American Dental Association Improves Mouth Cancer and Smokeless Tobacco Brochures

I have been critical of the American Dental Association’s distribution of misinformation about smokeless tobacco and tobacco harm reduction (discussed here and here).  New ADA brochures on mouth cancer and smokeless tobacco show significant improvement  over their past publications.

The new pamphlet on mouth (and throat) cancer (here) accurately describes the disease as occurring “…most often in people who smoke cigarettes, cigars, or pipes and drink heavily (30 drinks or more per week).  That combination is estimated to cause the majority of mouth and throat cancers diagnosed in the United States.  Here are some additional risk factors:

• “Current research shows that some types of human papillomavirus (HPV) can cause throat cancer, which affects the base of the tongue and tonsils. HPV is very common— many people have the virus in their bodies and don’t even know it.

• “People who often spend long periods of time in the sun are at higher risk for lip cancer.” (emphasis in the original)

The brochure mentions one other risk factor, “a diet with too few fruits and vegetables,” but this is relevant mainly for people in developing countries, not in the U.S.

The new brochure on smokeless tobacco (here) drops many of the unscientific allegations that appeared in earlier versions and focuses a good deal on cessation.  Mouth cancer goes unmentioned, which is appropriate, given that the risk is so low. 

Still, the brochure is flawed.  Here are some questionable statements:

1.  “One can of smokeless tobacco has as much nicotine as 60 cigarettes or three packs.”  This is about as meaningless as claiming that one bottle of bourbon has as much alcohol as 19 cans of beer.  Just as responsible drinkers modulate their alcohol intake when using different products, smokeless users and smokers modulate their nicotine intake based on the products they use, attaining nearly the same peak nicotine blood level regardless of the source.  In comparing product nicotine levels, the ADA demonizes nicotine, which, while addictive, is not a major factor in any smoking-related illness.

2.  “Smokeless tobacco … has over 3,000 chemicals, including 28 cancer-causing substances.”  This is technically accurate but meaningless. One could also make the factual statement: “Coffee has over 1,000 chemicals, including 21 cancer-causing substances.” (here)  Any food or drink is composed of thousands of chemicals, some of which are or may be carcinogens.  Focusing on these is a scare tactic, described by renowned biochemist Bruce Ames as “hysteria over tiny traces of chemicals that may or may not cause cancer.” (here). 

3.  “People may think that smokeless means harmless, but nothing could be further from the truth.”  No credible tobacco harm reduction scientist or advocate claims that any tobacco product is absolutely safe; suggesting otherwise is nothing but a straw-man argument. 

The truth about smokeless is readily apparent: A wealth of scientific data show that smokeless means almost no measurable health risk.

Allegations and Answers in Owensboro

A letter published in the Owensboro Messenger-Inquirer on December 12 challenged the veracity and ethics of the Switch and Quit Owensboro campaign (described here). The letter, authored by a former administrator of the Kentucky oral/dental health program, reflected the hostility towards tobacco harm reduction that is common among dental organizations (previously described here and here).

The Messenger-Inquirer published this response from me on December 19:

To the Editor,

Dr. Jim Cecil’s December 12 letter criticizing Switch and Quit Owensboro contained serious inaccuracies.

Dr. Cecil states that smokeless tobacco products “are known to cause” a number of diseases. In fact, research shows that the health risks from smokeless use are so minuscule that they are barely measurable, and they are a tiny fraction of the health risks associated with smoking. Dr. Cecil suggests that smokers only be told about “FDA-approved smoking cessation aids,” but those products succeed with only 7% of smokers. Smokeless tobacco works as a cigarette substitute because it satisfies nicotine cravings; it is also more affordable and more widely available than nicotine medicines.

Dr. Cecil incorrectly states that “there is no scientific evidence that smokeless tobacco can help a smoker quit!” Numerous scientific studies published in prestigious medical journals document that smokeless tobacco is an effective quit-smoking tool. These studies are summarized in two comprehensive reviews in Harm Reduction Journal (here and here).

Rather than being an industry ploy, as Dr. Cecil implies, Switch and Quit embodies a smoking cessation concept that has been endorsed by the esteemed British Royal College of Physicians (among others), which found “...that smokers smoke predominantly for nicotine, that nicotine itself is not especially hazardous, and that if nicotine could be provided in a form that is acceptable and effective as a cigarette substitute, millions of lives could be saved.” (available here)

Dr. Cecil believes it is “unconscionable” and “unethical” to inform smokers about vastly safer smoke-free tobacco products. Consider this fact: If all American smokers instead used smokeless tobacco, over 430,000 lives would be saved each year. The Switch and Quit campaign is consistent with the highest medical and ethical standards.

