Thursday, November 20, 2014

Surgeons General Say the Darndest Things About Tobacco

Acting U.S. Surgeon General Boris Lushniak recently tweeted, “@OxfordWords #Vape may be #WOTY but the increase in never-smoking youth using e-cigs is a not a trivial story.”  The tweet referred to the Oxford English Dictionary’s having designated “vape” as the word of the year, and reflected a CDC report claiming that e-cigarette use among children had increased in 2013.  The prevalence of e-cig use among youth who had never smoked was 0.3%. 

Tobacco use by youth is never trivial, but in taking an extreme position, Dr. Lushniak was acting in the tradition of previous surgeons general.

In December 1992, Surgeon General Antonia Novello announced: “The majority of our experts predict an oral cancer epidemic beginning two or three decades from now if the current trends in spit tobacco use continue.” (here).  That was shocking news for many, including this oral cancer expert.  As an oral pathologist for 15 years at Emory University and the University of Alabama at Birmingham – deep in smokeless tobacco country – I had made microscopic diagnoses in hundreds of oral cancer cases (almost all smoker/drinkers), and I had assisted in the treatment of hundreds more.  Over time, I had become increasingly bothered by the disconnect between the dogma I taught my medical and dental students (that smokeless tobacco was a death sentence for oral cancer) and what I had experienced in practice (that smokeless tobacco was almost never listed as a behavior on the pathology request forms, the rare exception being powdered dry snuff).

Dr. Novello’s announcement was the catalyst for my research, which led to my first journal articles in 1994 (here and here), and my book, “For Smokers Only”, in 1995.  (An updated version with a new chapter on e-cigarettes is now available in print and as an audiobook here).   

I testified at a 2003 Congressional hearing on tobacco harm reduction (available here), at which Surgeon General Richard Carmona also testified. (Dr. Carmona is today an NJOY director and chair of its scientific advisory committee.)  In that hearing Dr. Carmona said, “there is no significant evidence that suggests smokeless tobacco is a safer alternative to cigarettes.”  I subsequently noted in a Washington Times editorial (here) that the surgeon general had ignored decades of published research and the findings of Britain’s esteemed Royal College of Physicians.

Dr. Carmona so blundered in supporting a ban on all tobacco products that Bush administration officials had to backtrack.  “This is not the policy of the administration,” White House spokesman Scott McClellan said, adding that Dr. Carmona’s comments reflected his views alone.

The surgeon general occupies one of the most trusted positions in American medicine. The individual holding that post should speak the truth about safer cigarette substitutes, today and always.      

Wednesday, November 12, 2014

Dependence Level Higher with Cigarettes Than with Smokeless Tobacco

As noted previously (here), Drs. Karl Fagerström and Tom Eissenberg have described a continuum of dependence among tobacco and nicotine products.  They concluded that cigarettes are the most dependence-producing (addictive) product and that smokeless tobacco is intermediate, evidenced by clinical trials showing that quitting cigarette smoking is more difficult than quitting ST.

In a new study published in Nicotine & Tobacco Research (abstract here), I use data from the 2003 Tobacco Use Supplement of the Current Population Survey to directly compare time to first use (TTFU) among smokers and smokeless tobacco users in a nationally representative sample.  My collaborators in the work are Nantaporn Plurphanswat, research economist at University of Louisville’s Brown Cancer Center, and Karl Fagerström.

Time to the first cigarette (TTFC) after waking up in the morning is a well-established measure of dependence among smokers – the shorter the TTFC, the stronger the addiction.  This measure is the key component of a scale developed in the late 1970s by Dr. Fagerström, for whom the scale is named.  TTFC is strongly correlated with abstinence and time to relapse among smokers enrolled in cessation trials and in nationally representative samples of smokers from four countries.  A comparable measure has been developed for smokeless tobacco use.

We examined TTFU among 10,500 white men who were daily cigarette smokers and 1,200 who were daily smokeless tobacco users.  Smokers were classified according to number of cigarettes per day (cpd) smoked: light (1-14 cpd), moderate (15-24 cpd) and heavy (25+).  Smokeless tobacco users were subgrouped as exclusive users or former smokers.

The results show that dependence among smokeless tobacco users is similar to that among light smokers (1-14 cpd), 9% of whose TTFU was less than 5 minutes, and 23% under 30 minutes.  Differences in TTFU between smokers and smokeless tobacco users can be seen in the chart below, which is from our study.

Our findings support the Fagerström-Eissenberg hypothesis that the dependence level of cigarettes is generally higher than that of smokeless tobacco.  This has positive implications for tobacco harm reduction, which is the substitution of smoke-free tobacco products for cigarettes among smokers unwilling or unable to quit.  Switching from smoking to smokeless tobacco use is associated with a huge reduction in health risks.  This study adds evidence that a switch to smokeless tobacco might also increase the chances for becoming completely tobacco-free.

Wednesday, November 5, 2014

Colorado State Smoking Ban: No Impact on Heart Attacks

As early as 2004, various medical journals published articles claiming that small-community smoking bans resulted in nearly immediate reductions in heart disease.  For example, the high-profile BMJ reported that hospital admissions for acute myocardial infarction (AMI) declined 40%, from 40 to 24, in Helena, Montana, after implementation of a smoke-free ordinance (here).  Circulation, the journal of the American Heart Association, reported that AMI admissions dropped 27% “within months” in Pueblo, Colorado (here). Similar reports came from Bowling Green, Ohio (here), Monroe County, Indiana (here) and beyond. 

The striking implication was: Eliminating second-hand smoke saves lives by reducing heart disease.

There were two problems with these claims.  First, the declines, based on small numbers of observations, were actually consistent with random variation (here).  Second, none of the reports accounted for the long-term downward trend in heart disease in the U.S.; they credited no-smoking intervention with the lower number of AMIs at a time when rates were declining nationwide.

In 2011, I documented that state-wide smoking bans in California, Utah, Delaware, South Dakota, New York and Florida had little or no immediate measurable effect on AMI deaths. The study, published in the Journal of Community Health (here), eliminated the “tiny-number” problem and factored in the national downward trend in AMI deaths.

I discussed these findings in my blog (here), but the work was largely ignored, until now.

Recently, researchers from three Colorado institutions reported AMI rates before and after a statewide smoking ban there; their work appears in the American Journal of Medicine (here).  (Thanks to Chris Snowdon, who also blogged about it here).

Paul Basel and colleagues found that “No significant reduction in [AMI] rates was observed” after the Colorado ban was implemented.  They also referred to our study:

“[The Rodu et al.] study compared the decline in [AMI] mortality in 6 states with smoke-free ordinances, with the average decline among 44 states unaffected by smoke-free policy.  No state with a smoke-free ordinance had a significantly lower observed [AMI] mortality compared with that expected by the nationwide secular decrease in states without the ordinance.  This emerging evidence highlights the importance of accounting for secular trends in [AMI] incidence before definitive attribution to smoke-free ordinances can be made.” 

It is comforting to see unfounded second-hand smoke claims corrected, particularly in the pages of a prestigious journal.