Fabricating a Smoking Gateway

A Harvard School of Public Health report claims, according to Reuters, “Most young people in the U.S. who use newer smokeless tobacco products are smoking cigarettes.” (here).  In fact, the article, published in Pediatrics (abstract here), contains no specific information on cigarettes.

It is common knowledge that a high proportion of U.S. smokeless tobacco (ST) users – both men and boys – also smoke, as I have previously discussed in this blog (here and here).  So the main message of this study, that youth ST users are also smokers, is not new. 

The study, led by tobacco prohibitionist Dr. Gregory Connolly, could be seen as having one purpose – to fuel the campaign against tobacco harm reduction.  The journal article and the attendant media coverage are tainted by unscientific bias. 

 

The authors observed that 72% of ST users also “smoke,” a finding that the media reported as smoking cigarettes.  The authors, however, defined a smoker as anyone using any of these combustible products on one of the past 30 days: cigarettes, cigars, pipes, bidis, kreteks, roll-your own, flavored cigarettes, clove cigarettes, flavored cigars, or hookah/waterpipe.  Results were reported for this entire group of “combustible” products, not for cigarettes alone. 

 

The inclusion of the other products is just one of several tactics to maximize the percentage of ST users who smoked.  Another was the definition of a tobacco user: For all forms, it was anyone who used the product on at least one day in the past 30 – a broadly inclusive definition.

The most disturbing part of the media coverage of this study is the use of its results to attack tobacco harm reduction.  There is nothing in these findings that is damaging, or even relevant, to tobacco harm reduction, but it is clear that Dr. Connolly was campaigning to insert gateway the speculation – the fictitious idea that ST use causes smoking.  I have dealt with it previously (here).  According to Reuters, Dr. Neal Benowitz, “…who was not involved in the current research, noted that studies have shown use of smokeless tobacco among U.S. youth can indeed be a gateway to cigarette smoking.”

 

This is nonsense.  Dr. Benowitz cannot cite even one legitimate study showing that ST is a gateway to smoking.  Few cross-sectional or longitudinal surveys in the U.S. or Sweden have specific information on the order in which ST and cigarettes were first used – data that is required to demonstrate that ST use causes smoking.  ST users may also smoke, but this does not mean that ST use causes smoking.  Two studies (here and here) that have examined the causal pathway document that ST use may be protective against smoking.

 

Why do so many ST users smoke?  Dr. Connolly’s study, ironically, gives us a clue, as he notes that 67% of all ST users wrongly believe that all tobacco products are equally harmful.  (Ninety-two percent of nonusers of ST share the same mistaken view.)

 

American children, like their parents, are routinely misinformed about the risks of ST use and smoking.  Journal reviewers and editors, as well as journalists, should view biased and shallow research with a more critical eye.

Poisoning Public Health Issues

Anti-tobacco extremists have a big problem with smokeless tobacco. There is virtually no scientific evidence that long-term smokeless tobacco use is associated with ANY disease. So extremists have engaged in a media campaign to vilify these products in exceptionally creative ways.

I previously discussed the specious claim that smokeless tobacco products contained dangerous levels of wintergreen flavor (available here). Now a diatribe from Gregory Connolly, a Harvard University tobacco prohibitionist, has created the illusion that smokeless tobacco products are a major cause of poisoning among American children. The study was published in the journal Pediatrics (see the abstract here). It was tailored to produce a media frenzy, and it did. Here is a typical headline from MSNBC: “Tobacco mints tied to kids’ poisoning: smokeless products 2nd most common source of accidents.”

Most Americans will think that children all over the U.S. are dropping dead from accidental exposure to smokeless products. Connolly and his colleagues at Harvard, the CDC and an Ohio poison control center collected information on 13,705 incidents from the National Poison Data System from three years (2006-2008). Out of context, that appears to be an alarmingly high number.

I can’t provide context on the three-year data they accessed, but I was able to review the 2008 annual report of the American Association of Poison Control Centers (read it here). I think you will find the report informative.

It turns out that tobacco products accounted for only about 1% of the over 684,000 cases of exposure to non-pharmaceutical agents of all kinds in children less than 6 years of age in 2008. That’s 7,310 cases. Here’s a table of the top 20 exposures:


Non-pharmaceutical Exposure Cases Among Children Under 6 Years of Age, 2008

Product Category	Number of Exposures
Cosmetics and personal care products	170,210
Household cleaners	120,295
Foreign bodies	94,792
Pesticides	42,260
Plants	41,842
Arts, crafts, office supplies	28,331
Alcohols	23,569
Deodorizers	20,487
Solvents, oils	14,565
Bites, venom	10,808
Chemicals	10,470
Paint, paint strippers	9,593
Adhesives, glues	7,725
Essential oils	7,334
Tobacco	7,310
Batteries	5,432
Polishes, waxes	4,700
Building, construction products	4,683
Fertilizers	4,579
Food poisoning	4,503
Everything else	51,084
All	684,572

The MSNBC subheadline (“smokeless products 2nd most common source of accidents”) reflects another omission in Connolly’s abstract. He listed smokeless as the second most common TOBACCO source in the abstract, without revealing that it was a distant second. Cigarettes were responsible for 77% of 2006-08 tobacco exposures. In comparison, smokeless tobacco was only responsible for 13% of tobacco exposures.

