Tuesday, January 29, 2013

A Call to Action

I am not inclined toward political action, but I am inspired by Clive Bates’s call to action against the European Union’s appalling new tobacco directive (here).  Americans should take action at home as well, in support of tobacco harm reduction and an open U.S. market for vastly safer smoke-free products.  I have long argued for this in my blog and at my Smokers Only website (here).

Bates describes the EU directive as doing “three main bad things,” which are analogous in the U.S. to local, state and federal tobacco-prohibition efforts.  The strategies are the same.  The EU directive, he writes:

1. Bans snus, the least hazardous form of tobacco known to mankind, whilst allowing cigarettes to be widely sold.  Snus (or oral tobacco) is much less dangerous than cigarettes, and widely used in Sweden, where it is the main reason why Sweden has much lower rates of cancer and other smoking-related disease than anywhere else in Europe.

Why ban these products when they have been so successful at reducing harm in Sweden?

2. Treats e-cigarettes as though they are medicines – effectively banning or marginalising them…

3. Prevents any claim that one tobacco product is less harmful than another. The truth is that smokeless tobacco products may be many times less harmful than cigarettes, perhaps 10-1000 times less harmful.  So what looks like an attempt to stop false or excessive claims, is actually going to do real harm:

It denies consumers the most relevant information about lower risk tobacco products – information they could use to reduce their own risk and protect their health. This is misleading by omitting the most important information.

Why should a manufacturer bother to make or market these products or invest in innovation if they can’t say the one (truthful) thing that makes them valuable as alternatives to cigarettes? All this does is reinforce the market for the most harmful tobacco products by shielding them from competition from less harmful forms.

This makes a law out of misleading consumers – who benefits from it?

Bates encourages tobacco users to write representatives in their home country and in the EU parliament.  American tobacco consumers who are fed up with unscientific and inappropriate U.S. laws and regulations should do the same with their elected officials and government institutions. 

In other words, tobacco users should engage in political and policy matters that threaten your rights.  You need to protest if your city or state attempts to impose TIP-TOE (Tacit Incremental Prohibition - Tobacco Elimination), which involves banning nearly risk-free smokeless tobacco and e-cigarettes and assuring the continued market dominance of killer cigarettes (here).

You should respond by writing your public officials – mayor, city council members, governor, state and federal legislators.  I have adapted Bates’s Euro-centric suggestions for Americans who wish to express their views.

1. Be decent.  Always be polite and dignified, don’t make accusations or question motives – most public officials want to do a good job.

2. Be engaging.  Assume the official is open-minded but might need some persuading.  Don’t dismiss other views; tackle them.

3. Be authentic.  Express your views in your own words; public officials want to hear genuine heartfelt views, not borrowed text.

4. Be natural.  Formal language and legal terms aren’t required; it’s their job to understand you, not your job to understand the technicalities of legislation.

5. Be concise.  Concentrate on the things that really matter to you and stay focused – if you are writing about e-cigarettes, don’t dilute your message with views on other issues.  Keep it short (max two pages or 800 words) and to the point.

6. Be personal.  E-mail each legislator individually.  You can use the same basic text with each, but the personal touch goes a long way.

7. Be relevant.  When writing to Congress, for example, only write to your own legislators.

Bates also offers some great content suggestions:

1.  Write about your own experience – e.g., have you tried to quit smoking?  What experience have you had with e-cigarettes or smokeless tobacco use?

2. Tell why you think the proposed action will hurt you personally.

3.  Suggest what the official ought to do.

4. Ask questions that require a response; ask for a reply or a meeting.

5.  Explain how the proposed action may limit smokers’ options to quit cigarettes by switching to products that are much less risky, resulting in more smoking-related death and disease.

6. Describe how the proposed action could tie e-cigarettes in regulatory red tape, effectively banning these products by the back door.  It makes no sense to ban safer products while leaving dangerous cigarettes on the market.

7. Explain why the proposed action will make smoke-free products less attractive, more expensive and less innovative – for example by banning flavors, making the packaging look like medicine, and limiting advertising and marketing.

8. Tell the official why it is wrong to pretend that all tobacco and nicotine products are the same – smokers should have accurate information about risks so they can make informed choices.

9.  Explain why all smokeless tobacco products are much safer than cigarettes and are viable substitutes for smoking.  Smokers should not be denied this option.

10.  Convince officals that e-cigarettes should be regulated for what they are – consumer products, placed on the market as alternatives to cigarettes. 

11.  Note that if e-cigarettes are removed from the market, vapers will return to smoking.

12. Tell officials that government should encourage smokers to switch to e-cigarettes or smokeless tobacco, not ban or marginalize these products through regulation.

I will add one more content tip that is especially relevant to Americans: Strongly object to tobacco prohibitionists’ baseless claim that adult access to safer tobacco products is a problem for children.  It isn’t a children’s issue.  FDA regulation will ensure that tobacco companies don’t advertise or sell tobacco to children.  There are 45 million smokers in the U.S., and the eight million who will die from smoking-related illnesses in the next 20 years are not children today; they are adults, 35 years and older.  Preventing youth access to tobacco is vitally important, but that effort should never be used as a smokescreen to condemn smoking parents and grandparents to premature death.

In the U.S., the Consumer Advocates for Smoke-Free Alternatives Association (here) is active on e-cigarette issues.  They post calls to action on their website, and members of CASAA’s board of directors, including Elaine Keller, Kristin Noll-Marsh, Gregory Conley and Carl V. Phillips, are credible, persuasive spokespersons on the full range of smoke-free tobacco issues.

Smokeless tobacco users and switchers should take CASAA’s approach.  This post gives you some basic tools.  Get involved!

