Tuesday, April 6, 2010

Measuring Misperception About Smokeless Tobacco Health Risks

Consider an American addiction: automobile travel. Driving around town or around the country, we recognize and accept a small but measurable risk of dying in an accident. We take comfort in the fact that our cars’ seat belts and airbags will protect us.

Now imagine a world in which the American Automobile Association, the Fraternal Order of Police and the National Highway Traffic Safety Administration declared that cars with seat belts and airbags are just as dangerous as cars without these devices, and that the only way to avoid dying in an auto accident was to avoid automobiles altogether.

This is an outrageous scenario. We wouldn’t tolerate the dissemination of such demonstrably false information by non-profit groups, professional organizations and government agencies. It is well established that these harm reduction measures (seat belts and airbags) have helped reduce automobile accident deaths to record-low numbers (34,000 in 2009).

So why do we tolerate misinformation about smokeless tobacco, a harm reduction measure for smokers that could prevent over 400,000 deaths per year?

My research group just published a study documenting that misinformation about the risks of smokeless tobacco use has led to widespread misperception among highly educated university faculty, even those in health-related schools. The first author of our study was Nicholas Peiper, a doctoral student in epidemiology at the University of Louisville. Ramona Stone and Riaan van Zyl of the U of L Kent School of Social Work were our collaborators. The study was published in Drug and Alcohol Review (abstract here).

We conducted a survey that quantified the risk perceptions of cigarette smoking and smokeless tobacco use with respect to general health, heart attack/stroke, all cancer, and oral cancer among full-time faculty. We compared the results from faculty on the health science campus with those in schools not related to health.

We found that misperception was common among this highly educated group. For example, 51% of all faculty incorrectly believe that smokeless tobacco use confers general health risks that are equal to or greater than smoking. The misperception rate was lower for heart attack/stroke risk (33%) but higher for cancer (61%).

The misperception rate for oral cancer was stunning: 86% of all faculty incorrectly believe that smokeless tobacco use confers risks that are equal to or greater than smoking. Although faculty on the health science campus had a somewhat lower rate than others (81% vs. 91%), our survey provides evidence that most health professionals have a poor understanding that smokeless tobacco use is vastly safer than smoking.

Why are these highly educated people, especially those in health-related professions, so wrong about the risks of smokeless tobacco use? We offer some reasons in the manuscript:

“First, deficiencies in health education may exist with respect to tobacco use and health consequences. Numerous U.S. studies have shown that medical, nursing and dental school graduates may have inadequate training to provide effective tobacco education or intervention.”

However, we believe that misperception results from misinformation from “…anti-tobacco advocates and organizations. A 2005 review found that websites providing health advice and information tend to conflate the risks of smokeless tobacco with the risks associated with cigarettes, using either direct or implied statements. This misinformation came from respected international and American federal health agencies like the World Health Organization, the U.S. Department of Health and Human Services and the National Cancer Institute, as well as nongovernmental organizations like the American Cancer Society and the Academy of General Dentistry. Another systematic review of over 48 medical brochures from some of the same organizations (e.g., NCI and ACS) found that the risk of oral cavity cancer and of other conditions associated with smokeless tobacco use was frequently overemphasized, ‘reaching beyond the scientific data.’”

Here is an excellent example of misinformation from respected health organizations. The Canadian Cancer Society and the Canadian Heart and Stroke Foundation sponsor the quit-smoking website I Will Succeed. Look at question 4 of the simple quiz, “Chewing tobacco is safer than smoking it. True or False?” It is pitiful that these organizations consider False the correct answer, and their explanation is either completely misleading (“the exposure [to nicotine] is similar; a tin of snuff equals roughly 60 cigarettes”) or absolutely false (smokeless “can boost the chance of cheek or gum cancer times fifty”). These societies are misinforming Canadian smokers and health professionals.

Modern smokeless products, which satisfy smokers and can be used invisibly in any social situation, are as widely available in the U.S. as seatbelts. Thus there is no barrier to their widespread adoption as safer nicotine delivery substitutes for cigarettes by inveterate smokers. Still, large scale tobacco harm reduction will not happen in the U.S. until smokers are provided truthful information about the low health risks of smokeless products.

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