the explanation of this heterogeneity, these differences in the variance, and you rate the confidence in these estimates. So we're really looking for a single measure to tell you how good this combination of articles are. Well, here's a checklist that people come up, and you can kind of check your own. I'm suggesting I'm going to kind of spin through this. The selection criteria was pretty good from what you could read. There was no flow chart to show how many articles reviewed and how many were thrown out. And if it's there, you proceed. If not, you got to have to really question the article. Is there a summary table that showed what process they went through? And I'll show you what a summary table looks like. That was not included. Is there a test for heterogeneity, this variance? And there are statistical tests to do that. He mentioned one, but didn't show it. And did the authors assess this in some way with a confidence interval? The answer was no. Is there a summary effect size with a p-value? The answer is yes, but none. Is there an investigation on the heterogeneity? Like, did they do a subgroup analysis or something to show where the variance was? The answer was no. So from a statistical argument on the way the article was presented, it is not a good article. So I went and I said, now how would this look like? It's such a short article for such a heavy study. And I think the problem lies in the instructions to the author by the publisher of the journal, because they want then only like an expanded abstract as opposed to a definitive study. This was like a three-page article. I downloaded it. It's free for downloading. And it's an international journal. And you look at all of those, and they're all about the same length. It's all like limited to so many words. So that's where the problem comes in. So this may be a very short presentation. Okay. So we're going to talk now about a little bit about the biggest hole in meta-analysis. You remember he said he cherry-picked the articles. Remember the gentleman who changed himself to the stove. This is the bane of meta-analysis. Do you cherry-pick? Let's think about this for a moment. If I'm going to look for articles, I'm looking for published articles. Journals have a penchant to publish only things which are statistically significant. And when you do a meta-analysis, we have what we call, you have to do, desk drawer searching. That is to say, things which are in process, things which wanted to be published but were rejected, even though the authors have them, because it didn't show statistical analysis. Well, holy smokes, that's what the opponents of this study want. They want articles which show there is a relationship between gas stove and asthma. And that's why it didn't get published. Therefore, it never got into this literature review. So the publication bias, it omits unpublished studies from a review which could yield a biased result in their intervention. It showed only positive results. So we have to balance this out. Negative studies are not being published, leads to an overestimation of the effect of what you read. So to avoid that, you have to go to things like conference proceedings. Where would that be? Oh, I don't know. How about this meeting? You got people that have presented articles. They presented their findings. Some good. I mean, some show significance. Some do not. We found no difference in this, that, or whatever. The other thing is, is that technical reports, like governmental agencies, put out reports all the time. They don't publish. I mean, they don't look for peer review. They prefer accuracy. Organizational websites, dissertations, primary researchers, and so on. So the idea is you must exhaustively search for articles. And what if you find possible evidence of a publication bias? And the way is now is that, first of all, we try to look at, and the number one thing which you'll probably hear about on Sunday, if you had to remember anything about reading an article or judging an article, you say, what is the comparison group? That's the one single question that will help you determine whether or not you got good or bad studies. If you compare it to a cheesy control group, you don't need the article. The classic case is when they looked at avocational versus vocational athletes and found out who had the best results in things like overall health. And what did they do for comparison group? They used accountants during January through March. What the hell do accountants do between January and March? They're doing tax returns. You know, they sit in offices and smell bad. Honest to God, they don't even get out for showers. And you're expecting these people to be compared with the athlete who essentially they use or football players at a major Midwestern university who only work out when you say, when's the last time you worked out? They look at their watch. When's the last time you went to class? And they said, what? You know, so they don't know where the building is. So that was a large Midwestern university I had in mind, but the point I'm really trying to get to, yeah, and they didn't do too well this year, I might add. Now, one of the things that I'm really after is you've got to look at that. And that's where the going gets, and you don't need to be a statistician. You just take a look, see what they did. Okay. Now, what did the authors do correctly from Titlebomb's point of view? And when the stuff comes out in red, it's my remarks. First of all, they used PubMed. Have any of you used PubMed in searching for articles? It really is. It's a little broader. Google Scholar is good. It doesn't have the pizazz, see, of PubMed, but it's a good search engine. JAMA did a study. The number one searching tool for articles in the medical profession, you got it, Google. Number one. Nobody wants to admit it because