Wednesday, June 29, 2011

To the American Cancer Society: Fill in the Blanks

In April, I wrote that the American Cancer Society (ACS) is withholding important information on the health risks of smokeless tobacco use (post here). Here’s how the ACS can fill in the blanks on the missing information.

In 1997 the ACS published death rates among non-smokers and smokers from their Second Cancer Prevention Study (CPS II), which the organization promoted as “the largest and most recent prospective study of smoking and disease.” (Available here). According to ACS at the time, “relative risk estimates from CPS-II already have been used extensively to estimate smoking attributable mortality in the United States, Latin America, and nearly 50 other developed countries.”

CPS II involved monumental effort. In 1982, ACS recruited almost 1.2 million Americans, and collected information on smoking, smokeless tobacco use and other lifestyle factors. During the next six years, it meticulously recorded deaths among participants, so that it could determine to what extent smoking and smokeless use influenced death rates

Death rates among smokers from CPS II are the basis for the entire American anti-smoking crusade. For 20 years, this data has served as the basis for estimates by the Centers for Disease Control of how many Americans die from smoking. As seen in the table, smoking is responsible for a two- to three-fold increase in death rates for male smokers compared with nonsmokers.

All Cause Mortality Rates (Deaths per 100,000 per year) Among Men Who Are Nonsmokers, Cigarette Smokers and Smokeless Tobacco Users, 1982-1988
Age (years) Nonsmokers Rate Smokers Rate Relative Risk ST Users Rate Relative Risk

Let’s interpret just one line in the table. Over the six year period, there were 368 deaths among 100,000 nonsmoking men who were 55-59 years at the start of the study. In contrast, there were 1,084 deaths among 100,000 smokers -- 2.95 times more (rounded to 3.0). That is a big difference.

But the table is incomplete. The Cancer Society has never released death rates among smokeless tobacco users for the period 1982-88. ACS has this information, but it refuses to release it. I believe that ACS is withholding death rates from smokeless tobacco use because they are not significantly different from those for nonusers.

The FDA should be required to address this appalling information gap. The agency mandates that smokeless tobacco packages carry this warning, among others: “This product is not a safe alternative to cigarettes.” It is outrageous that the FDA lacks hard data to support the statement. Potentially life-saving comparable risk information is being withheld from smokeless tobacco users, smokers and the FDA by the American Cancer Society.

Friday, June 24, 2011

A Nationwide Campaign Against Smokeless Tobacco

Smokeless tobacco and e-cigarettes are being recognized as safer, satisfying cigarette substitutes by increasing numbers of American smokers. Tobacco prohibitionists appear to be countering with a national misinformation campaign aimed at dissuading smokers from switching to smoke-free alternatives.

Letters to editors and commentaries are appearing regularly around the country, over the signatures of local public health officials, physicians and other respected health figures. Many of these items share similar talking points, including the scourge of nicotine, misrepresented health risks, and baseless accusations of marketing candy-like products to kids. All of this is attributed to the tobacco industry, despite that sector’s regulation by the FDA.

There is another common thread: Most of the articles cite the Campaign for Tobacco-Free Kids as their source for the specious claims. Here is an example, written by Montana’s Lewis and Clark County health officer Melanie Reynolds and published in the Helena Independent Record (here).

To set the record straight, I wrote the following to the newspaper’s editor:

“It is clear that Melanie Reynolds’ commentary (Beware of tobacco…, June 15) promotes prohibition (‘We in public health recommend avoiding all tobacco products…’), but that goal does not justify its use of misleading and inaccurate information.

“Ms. Reynolds portrays these products as ‘dangerous,’ but she completely ignores decades of research documenting that smokeless tobacco use is 98% safer than smoking. While no tobacco product is absolutely safe, the majority of cigarette smokers are routinely misinformed – by government agencies and by anti-tobacco extremists – about the relative safety of smokeless products. Unlike cigarettes, smokeless does not cause lung cancer, heart disease or emphysema. Smokers rightfully worry about mouth cancer, but they should take comfort in the fact that the risk for mouth cancer with smokeless is far lower than it is with cigarettes. Statistically, smokeless users have about the same risk of dying from mouth cancer as automobile users have of dying in a car wreck. In fact, switching from cigarettes to smokeless provides almost all of the health benefits of complete tobacco abstinence.

