Robert Kennedy’s Nicotine Pouch Can Make America Healthy Again

 

The level of misunderstanding among American doctors about vastly safer cigarette substitutes is stunning.  Last week I critiqued the president of the American Medical Association (here), and this week it’s Dr. Nicole Saphier, a breast cancer imaging specialist at the Memorial Sloan Kettering Cancer Center.  In her January 30 New York Post column she called Robert Kennedy a “hypocrite” because he appeared to use a nicotine pouch during his Senate confirmation hearing.

Here are excerpts from Dr. Saphier’s screed, followed by my comments.

“After decades of relentless public health campaigns and advocacy against cigarette smoking, we are witnessing the tangible benefits, with declining smoking rates and the illnesses associated with it.”

She is only half correct, as smoking rates have declined, but mainly among children and young adults (here).  Too few older smokers at highest risk have quit, which is why nearly a half-million of them die prematurely every year.

“These small, flavored packets — filled with nicotine and other additives and tucked between the user’s gum and lip — are surging in popularity, mainly under the pretext that they are a safer alternative to traditional cigarettes.”

“The FDA has authorized Zyn and other pouches as a smoking reduction aid, giving them a reputation as a less harmful alternative.”

Nicotine pouches – in fact, any products delivering smoke-free nicotine – are vastly safer than smoking.  That is why the FDA authorized Zyn sales.  Also, the agency did not designate Zyn as a “smoking reduction aid.”  

“Yet this authorization does not equate to a declaration of safety.”

The FDA authorized Zyn as “appropriate for protection of public health.” 

“And these pouches come in varying strengths — with some providing far more nicotine than cigarettes or vapes.”

Saphier repeats a common, inaccurate claim comparing cigarettes, that deliver about 1 mg. of nicotine deep into the lungs, with a wide range of smoke-free products that deliver vastly different amounts of nicotine to the mouth and upper airway.  

“This is particularly dangerous to adolescents and young adults. Given their still-developing brains, nicotine can impair cognitive function, alter brain development…” 

The “brain development” claim has been fully debunked here.

“It’s alarming to see a new generation hooked on nicotine, reversing years of progress made in reducing smoking rates among young people.”

This is 180 degrees wrong, as the decline in smoking among young people has accelerated during the rise in use of alternative nicotine products (here).

“As he championed the Make America Healthy Again movement before the Senate committee, he was positioning himself as a warrior against chronic illness and discussing how he plans to combat diseases including food and drug addiction. Here is a figure publicly advocating for health, yet engaging in the use of a highly addictive product while doing so. In its most charitable interpretation, the incident shows how even those championing health can be ensnared by the allure of nicotine’s addictive nature.”

If Kennedy used a nicotine pouch during the hearing, it was entirely consistent with making America healthy again, and combatting the diseases and the consequences of smoking, America’s most dangerous drug addiction. 

 

 

 

BBC Drops the Ball on Baseball & Smokeless Tobacco

It’s almost baseball season, which means it’s time for anti-tobacco extremists to start grabbing easy headlines.  One especially zealous state lawmaker wants to ban smokeless tobacco by players and fans in all California ballparks (here).  It’s all based on smoke and mirrors, as illustrated in a woefully inaccurate recent BBC story on smokeless tobacco and baseball.

The report includes an erroneous claim that baseball stars Tony Gwynn, Curt Schilling and Babe Ruth died from cancers caused by smokeless tobacco. 

Neither Gwynn’s nor Schilling’s cancer was related to smokeless products, as I have detailed before (here and here).   Reporter Nada Tawfik concedes that “doctors say a link between [Gwynn’s salivary] cancer and chewing tobacco cannot be proven.”  I have previously noted the absence of a scientific link between smokeless tobacco and this cancer type (here).  As for Schilling, he never said he had mouth cancer and not one of his doctors has supported his statement that smokeless tobacco caused his illness.

The BBC repeated the decades-old myth that Babe Ruth suffered from smokeless tobacco-induced mouth cancer.  In truth, Ruth had nasopharyngeal carcinoma, a rare disease caused by the Epstein-Barr virus.  Ruth was a prodigious consumer of cigars and alcohol, but neither are strongly associated with nasopharyngeal carcinoma (discussed here).  He also used smokeless tobacco, which has no link to this cancer type.

Included in the BBC story was a remarkable quote attributed to Dr. Jatin Shah, who runs the Head and Neck Service at New York’s Memorial Sloan Kettering Cancer Center.  Chewing tobacco, he is reported to have said, is “probably more harmful than smoking.”  I emailed Dr. Shah to ask if he had been misquoted.  He responded with a comment on South Asian products, but the BBC’s vast audience has been left with the grossly erroneous impression that American smokeless tobacco is more dangerous than cigarettes.

Thus are myths perpetuated and the public health undermined.     

Sloan Kettering Corrects E-Cigarette Study

Memorial Sloan Kettering Cancer Center researchers, led by first-author Sarah Borderud, claimed on September 22, 2014, that e-cigarettes did not help cancer patients quit smoking (media story here). They based that statement on a study they published online in Cancer, a journal of the American Cancer Society (abstract here).

The researchers had enrolled 1,074 cancer patients in a smoking cessation program.  They subsequently found that “E-cigarette users were as likely to be smoking at the time of follow-up as nonusers (odds ratio, 1.0; 95% confidence interval, 0.5-1.7).” 

Upon reading the study, I found a significant error: the main results table reported the exact opposite of the text.  On October 16, I submitted a letter to the Cancer editor, co-signed by my colleagues Nantaporn Plurphanswat and Carl Phillips, requesting a correction. 

Six weeks later, on November 25, a correction was published on the Cancer website.  It said: “The authors discovered some errors…in Table 2.”  The circumstances strongly suggest that the authors didn’t “discover” the errors, we did.  The journal office had our letter on October 16, six weeks before the correction appeared. 

Our letter, published online on March 4 (here), described other problems with the study; one is particularly important.  Borderud et al. claimed: “Using an intention-to-treat analysis, E-cigarette users were twice as likely to be smoking at the time of follow-up as nonusers (odds ratio, 2.0; 95% confidence interval, 1.2-3.3).”  In other words, e-cigarettes were harmful.

They reached this striking result by assuming that anyone lost during follow-up had continued to smoke.  We pointed out that “Smokers who were E-cigarette users were twice as likely to be lost to follow-up as the other smokers (66% vs 32%)… The conclusion that E-cigarette users were twice as likely to be smoking is purely an artifact of the assumption. An equally plausible counter-assumption is that dropouts left the program because they had quit smoking...”  They didn’t consider this possibility, but they should have. 

Carl Phillips’ goes into more detail about the technical irregularities here.