Thursday, April 11, 2024

Harm Reduction in the U.S.: Center Stage (Narcotics) and End Stage (Tobacco)


The International Drug Policy Consortium (IDPC) “is a global network that works collectively to promote person-centred, rights-affirming drug policies at the national, regional and international levels.”  The IDPC published a summary of the 67th session of the United Nations Commission on Narcotic Drugs, which ended March 22, reporting that “member states resorted to voting on resolutions for the first time in modern history, and finally included the words ‘harm reduction.’”

The entire summary is worth reading, but I want to point out what it describes as a transformative moment for American representatives:

“All eyes then turned to the overdose prevention resolution from the USA – signalling their 180-degree transformation on harm reduction at the UN, driven by the appalling human toll of a domestic overdose epidemic (quite a shift given that, for decades, the USA have been the most vociferous barrier to this term being accepted in Vienna).”

Yes, you read that correctly.  Due to drug overdose deaths totaling over 100,000 every year, per the CDC, the U.S. is finally endorsing harm reduction for opioids and other killers.

With that turnaround, you might think that the Biden administration would consider harm reduction for cigarettes, which have killed 480,000 users every year for decades.  Like those smokers, you would be dead wrong.



Tuesday, April 2, 2024

Tobacco Harm Reduction Is A Life-Saving Policy, No Matter Who Promotes It


Dr. Joanna Cohen recently authored a misleading and factually incorrect commentary on tobacco harm reduction in The Hill.  Here is my rebuttal, in bold.

Cohen: “So why should we trust cigarette companies to help reduce tobacco use?”

No one trusts cigarette companies.  That’s why Congress gave the Food and Drug Administration regulatory authority over tobacco in 2009.  Cohen misrepresents the principle public health goal, which isn’t to reduce tobacco use, but to prevent the 480,000 premature American deaths that result each year from smoking. That number hasn’t appreciably changed for the 15 years the FDA has had regulatory authority.

Cohen: “For the last several years, the tobacco industry has been co-opting the term ‘harm reduction’ from public health, using it to frame electronic devices and e-cigarettes as the be-all, end-all of smoking cessation tools.”

False.  Harm reduction wasn’t co-opted, because Cohen and most public health officials never applied it to tobacco.  They insisted that smokers quit only through total nicotine and tobacco abstinence.  Conversely, cigarette manufacturers did ultimately acknowledge that their products were deadly, and that there were vastly safer smoke-free ways to consume nicotine.  In the mid-2000s, they started acquiring smokeless tobacco companies, which produced those safer products, and more recently, pushed by disruptive technology and new competitors, they adopted vapor and heat-not-burn tobacco products, which are also significantly safer than cigarettes.

Cohen and company are the only ones calling e-cigarettes “the be-all, end-all of smoking cessation tools.”  They seemingly forget that only 5% of all smokers achieve nicotine/tobacco abstinence in any given year. 

Cohen: “Such [harm reduction] methods include restricting tobacco advertising and promotion, increasing the price of tobacco products, and establishing 100 percent smoke-free public spaces. These all support people who are ready to quit without requiring abstinence.”

How do those steps support people who are ready to quit without requiring nicotine abstinence?  Cohen merely recycles failed measures that limit smokers’ options of ‘quit or die.’       

Cohen: “It is critically important, however, to note that, to date, no company in the U.S. has sought out FDA authorization to market these products as approved cessation devices.”

No, it’s not.  Authorization as a cessation device would not be handled by the FDA tobacco center, but by the drugs or medical device centers.  The FDA approved nicotine medications decades ago, even though, to meet FDA requirements for approval, they’re expensive and ineffectively low-dose, require warnings far greater than those on cigarettes, and don’t provide the nicotine spike that smokers get when they light up.  With a regulatory framework like this, no wonder nicotine medications are successful for only about 7% of smokers who try them. For what other medications does the FDA accept a 93% failure rate?  Let alone medications to treat a condition that will unnecessarily kill 480,000 Americans this year.  It is outrageous that the agency and most of the public health community promotes this failed strategy when safer, popular harm reduction tools are readily at hand.

Cohen: “…enabling tobacco to remain the leading preventable cause of death around the world.” 

Cohen knows that tobacco is not a synonym for smoke, but she repeats the egregious conflation, proving again she chooses to ignore that nicotine is the reason people smoke, but not the reason that smokers die.

Cohen: “tobacco industry allies baselessly position e-cigarettes and heated tobacco products as the only viable harm reduction method for people who want to stop smoking. They discount existing FDA-approved cessation methods entirely.”

This statement is full of falsehoods.  Tobacco harm reduction proponents are not industry allies; they are allies of those 480,000 smokers who will die prematurely this year.  The FDA-approved cessation methods Cohen et al. diss have only a woeful 7% percent success rate, as noted above.  Many other alternatives to cigarettes are already available, and many others are under development.