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

Anti-Harm Reduction Tactics By The American Dental Association

On June 24 the American Dental Association (ADA) continued its long assault on tobacco harm reduction in a news article on FDA cigarette warning labels (here). The dental group repeated its 2009 statement about smokeless tobacco substitution: “As a matter of public health, we have become increasingly alarmed by recent attempts to market smokeless tobacco as a healthier (or less harmful) alternative to cigarettes. Smokeless tobacco is not a healthy alternative to cigarette smoking; both products pose health risks.”

Under the guise of “public health,” the ADA continues to deny smokers information that smokeless tobacco is a satisfying and vastly safer substitute.

The ADA has a long history of undermining this lifesaving strategy. In 1994 I published the first two articles in the medical and scientific literature proposing that smokers switch to smokeless tobacco (here and here). At the time I was chairman of the oral pathology department at the University of Alabama at Birmingham School of Dentistry, and I was a member of the ADA. Nevertheless, the organization aggressively worked to destroy my reputation and my career.

On August 17, 1994 the president of the ADA wrote to the dean that my proposal was “naïve at best and irresponsible at worst,…a disservice to the faculty and the public at large. He called the “notion that smokeless tobacco is a safe alternative to smoking tobacco” a “deception,” and he urged the dean to “repudiate the advice being promulgated by Dr. Rodu in the strongest possible manner.”

The ADA letter was a thinly veiled request to silence me. I do not know if the dean responded, but I know that the ADA expanded its destructive campaign by trying to convince the local dental society to condemn me. However, in November 1994 Dr. Alvin Stevens, the local society’s president, published a letter supporting me in the nationally distributed ADA News. Dr. Stevens wrote that “Dr. Rodu’s message is simple and is backed up by published medical and dental data…statistically, the morbidity of smokeless tobacco use is dramatically and significantly less than the use of cigarettes…Dr. Rodu’s proposal is a viable and realistic option.”

Dr. Stevens concluded that “we think that it is a disservice to call a fellow dentist ‘irresponsible’ without acknowledging, recognizing or listening to his total message…”

The ADA encouraged my professional organization, the American Academy of Oral and Maxillofacial Pathology, to condemn me and my proposal. The president replied that “…it is not the role of the AAOMP to make public statements in support of or disagreement with any individual research that has been appropriately reviewed…”

The ADA also collaborated with the American Association of Oral and Maxillofacial Surgeons, which contacted all of their members, suggesting that they send a form letter under their signature to the local newspaper. The letter contained the false punchline: “Suggesting this switch is like telling someone to use a rifle instead of an Uzi.” In retrospect, we know now that the analogy would have been more accurate if the substitute was a water gun.

In the seventeen years since 1994, approximately 6.8 million Americans have died from diseases attributable to smoking. Yet, there is no evidence that officials at the ADA, or at other national health organizations, have even considered the hundreds of scientific and medical studies documenting the benefits of tobacco harm reduction.

One of the most frequently asked questions about tobacco harm reduction is: “Why don’t all health professionals recommend that smokers switch to smoke-free alternatives?” In addition to the widespread misperception about risks (documented here), health professionals are reluctant to draw the wrath of powerful national organizations that believe that the destruction of the tobacco industry is more important than the health of America’s smokers.

Misinformation from the American Dental Association

On October 9, the American Dental Association submitted a letter to the Food and Drug Administration in response to a federal register notice requesting public input on the role of the FDA in tobacco regulation. In the letter, available on the regulations.gov website, the ADA uses pseudo-scientific language to advocate for prohibition of all tobacco products, including smokeless tobacco. Following are some of the letter’s most absurd statements.

1. “We also ask that you begin your work by regulating industry assertions that smokeless tobacco is a healthier (or less harmful) alternative to cigarette smoking.”

While the ADA refers to “industry assertions” about the relative safety of various tobacco products, it ignores the growing number of independent health assessments from academia, public health organizations and other non-industry sources. The British Royal College of Physicians, the American Council on Science and Health and the American Association of Public Health Physicians have concluded that smokeless tobacco use is associated with a tiny fraction of the health risks of smoking.