The 2008 report shows that smokeless tobacco products were responsible for 1,105 of the 7,310 tobacco exposures, or about 15%.

So let’s do the math: in 2008 smokeless tobacco exposures were 0.16% of the 684,000 total exposures among children less than 6 years of age.

There is one more flagrant omission in Connolly’s journal article: he didn’t report the number of exposures involving nicotine medicines. That information is available from poison control reports; in 2008, 589 children under 6 years were exposed to nicotine medicines, slightly more than half of those exposed to smokeless tobacco. It’s another example of Connolly’s extreme selectivity.

Connolly used the results of his study to comment that tobacco manufacturers were “recklessly playing with the health of children.” When put into proper perspective, (exposures like household cleaners, solvents and oils, paint and paint strippers, fertilizers), Connolly’s selective reporting of poison control information is recklessly playing with the tolerance of the American public for honest discussion of important public health issues.

[Originally created on April 19, this entry was updated on April 20.]

Tobacco Harm Reduction in the New York Times

On January 31, the New York Times published an article on tobacco harm reduction written by Duff Wilson and Julie Creswell. It focused on a series of submissions to the FDA by Altria, the parent corporation of Philip Morris and U.S. Smokeless Tobacco.

The article suggests that Altria’s argument for FDA endorsement of tobacco harm reduction is a cynical and insincere strategy: “…by focusing the F.D.A.’s attention on smokeless products, a much smaller but growing industry, Altria and other tobacco companies are diverting regulators’ attention from the source of the real public health problem: cigarettes.”

This post takes a critical look at the Times article.

The piece describes Altria as a “corporate pariah blamed for the deaths of millions of people,” noting that cigarette smoking is addictive and causes disease. Altria and other cigarette manufacturers have acknowledged these facts; they believe that the FDA should oversee a program that fully informs smokers about safer smokeless options.

Tobacco prohibitionists were quoted in the article. Stanton Glantz (University of California at San Francisco): “If you look at how they’re marketing smokeless now, they’re marketing for dual use, and to protect the cigarette market, which is their big money maker.”

By this, Glantz acknowledges that manufacturers are marketing smokeless tobacco to smokers. But Glantz seems to believe that Altria has power to “protect the cigarette market” by keeping smokers from switching entirely to smokeless tobacco. If smokers are informed that smokeless products are vastly safer, many will switch, significantly reducing the 400,000 smoking-related deaths that occur in the U.S. annually.

Gregory Connolly (Harvard University): “[Altria is] taking the FDA debate and making it on smokeless rather than ‘light’ cigarettes, which is where the real harm is.”

Kudos to Connolly for implicitly acknowledging that there is no “real harm” in smokeless tobacco. That is precisely why Altria wants FDA permission to tell smokers the truth.

Wilson and Creswell report that Matthew Myers (Campaign for Tobacco-Free Kids) “argues that there is no evidence that smokeless products are effective tools to help people quit smoking.”

This is utter nonsense. Smokeless tobacco is established as a gateway to smoking cessation for men and women in Sweden, and in Norway. In 2008, I provided the first population-level evidence that American men have quit smoking by switching to smokeless tobacco. Using data from the 2000 National Health Interview Survey, which the CDC uses to estimate smoking prevalence in the U.S., Carl Phillips and I estimated that 359,000 American male smokers had tried to quit by switching to smokeless, and 73% (261,000) were successful, the highest percentage of all methods. In comparison, the nicotine patch was tried by 2.9 million smokers, but only 35% were successful. Of the 964,000 smokers who tried nicotine gum, only 34% succeeded.

As I predicted in an earlier post, Kenneth Warner (University of Michigan) attacked the use of flavors in smokeless tobacco products: “The flavors are designed to attract kids.”

This may be evidence of an overzealous imagination. Tobacco manufacturers are prohibited by law from marketing to children. But prohibitionists are adept at making draconian policies seem palatable by pitching them as “protecting children.” Prohibitionists promote a flavor ban because they know that unflavored smokeless products won’t appeal to many smokers. Banning all flavors in smokeless tobacco makes about as much sense as banning flavors in alcoholic beverages.

Wilson and Creswell avoided discussion of the scientific and medical issues in Altria’s FDA submission, instead focusing on the shrill complaints of tobacco prohibitionists. I suggest that you read the documents, available here; they are accurate and based on scientific and medical literature. I also invite you to read my FDA submission, entitled “Tobacco Harm Reduction: Medical, Scientific and Public Health Rationale”.