“Ms. Reynolds repeats Tobacco-Free Kids’ flimsy allegations about children. If Lewis and Clark County health officials have evidence that tobacco manufacturers are marketing to children, these very serious charges should be directed to the Montana State Attorney General. Since the 1998 Master Settlement Agreement, tobacco manufacturers have been prohibited from directly or indirectly targeting children, and many states have an expedited process for policing and enforcing MSA provisions. Otherwise, these represent nothing more than hollow and specious diatribes.

“New smokeless products are for adult smokers, not children. The 8 million Americans who will die from smoking-related illnesses in the next 20 years are now adults who are at least 35 years old. Preventing youth access to tobacco is vitally important but should not be misused to condemn smoking parents and grandparents to premature death.

“Ms. Reynolds describes tobacco manufacturers as ‘devious’ for introducing vastly safer smokeless products, but this is irresponsible. If any other consumer product was as dangerous as cigarettes, society would demand safer alternatives, and it would be scandalous if consumers were denied them. Tobacco prohibitionists wish to do just that.”

Brad Rodu
Professor of Medicine
Endowed Chair, Tobacco Harm Reduction Research
University of Louisville

On June 15 John Doran, Editor at the Independent Record, replied that he would “get [my letter] in as soon as we can.”

Thursday, June 16, 2011

Weight! Quit Smoking Without the Gain

It is well established in the scientific literature that smokers generally weigh less than nonsmokers, and that smokers who quit are at risk for weight gain. A recent article in the journal Science (abstract here) reported that nicotine activates specific nerve cells in the section of the brain called the hypothalamus. This interaction may be responsible for decreased appetite; it is different from nicotine’s trigger of reward and satisfaction in the brain. This complex research was conducted in mice, so the results will need confirmation in human studies. Still, they substantiate two dreaded downsides to quitting smoking: the loss of the powerfully rewarding and satisfying activity, and the gain of unwanted pounds.

We already know that switching from cigarettes to smokeless tobacco keeps smokers satisfied while giving them almost all of the benefits of complete tobacco/nicotine abstinence. But does switching keep the weight off?

In 2004, I published the first and only research article answering this question (abstract here). Along with colleagues from UmeƄ University in Sweden, I used a World Health Organization dataset to evaluate weight gain among nearly 3,000 men in Northern Sweden.

Weight Gain Over Nine Years Among Men in Northern Sweden
Tobacco CategoryAverage (lbs)
Nonusers (Referent group) 7.0
Smokers 5.1
Smokers who quit completely 15.0*
Smokers who switched to snus 7.9
Snus users 6.8
Snus users who quit completely 11.2*
*significantly elevated compared with nonusers

The big gainers were smokers and snus users who became completely abstinent from nicotine and tobacco. But snus users and smokers who switched to snus didn’t gain any more weight than nonusers. This is important news for smokers who are concerned about putting on pounds when attempting to quit smoking.

I also noted that the rate of overweight at the start of the study was 32% among those who didn’t use tobacco, 29% among smokers, and 42% for ex-smokers. These percentages are somewhat lower than other reports because our group defined overweight as a body mass index (BMI) of 27 or higher. The standard definition of overweight starts at a BMI of 25. For more information about BMI, go to this website at the federal National Heart Lung and Blood Institute.

Fear of gaining weight should not deter smokers from quitting. Research shows that a switch to smoke-free tobacco can leave them healthier with no added pounds.

Wednesday, June 8, 2011

The Truth About Federal Warnings on Smokeless Tobacco Products

Cigarette smokers who are considering a switch to vastly safer smokeless tobacco are confronted with confusing government-ordered warning labels. Most would be surprised to learn that three of the four mandated warnings were fabricated by tobacco prohibitionists and codified into federal legislation in 1986 by a misinformed U.S. Congress. Despite their obvious flaws, the original warnings were re-confirmed in the 2009 Tobacco Act and a fourth was added.

Here are the underlying facts and fallacies related to the four warnings:

1. “This product can cause mouth cancer.” This warning was mandated in 1986, five years after Dr. Deborah Winn egregiously misinformed Americans about the magnitude and scope of mouth cancer risk from smokeless tobacco (discussed previously in this blog here and here). This warning is highly misleading. Contemporary American and Swedish smokeless products confer vanishingly small risk for mouth cancer. Now that the FDA has been given authority over the warnings, I hope the agency will provide comprehensive information about all health risks, as I did in this blog (here and here).