The task of regulating “industry assertions” was intensively covered in the bill granting FDA regulatory control over tobacco. In fact, the agency was empowered to restrict any action that could “be reasonably expected” to result in “consumers believing” that an alternative tobacco product may have some health benefit vis a vis cigarettes. That’s not just regular commercial speech (e.g., advertisements), but ANY speech, and it’s one reason that several tobacco companies are suing in federal court to block this part of the law.

2. “Smokeless tobacco is not a healthy alternative to cigarette smoking; both products pose health risks. Compared with cigarettes, smokeless tobacco products are less likely to cause lung cancer but they are associated with oral (mouth) and pharyngeal (throat) cancers, as well as cancers of the stomach and pancreas (5,6,7,8).”

No one is suggesting that smokeless tobacco is a “healthy” alternative. The ADA is inappropriately manipulating the legitimate message of tobacco harm reduction.

At least the ADA admits that smokeless tobacco is “less likely” to cause lung cancer. In fact, the most comprehensive study of smokeless tobacco and cancer (previously discussed in this blog) revealed NO risk for lung cancer. Apparently, the ADA doesn’t consider the elimination of 125,500 deaths from lung cancer to be a sufficient public health gain to offset what it believes are risks from other cancers. That meta-analysis also proves that the ADA is wrong on the other cancers as well.

Note that three of the four numbered references supporting the ADA’s statements about other cancers were from the 1990s, when many experts mistakenly believed that smokeless products weren’t much safer than cigarettes. Either the ADA only reviewed selective scientific literature prior to 2000, or the organization chose to ignore irrefutable evidence supporting tobacco harm reduction. The fact is: If all U.S. smokers had instead used smokeless tobacco, cancers now attributable to smoking would plummet to around 1% of their current numbers.

3. “Researchers have found that adolescent boys who use smokeless tobacco products are highly likely to become cigarette smokers within four years (14).”

This is the ADA’s major rationale for its allegation that smokeless tobacco is a “gateway” to cigarette smoking. The reference is to a study by Scott Tomar, a staunch opponent of tobacco harm reduction at the University of Florida. Tomar’s theory has been disproven by Kozlowski and colleagues in published articles available here, here and here. These studies carefully examine datasets in order to determine whether ST or cigarettes were used first. They concluded that ST use plays no significant role in smoking initiation. The vast majority of smokers never used ST, and two-thirds of ST users either never smoked, or they smoked prior to using ST. That makes two-thirds of ST users ineligible to even be considered as gateway users.

It is not surprising that boys who use ST are more likely to become smokers, since experimentation with one tobacco product is closely linked to other similar behaviors. But opponents of harm reduction are deliberately confusing association with causation. Smoking among teenagers is also associated with alcohol use, drug use, risky driving, risky sex, bad grades and behavior problems, but it doesn’t cause them.

4. “That is one among many reasons former U.S. Surgeon General Richard H. Carmona classified the smokeless tobacco alternative as a ‘public health myth.’”

I am astounded that the ADA is still quoting the 2003 Congressional testimony of former Surgeon General Richard Carmona; he has virtually no credibility on this topic. I also testified at that hearing, and I was stunned by Carmona’s uneducated and completely inaccurate statements.

In his testimony, Carmona stated: “There is no significant scientific evidence that suggests smokeless tobacco is a safer alternative to cigarettes.” Carmona ignored decades of published research and the prestigious British Royal College of Physicians, who had reported a year earlier that smokeless tobacco products are “on the order of 10 to 1,000 times less hazardous than smoking”.

Carmona also testified that he wanted to ban tobacco products. Asked if he “would support banning or abolishing all tobacco products,” Carmona responded, “I would at this point, yes.” This marked the first time a Surgeon General had called for outright prohibition, and he sent would-be supporters running from the Hill. Even the Campaign for Tobacco-Free Kids, which has shown no interest in helping inveterate adult smokers, couldn’t support Carmona. Its spokesman commented that “We would all like to see a tobacco-free world…we can’t just take away their tobacco.” Bush administration officials responded quickly. “That is not the policy of the administration,” commented White House spokesman Scott McClellan, saying that Carmona’s comments represented only his views as a doctor.

The American Dental Association’s prohibitionist policy towards tobacco use is a disservice to dentists and their smoking patients; it denies them life-saving information about effective and vastly safer smokeless alternatives.