it doesn't have the stack, you know, PubMed, but there you go. They included things like gas cooking in children, gas appliances. You can read it as well as I can, but the whole notion is after including only manuscripts of human studies published in English since January 13—remember, his article said the meta-analysis went up to 2013. Now, 10 years later, we'd like to pick up that gap to 2013 and 2023. That's the study they're looking at to see what happens. That notion is they had 357 studies remain for possible inclusion. They reviewed this. They kindly end up with a reduction and a completion rate of only 27. That's what met their criteria. This is not unusual, and they're to be applauded for at least applying their criteria for that. Full manuscripts, as I say, were independently reviewed by the co-authors. None reported new associations between gas stove use and childhood asthma, specifically in North America or Europe. Now, you may ask, is Europe that much different than the United States in their cooking habits? And the answer is yes. What does that—remember, I said look at the comparison group. Whether or not you think the stoves over there leak a little more than that in the United States, if you believe that, then the exposure is going to be enough different that maybe we need to think about subgrouping. In other words, look at the United States, look at Europe separately. Now, the notion is authors—new association between gas stove and childhood asthma. Now, the next thing the authors did use is they said they used the inverse variance method to form an overall effect size. This—the only person who gets orgasmic over this is people like me, okay? This is a neat statistical work. It's perfectly legitimate and is a common use to combine and address this heterogeneity, heteroscedasticity, which is this heterogeneity, which is the differences in variance. And that's a perfectly good way to do it, and they did it. What the hell is going on here? Good. John, let me just go back here. All right. So the point is is that they used it. It worked very, very well, and they've done a very good job of it, and that's what Brunckreth used in his article in 2013. He used the effect size of the calculation for something and calculating a population attributable fraction. Fully acceptable. It's a good epidemiological measure. I've given you the formula in case, you know, you're on jeopardy, and here it basically says P is the proportion of households with children exposed to gas stoves. Rr is your relative risk, which you'll probably hear about a little bit later on this week, is the relative risk of developing asthma given exposure to gas stoves. That's a quote from them, and I want to criticize that. Remember my opening slide. Correlation does not improve causation. The authors were very clear. We're not talking about causing asthma. We're talking about exacerbating asthma. That's an important decision to make, and that was glossed over by the critics. They're saying it's causing asthma when in fact all it does is make the situation worse. I'm going to come back to that over and over again. What they did in order to calculate this proportion, they used certain statistics in North America and Europe and combined the odds. I think they may have made a slight error there, but using the summary statistics they did generate a distribution, and then they took the average of that distribution by drawing a sample and calculating it that way. Perfectly legitimate. No argument there, but I'm just trying to say if you think there's a difference between Europe and the United States, we might want to just separate that out. Another little wrinkle was, as the authors claim to use combined Northern Europe to odds ratios, and I want to try to say that we got a problem because the prevalence of childhood asthma in the United States is relatively rare. When you look at that study, you think, my God, it's occurring in every household. Essentially, it's one in 12, according to CDC estimates. Not a common situation. The proportion of children less than 18 years old exposed to gas stoves was obtained from the American Housing Survey. I've given you the reference. Now, what they did was also look at state who has collected data on this. There's only been nine states, which means there's a whole lot that haven't. And you can see they go from Illinois down to Florida. And the overall ratio, if I combine all of those, sorry, the overall average combining those things comes out to be 12.7. And that's going to be their conclusion in the United States. 12.7% of children who have asthma really suffer the results with gas stoves. And they did that by combining across the states. I said only nine states report data. The limitation in red by Title Bam is the limitations particularly noted because of the wide variation in the graph. They range from Illinois for 21% to Florida with 3%. Why in Florida? And that's because windows are open all the time. There's various vent situations that go on and children are usually outside quite a bit. The population attributable fractions differ and that's explainable because of the difference in exposure to gas stoves among children. 