Wednesday, January 23, 2013

A “News” Study on Smokeless Tobacco

A study published this month in Nicotine and Tobacco Research (abstract here) provides evidence that coverage of smokeless tobacco (ST) in the context of tobacco harm reduction was infrequent and negatively slanted during the period 2006 through 2010. The lead author was Dr. Olivia Wackowski from the University of Medicine & Dentistry of New Jersey, with coauthors from her institution and from the University of California San Francisco.

The authors searched for articles primarily about ST in the Wall Street Journal, the New York Times and USA Today, and in the top 2-4 newspapers in each state.  She also searched national news services (Associated Press, Reuters, UPI), the Winston-Salem Journal (home of RJ Reynolds), The Richmond Times (home of Altria) and health wire news services. 

Dr. Wachowski found 677 news articles, the largest group of which (n=191, 28%) were business-focused.  Other categories included prevention/cessation (11%), taxes (10%), use trends (9.0%), bans (8.1%), tobacco industry promotions (4.9%) and health risks (4.9%).

Only 130 ST articles focused on tobacco harm reduction (lumped with new products and product regulation), a low number considering the subject’s potential to save millions of lives.  Of these, only “…about 58%... referred to ST products as being [or] possibly being less risky or harmful than smoking.”  This category also had the highest percentage of articles (69%) with references to health risks, but it is likely that few of them were positive.  Tobacco hometown newspapers contributed the most articles to this category (38%), followed by state papers (35%) and national papers (23%). 

The researchers also found 176 “opinion” articles; 89 were letters to the editor, 70 were editorials and 17 were op-ed pieces.  Unfortunately, 64% were classified by the researchers as anti-ST, only 26% were pro-ST, and the remainder were neutral.  Of the 61 articles in the harm reduction category, 43% were pro-ST. 

One positive note: The use of the derogatory term “spit tobacco” was uncommon, except in state newspapers (15%).    

In short, coverage of ST has been scant and heavily biased against and tobacco harm reduction.  This is unsurprising, given the national misinformation campaign that I discussed previously (here).    

Thursday, January 17, 2013

Finally, U.S. Official Admits that Smoking Deaths are Declining

Dr. Phil Cole and I asserted in 2008 that smoking-related deaths in the U.S were on the decline. Finally, this month, an FDA official arrived at the same conclusion in a journal article.

In “Calculating the Big Kill,” which appeared in Regulation, the Cato Institute’s flagship publication (here), I made the case that “CDC [Centers for Disease Control and Prevention] estimates of smoking-related deaths do not add up.”  I noted that “U.S. smoking rates have been declining almost continuously since the mid-1960s, when 42 percent of American adults smoked.  The rate dropped to 28 percent in 1988 and has now declined to 21 percent.  Put simply, the proportion of Americans who smoke has been cut in half over the past 40 years.”

I asked, “Why have the CDC [big-kill] estimates not fallen?”

My question was based on a research study that Dr. Cole and I published a year earlier in Nicotine and Tobacco Research (abstract here), showing that “there were 402,000 deaths attributable to smoking in 1987 and 322,000 in 2002.”  We noted that despite the substantial decline in smoking prevalence, the estimate of smoking-attributable deaths from the Centers for Disease Control and Prevention had changed hardly at all. 

Five years later, my question is still relevant.  The answer is clear: The CDC chose not to acknowledge the fact that deaths had plummeted.

Brian Rostron, a scientist at the FDA, has now published a study, also in Nicotine and Tobacco Research (abstract here), demonstrating that smoking-attributable deaths declined from 398,000 in 2000 to 370,000 in 2007.

As I explained in my Cato article, most people mistakenly believe that CDC officials actually count the number of smokers who die each year.  The truth is that the CDC uses a model that estimates the number of current and former smokers based upon data in the National Health Interview Survey (NHIS); the CDC subjects those smoker estimates to relative risks developed by the American Cancer Society in the 1980s, and then produces an estimate of the number of deaths that would not have occurred if they had never smoked.  Like any model, the quality of the output is dependent on the quality of the input.

I had noted that the CDC was using 20-year-old data to produce its “big-kill” estimates; Dr. Rostron concurs, saying that “the CDC has not substantially revised the methodology or data that are used in this procedure since their introduction in the 1980s.” 

Rather than using decades-old risk estimates, Dr. Rostron updated the relative risks for smokers and former smokers by calculating them from NHIS subjects from 1997 to 2004 who were followed through 2006 with linkage to the National Death Index.  Unlike the outdated CDC estimates, he adjusted risks for age, race/ethnicity, education, alcohol consumption and body mass index, which are important confounding factors for some or all smoking-related diseases.

Here are Dr. Rostron’s big-kill estimates:

Smoking-Attributable Deaths Among Men and Women in the U.S., 2000, 2004 and 2007

Although declining, Dr. Rostron’s big-kill numbers may still be too high because of the way he estimated deaths among former smokers.  Using his model, former smokers accounted for about 177,000 out of the 370,000 deaths from smoking in 2007.  This seems to be excessively high, as the 2007 NHIS documents that 60% of the 39 million former smokers had quit over 15 years previously.  Any excess risk for a smoking-attributable death was minimal to nonexistent in this group. 

Dr. Rostron’s deaths among former smokers were likely concentrated in those who quit less than 5 years earlier, and who therefore have risks similar to those of current smokers.  But it is inconceivable that this group of 6.3 million former smokers produced almost as many deaths as the 27.5 million current smokers in 2007.  Dr. Rostron’s model should be revised to reflect the different risks among former smokers who have short or long quitting histories.

Regardless, the main message of this study is valid: Smoking-attributable deaths have been in decline for over a decade.  This is good news that the CDC and other federal agencies have ignored for far too many years.