2. “This product can cause gum disease and tooth loss.” In 1986, prohibitionists were desperate to blame smokeless tobacco for causing something besides mouth cancer, but twenty-five years ago there was virtually no scientific evidence that smokeless tobacco was an independent risk factor for any dental problem. The same is true today. A comprehensive review of the subject was published by Kallischnigg and colleagues in BMC Oral Health in 2008 (available here). The risk for all dental problems is either very low or nonexistent among smokeless tobacco users.

3. “This product is not a safe alternative to cigarettes.” The purpose of this 1986 warning was to deceive smokers into believing that smokeless tobacco was just as dangerous as smoking. As I wrote in my 1995 book, For Smokers Only: How Smokeless Tobacco Can Save Your Life (link), this warning “is simply ludicrous…Not even potato chips or nature hikes are ‘safe.’ If we look at ‘safe’ to mean relatively safe or ‘safer,’ something the government warnings inanely avoid here, then use of smokeless tobacco products is far safer than cigarette smoking.”

To apply an absolute standard of safety to any product or activity is preposterous. It’s worse to use this standard to deny smokers access to life-saving smokeless products and information.

4. “Smokeless tobacco is addictive.” This was added in the 2009 legislation, and it’s the only warning with a legitimate scientific rationale. It is entirely appropriate for consumers to be warned that any product containing nicotine is addictive. But the warning also reinforces what switchers already know -- that smokeless tobacco can be a satisfying cigarette substitute precisely because it provides satisfying doses of nicotine.

Congress was misinformed in 1986, when it dictated the mouth-cancer, gum-disease and not-safe warnings for smokeless tobacco. In view of the extensive relative risk data published since then, Congress should have revised the warnings to reflect the facts, rather than just rubber-stamp them in 2009.

The FDA prides itself on being science-driven; that provides some hope that smokeless tobacco warnings will some day be appropriately and accurately revised. In the meantime, the mouth-cancer, gum-disease and not-safe warnings exaggerate and distort the vanishingly small health impact of smokeless tobacco. Medical ethics and principles of public health dictate that smokers and smokeless tobacco users should not be subject to such health-endangering deception.

Wednesday, June 1, 2011

The True Impact of Snus in Sweden: Smoking Cessation Up, Initiation Down

It is a widely accepted myth that snus use among men in Sweden has only served as a quit-smoking aid. While my published studies from 2002 to 2005 (described here, here, and here) and many others (here, here, and here) have documented that male smokers in Sweden have used snus as a gateway to a smoke-free life, that is only part of the story.

Snus use has also played a valuable role in steering tobacco initiators away from more dangerous cigarettes. In 2005, I authored a study of tobacco use among Swedish boys and girls age 15-16, which was published in Tobacco Control (here). The results are impressive: “During the period 1989 to 2003, the prevalence of tobacco use [in Sweden] declined both among boys and girls. For boys, regular smoking declined after 1992 from 10% to 4%. Their snus use was about 10% in the 1990s but increased to 13% by 2003. Regular smoking among girls was 20% in early years and declined to 15%. Smoking among girls was always double that among boys. Patterns of occasional tobacco use were similar to those of regular use.”

I also observed that “…specific patterns of tobacco use differ strikingly between Swedish boys and their EU counterparts…In 2002 the World Health Organization reported that the average prevalence of daily smoking among 15 year old boys in 25 European countries (excluding Sweden) was 18%.7. In that report boys in Sweden had the lowest smoking prevalence of all countries (5.7%), at about one third of the EU average. The next highest prevalence was in Greece (9.2%). All other countries reported prevalences from 12% (Wales) to 27% (Lithuania). Thus, high prevalence of snus use by Swedish boys may be a factor in low smoking prevalence.

“In contrast, smoking rates among 15 year old girls in Sweden do not differ from those among girls in other European countries. In the 2002 WHO report smoking prevalence among Swedish girls was the fifth lowest in Europe (14%), but still close to the average for all other countries (19%, range 11% in Greece to 29% in Germany).”

I want to be absolutely clear: I strongly support all measures to keep tobacco away from children. However, a tobacco-free world, for adults and children, is as likely as an alcohol-free world was in 1920 (here). Teenagers will use tobacco, no matter what measures are taken to stop them. The remarkable story from Sweden is that most boys choose snus, the product their fathers use. This fact is well-received by health and policy professionals who understand that snus users lead lives that are virtually indistinguishable (in measures of years and health) from those of their abstinent peers.

Finally, the “Swedish Snus Experience” is not only about men. Recently, more women in Sweden are also using modern snus products (evidence here), which are spit-free and socially acceptable. This may represent the first time in recorded history that women have adopted a healthier behavior – from their husbands.