79.9% in Illinois were exposed, only 9% in Florida. States with a higher percentage of children living in households with gas stoves have higher proportions of current childhood asthma attributable to gas stove usage. That was one of the things they said, I'm saying, have symptoms exacerbated by the presence of gas stoves. So they used aggregate data for the results. You have to do that. And then it's really helpful if a table were included that shows what exactly they did. And these were slides that I used in the Achmed lecture in OMED. And it basically shows the study. It will show something called the weight. But more importantly, you see the risk ratio there on the right that I've circled the effect estimates, where they go. This little bar graph tends to show what the effect was. And that black diamond shows the average of everything. It just tends to show what the data was on each study. Remember, they only had 27 of these things. We're not talking about a lot of information. They ended up with how many favors it. And the thing I want to point to, I'm sorry for those individuals watching this on Zoom, but if we take a look right here, this is the estimate of the homogeneity. And you can see that they very well corrected for it with a p-value. Nothing goes wrong. The overall effect is 1.51. This is the average they came up with, the 12.7, which is the proportion of people, of the children who were exposed. But a table like that would have satisfied and scratched a lot of the itches I have with this study. They didn't do it, whether it was an author's situation or not. It was a standard performed. You see that in articles you read all the time with analysis of variance tables or correlation tables. This is a standard meta-analysis table. They didn't include it. Additional concerns, Teitelbaum says. Previously on slide 12, I showed about this estimate of time for children. This, I submit, is something the authors need to consider, particularly since the equation for effect is based on time of exposure. The PAF are used to measure the strength. But again, do not prove that one causes the other. Correlation does not causation. So the article cite an assumption that needs to be underscored again, which is to say they've exposed the gas cooking among children is orthogonal and other risk factors such as tobacco smoke. What I mean by orthogonal is this. They're going to treat each potential contributor as independent of the other. In other words, being in a house with gas stoves, they're only looking at gas stoves independent of the fact of whether or not mom and dad smoke in the house. They're knocking out the interaction between these two factors. And an earlier slide I showed could be how much dust is in the house, mice, mold, other sorts of devices, and so forth. They're treating each independently. You can do that, but there's a statistical way of, quote, adjusting for these confounding or contributing variables. They did not do that. Yeah, once you adjust on something, we can't then use that as a basis for the causation issue. What you can do, no, but what you, you're correct, because what it does is underestimate, pardon me, overestimate the contribution of that variable. Now, the reason because maybe what they do is they act synergistically, or what they're going to say is if you smoke and you have gas, then that's going to increase your chances this much. If I only use gas, it would be this much. If we can set up a table and we can show the reduction in each one of those, you take out a few things again, which is I love to do, but then again, I'm me. So the notion is what we have to be able to do is we can reduce that, and we can end up with an accurate estimate, the individual contribution. And that's what they've done. They say when they make it orthogonal, they're stripping out the joint effect of those variables. Sir? Are you talking about subgroup analysis? In a way, subgroup analysis would be splitting your independent variables. In other words, analyze United States separate from Europe. Here, I'm talking about my dependent variable. What is the outcome? I'm separating out things which influence my outcome. I'm stripping that away. So I'm left with only that outcome variable. And that's very, very difficult. Boy, I'm, it and I are not going to get along, are we? I'm so sorry, folks. I don't know if I can get back. I want to see that you'll call Jeffrey. Yeah, I think Jeff's got to come in. Nope, here we go. Jeffrey, I've never seen you look better. You're great. All right. Thank you very much. That's perfect. Well done. Thank you. Okay, this is yours that you're doing. That's perfect. Yes. We'll start right there. Hang on. We got to share the screen first. Yeah, that way. This right here. How's that? Perfect. Thank you. Thank you so much. Don't go too far away. Okay. The good news is we're almost done. Start your friend from center. Of course, that much I could. I can do that. Thank you, ma'am. Okay. So, the warning is that they strip that stuff away. Like, I got dogs and gas stove. What we're going to do is get the independent contribution of dogs, independent of gas stoves, rather than we know that that point is a combination of both of those variables. Okay. The authors are very good about the word cause. They don't use it, but the critics of the article do. Please recall again that correlation doesn't prove causation, but the authors do show that exposure to higher levels of NO2 does produce more symptoms, and that has been consistent with the other findings. So, from a substance, I think the article is very good. From a statistical point of view, I think there are details that are lacking. So, what are the other sources of methane? Particularly in a home, it's gas heaters, furnaces, and dryers. How many have a gas dryer? Okay. How many have electric dryers? How many don't know? Okay. There you go. Substance dryers. Remember, we had a kid. My nephew was in college. He thought, you know, washing wear meant getting dressed by the dryer. I mean, you know, kids, they don't understand this stuff. So, here you go. Conclusions for this. 12.7 percent of the current childhood asthma nationwide is attributed to gas stove use. I've chosen that word. It's attributed to that, for which, similar to childhood asthma burdened by secondhand smoke, just also have 12 percent. I'm saying the conclusion is justifiable because it's consistent with other studies. The assumption of orthogonality, given the results, would eliminate, would