Cohen: “…we know that nicotine can still be extremely addictive.”

Yes, nicotine can be addictive, which is why her goal of nicotine-and-tobacco abstinence is so misguided.  Harm reduction proponents recognize that many smokers cannot achieve Cohen’s abstinence nirvana, so they promote practical solutions that save lives.

Cohen: “a whole new generation of consumers, including children and young people enticed by appealing flavors, who may spend the rest of their lives trying to curb a nicotine addiction.”

Everyone shares Cohen’s concern for children, and society should discourage them from adopting dangerous adult behaviors.  If Cohen was consistent, however, she would call for sanctions on companies selling alcohol, which poses a far greater threat to teen health, and she would focus on marijuana, used by 25 percent of all teens over the past 30 years.

Cohen worries that teens “may spend the rest of their lives trying to curb a nicotine addiction,” but nicotine is no more dangerous than caffeine, another addictive substance.  Cohen’s prescription – a ban on nicotine and tobacco – is doomed to fail, just as the complete ban on marijuana use failed for 30 years.

Cohen: “This playbook isn’t new. For decades, the tobacco industry refused to acknowledge that cigarettes are deadly…” 

Actually, the playbook changed dramatically, as cigarette manufacturers now acknowledge that combustible products kill.  But by denigrating safer tobacco products, Cohen et al.  prolong cigarettes’ dominance of the tobacco/nicotine market. 

In summary, do not mistake Cohen’s distorted idea of harm reduction as anything more than cigarette market prolongation.


Tuesday, March 26, 2024

For Women’s History Month, Noting a Historic Misrepresentation of Mouth Cancer in Women


This post honors Women’s History Month by focusing on a subject long-neglected by government-funded cancer investigators:

Why do American women who use smokeless tobacco have 10 times the risk for mouth cancer compared with American men who dip and chew tobacco?

This question arose in 2016, when Annah Wyss of the National Institute of Environment Health Science and 20 government-funded coauthors reported that American men had no excess mouth cancers associated with dipping or chewing tobacco (Odds Ratio, OR = 0.9), while American women, who mainly used powdered dry snuff, had ten times the risk (OR = 9) (here). 

Those findings weren’t outliers.  Epidemiologist Philip Cole and I in 2002 published a meta-analysis of smokeless tobacco and oral cancer (abstract here), concluding: “The use of moist snuff and chewing tobacco imposes minimal risks for cancers of the oral cavity and other upper respiratory sites, with relative risks ranging from 0.6 to 1.7. The use of dry snuff imposes higher risks, ranging from 4 to 13.”

Why did those 21 government-funded researchers, including one Debora Winn and at least seven other women, ignore these major differences?

Winn, as the first author of an epidemiologic study 43 years ago in the New England Journal of Medicine (abstract here), reported that “exceptionally high mortality from [oral cancer] among white women in the South is primarily related to chronic use of snuff. The relative risk associated with snuff dipping among white nonsmokers was 4.2.”  That study led the public and the medical establishment to falsely believe that smokeless tobacco was responsible for an American oral cancer epidemic. 

Winn had exaggerated her own findings. She claimed that smokeless tobacco produced an “exceptionally high mortality from [oral cancer],” even though her risk estimate only resulted in approximately 12 deaths per year among 100,000 long-term smokeless tobacco users. That mortality rate is not trivial, but it is not “exceptionally high.” It is comparable to the annual death rate of 12 -15 per 100,000 users of automobiles – a figure that does not deter American drivers.

Exaggeration is unacceptable, but Winn’s study has a special place in the annals of American smokeless tobacco misinformation. It focused solely on a niche tobacco product -- powdered dry snuff -- used by a tiny number of women in the southern U.S. But this passage in Winn’s article assigned dry snuff’s risk to all smokeless products: “The carcinogenic hazard of oral snuff is of special concern in view of the recent upswing in consumption of smokeless tobacco in the United States.” This misleading statement was featured in an AP wire story that was published throughout the nation.

Winn’s results actually did not apply to chewing tobacco and moist snuff, popular American smokeless products that have been used widely with significantly fewer medical consequences than powdered dry snuff. Long after her widely cited article was published, Winn acknowledged in two obscure scientific forums that her results were specific to powdered dry snuff. In 1986, Winn was asked whether the patients in her study had used “dry snuff or [moist] snuff.” She replied, “Almost exclusively dry snuff,” and then admitted that “Dry snuff is now [in 1986] a minor portion of the U.S. market.” Her late acknowledgment at a sparsely attended scientific meeting did nothing to deter tobacco prohibitionists from misapplying her mortality claims to all smokeless products, and to misdirection health professionals and the American public for the next 40+ years.