be increased or decreased. Therefore, a table would have eliminated showing these confounding variables in Teitelbaum's view, would have sincerely strengthened the article, and not knocked down, and would have knocked down a lot of the criticism. So, now let me go to my last slides. I don't know what time we're going here, but here we go. The study should have followed the steps. I don't think if they did, they didn't demonstrate it. The time to interval for inclusion is very good. They built on the 2013 meta-analysis, and that helped things go on. The author's source of data did not include time of exposure to noxious stimuli. From my point of view, that was kind of bad. The authors have separated out non-European countries. That's good. And that only because now we can take a look at us individually. Now, modern kitchens, and I'm going to come back again to this. Think about your kitchen. How many of you have a hood over your stove, right? It's kind of standard, supposed to. How many of you turn them on? Cold cookies. I'm going to tell you right now. Yes, sir. That's the next question. That's the next one I'm going to come up with. Deliberately. Yes, sir. Yep. Okay. Now, here's the deal, folks. Most of you do not... Before we start throwing things at each other, let me suggest a phone. Most of you use this. How many use them on maximum speed? Yeah, hand down, all the hands go up. But the reason most people offer for that is too noisy. Yes. Now, the notion then is, where are these vented? How many say they vent outside? How many live in apartments? Yours vented outside? No, unless you live on the end unit. They either vent into a common duct or they do what? Blow it back into the kitchen. Now, the question is, how many of you have changed the filter in the hood? Not as many hands go up because you don't think about it. And the notion is that you've got to be able to do it. And I'm going to come up with some recommendations. I'm just kind of laying the groundwork, but so you can see. Yes, ma'am. Also assuming... Well, now that becomes a real issue. It's not an issue. And you're absolutely correct. And if you remembered some of the things they were saying, and the guy who chained himself to his cook stove in the restaurant says they thought microwaves would save the day relative to the gas leak. He never designed gas leaks. What he tried to show is that microwave would eliminate the problem. And it hasn't because people still use their stoves. And now with these convection ovens, it's going to be... There's a new oven coming out. It's dropping in price now that they think it's going to... I know most new houses will have. The question also is, if you live in apartments, you live in older homes. Older homes, as a rule, do not vent to the outside. What they do vent to the outside are the dryers for clothes. But cooking is kind of left alone. All right. Major debate is one of both prevention and politics. Many ways that dangers get thwarted. Again, we've talked about the problem with vent stoves. A lot of people don't use them. You want to make sure they're vented to the outside. They don't use vent stoves at maximum speed. And there should be review of standards for new stoves and associated equipment. According to the National Health and Nutrition Examination Study, children living in households that use gas stoves, only 21% live in households where the stove exhaust is vented and always used. I'm just saying. Now, here are the other sources. How many have a fireplace in their home? How many haven't vented? Absolutely, they have to. It's a standard. Now, unless they have a Swedish stove, which is supposed to be self-venting. Never heard of such a thing. Now, let me ask you this. How many turn the pilot lights out in their fireplaces during the summer? Okay, not all hands go up. And now, I'm going to come back to that in one of my last points. Here's some of the things that we want you to be able to do to prevent their cut down on this. Make sure all your burners are turned off completely after use. Ensure the burner's light every time. So, you should be able to keep an ignition source near the stove in case that doesn't happen. How many of you know how to relight your pilot light? Okay, that's a very, very critical task. Some people don't do it right and we end up with explosions. We end up with fires where they shouldn't be. You've got to do it. You've got to hold it till the thing clicks and then turn it off. Turn it back on and light it. You should read the instructions and takeaways. The second point for my remarks, learn how to stop and start and reignite the pilot light. Critical hot water heaters used to be the biggest one. We used to go down in the winter and relight them. And sometimes when people leave their homes for vacation and stuff, they just ignore the pilot light. They just leave it on. You say, what the heck? Well, use a gas detector near the bedrooms because you're going to be spending more time there than in the kitchen. Think about maintenance schedule for all gas appliances, however that goes, to make sure there's no leak. And I've given you the resources that I've used in here. So the question is this, my summary statistically on the article is the fact that it is not as strong as it is written. It may have been stronger when it was done, but the restrictions did not make this a good article at first blush. I'm not saying a bad article. It's just, there were some holes in it relative to the criteria of meta-analysis. However, from a contribution to the literature, it was very good because it showed the results from 2013 forward were consistent with what went on before, even with the modern advances we'd made in the kitchen. So I have mixed reviews. I think it's a statistically not the strongest as presented, but from a substantive point of view, I think it was good by itself. And so I would recommend the article for its conclusion. I would not recommend the article for its methodology. Well, its methodology isn't that good. How can you support use of it? Because of the consistency of the findings. And the question is, as I agree with you, it's a weaker argument, but they could have done, maybe they've done it because of some of the techniques they've used, they would have had to do it, but they didn't show it. The inverse method for combining it using a PAF in order to do it. I think the orthogonality column was there and they could have done subgroup analysis to make it stronger. It was some holes, but I don't think they were fatal errors. Any questions? Yes, sir. How about rewriting the title of the damn article that I would have read? Children with asthma have the worst cease process in homes with getting stones. I would have read that. Symphony in F major. I was going to say, the answer is yes. If you realize that the title of the paper, sometimes, the thing which made the news was not the paper, it was the commentary on the paper. Okay. Scientific American, Professional Journal, Gas Stoves Cause F. But a better title would have kind of thwarted that a little bit. Well, you're right. This was the International Journal of Epidemiology. I know it's on my bench stand. I don't know here. That was it. You probably want to cancel your subscription. Oh, okay. But the note that I was going to give, I'm going to read it. Yes, sir. The note that I was going to give, I'm going to read it. How are you sleeping? Do you doubt that that's sleeping? Yes, it is. Well, let me check my CPAP compliance when I put that in your office. I speak of that on Sunday. But, anyway, that's my group. Any questions? Did I finish on time? I'm not looking at my watch. My boss is checking in on me. Got it. No problem. Any questions of me? Sir, this is probably the most interesting story. You said the correlation is the same as the one I wrote. Sorry? You said the correlation basis from 2013 to 2023 was the same as what I think it was. Consistent. Consistent. And yet, we've had a lot of improvements and changes since then. So, would that lend one to say that the compounding factors were more of an issue than it was actually? I want to say, yes, but there's been a change in the habits of the household from the previous 10.2 to the last 70. The amount of time, for example, spent in the kitchen is reduced. That's because of workforce issues. And where it goes down. There was one article, which I must say, I just got to use the mic. There was one article that was not mentioned that I wish was, and I went in and looked at the articles that were used, and also in the earlier meta-analysis. People think that their gas stove only spills into the kitchen. The point is, it spills into every room of the house, including the bedroom, where that's where children spend most of their hour, if they're not outside. So, that's kind of. Thank you. You're confounding this, sir. Yes, absolutely. Absolutely. Yes, yes. From a technical perspective, old gas stoves, and they do sometimes last forever, have a pilot light that runs and is constantly burning 24-7, 365. Absolutely. One of those other gas stoves, which is, and they didn't seem to divide, the only kindle of fire when necessary. So, that meant being, you know, my gas stove at my mom's house now, there's no gas being used at all until you summon a fire. I would absolutely agree. Nothing happened until you turn it on, right? See, the question is, but it's not all. Maybe, the question is, what are you looking at? Remember, I said type of stoves are all stoves created equal. That was one of the things that I had on my slide. That's one of the things we should try to take a look at. And so, my position would be, it's cut down on the percentage, but the notion is, does it still have an effect on individuals with asthma? The answer is yes. But is it 12.7 on average? Can we subgroup analysis, as was pointed out, subgroup analysis a little bit more? And I think it should. My other question is other gas appliances. And you tried it, you got into this. I mean, because some houses are gassed. You have more gas, and all of them can be inefficient for all this stuff into the air. Other, if you don't have gas at all. Great comparison. Unfortunately, at my current house, we have an electric stove and a gas heater. That's correct. Is that, what's the risk? Because you've lumped everything. And the question is, not if you have a basement, it's a little bit less location. But I think the dryers, the vents. The thing is, is that these stoves would really be, we could cut it down if we just use the human factor sort of a deal. Maximum vent to the outside. And you can't do that in apartments. They just don't do that. Sherry put out indoor air quality standards for homes. For home construction. Yeah. Change the whole thing. Well, the notion would be if we start to go to, and there's nobody's going to grab the gas stoves. Let's be clear about that. And the notion is it's corporate. The notion would be on the construction. Is it in fact mandatory to vent to the outside? The answer to the question is, that's what they're really trying to do. The answer should be yes. And in apartments, you want to vent to a common duct. Which runs through the, and blows it up through the ceiling. New York, that's all they worried. Remember, it's soap pipes that went up to the top of the wood sauna. The godfather dropped the pieces of the gun in, as he went from unit to unit. Anything else? With that, thank you all very much. The conference, you know, has been very good. And I hope you all enjoyed. Thank you so much.

gas stoves

respiratory health

children

public health

asthma

nitrogen dioxide

meta-analysis

ventilation

Dr. Teitelbach

Congressman Bill Huizenga