Health Professionals Who Disrespect Smokeless Tobacco Users

When I started conducting research on tobacco harm reduction in the early 1990s, I noticed a disturbing trend: replacement of the term “smokeless tobacco” with the demeaning and disrespectful term “spit tobacco.”

This degrading term was not only used by extremists at the margin of tobacco control; by 1994, health professionals were using it in medical journals. The first instances were in the Journal of the American Medical Association (citation here) and the Journal of the American Dental Association (abstract here). The latter article was the first of 10 by Margaret Walsh, a professor of dentistry at the University of California/San Francisco; her most recent publication was in 2009 (abstract here).

Other professionals who have used this terminology include John Ebbert and Lowell Dale of the Mayo Clinic (here, here and here) and Dorothy Hatsukami at the University of Minnesota (here and here). Dr. Hatsukami’s adoption of the loaded term is especially troublesome since she now sits on the FDA tobacco products advisory panel.

The most egregious use of the spit terminology has been by the American Cancer Society and the CDC. The Cancer Society published research studies in 2005 and 2007, prominently using “spit” (here and here). The CDC institutionalized the practice in a 2006 federal report in collaboration with the National Center for Health Statistics (here).

The 2006 CDC report was especially deplorable, because it treated smokeless tobacco use differently than three other adult health risk behaviors -- cigarette smoking, cigar use and alcohol consumption.

On February 19, 2007, I wrote to CDC Director Julie Gerberding and NCHS Director Edward Sondik (available here). I pointed out that “the report’s use of [‘spit’ tobacco] is clearly inconsistent with its use of other terms relating to tobacco use and drinking behaviors. Furthermore, I believe that the use of ‘spit’ tobacco violates NCHS and CDC guidelines for ensuring the quality of information disseminated to the public. The NCHS and CDC guidelines are identical with respect to this matter, as it is each agency’s policy to ‘ensure and maximize the quality, objectivity, utility, and integrity of information that it disseminates to the public.’”

I strongly urged “CDC and NCHS to issue a corrected version of the Advance Data Report Number 378. Furthermore, I am asking that CDC/NCHS officials and staff to avoid the use of the term ‘spit’ tobacco in future official government publications, and to remove the term from existing web pages. This term is inappropriate because it is inaccurate, biased and unobjective. In addition, its use is inconsistent with the fully appropriate and non-pejorative terms ‘cigarettes,’ ‘cigars’ and ‘alcohol’ used in this and other government documents.”

In April, I received a response from Dr. Gerberding (read it here). She acknowledged that “an inappropriate term was used in this report. We agree that the term ‘smokeless tobacco’…would provide a better description of the information and we will take swift action to make that change. A revised version of [the report] will be posted on NCHS’ website. The printed version of this report will be changed should we reprint in the future.”

In May 2007, I wrote to John Seffrin, CEO of the American Cancer Society. I included a copy of Dr. Gerberding’s decision, and I listed several specific publications in which Cancer Society officials had used “spit tobacco”. I made the following key points:

“In a March 27 Wall Street Journal article, American Cancer Society Vice President Dr. Michael Thun summarized a growing consensus among tobacco research and policy experts regarding the vast difference in risk between smoked and smokeless products: ‘There's no question that switching to spit tobacco and quitting tobacco altogether are both far less lethal than continuing to smoke.’ Recognizing these differential risks is consistent with the American Cancer Society mission, which includes ‘preventing cancer, saving lives, and diminishing suffering from cancer.’ Describing all tobacco products in objective and professional terms would enhance the essential humanity of your mission by treating all tobacco users with dignity and respect.

“I believe that the American Cancer Society strives for high standards in its professional reports and communications, and I request that Society officials describe tobacco use in a non-pejorative, unbiased and objective manner consistent with the change made by the CDC. Specifically, I ask that Cancer Society officials and staff not use the term ‘spit tobacco’ in future reports and communications, and that the term be removed from existing web pages and other electronic reports and documents.”

In July 2007, Dr. Seffrin wrote back: “Thank you for sharing your concerns regarding the use of the term ‘spit tobacco’ by health and policy professionals at the American Cancer Society. I have forwarded your letter to the appropriate staff for further review and any appropriate action.”

I don’t believe that Cancer Society officials at the national level have used “spit tobacco” since that time.

Use of the phrase “spit tobacco” shows that anti-tobacco extremists are completely out of touch with contemporary use of smokeless products. The “Swedish miracle” has shown the world that smokeless tobacco can be an effective substitute for cigarettes, resulting in population-level health improvement. Swedes have also shown how to use smokeless tobacco without spitting. They place smokeless products in the upper lip, reducing or eliminating the need to spit.

Modern dissolvable products (here and here), which are about the size of small breath mints, can also be used invisibly in any social situation. No tobacco juices are produced when these products are used, so spitting is as unnecessary as the derogatory terminology.

It’s a GAS, Take 34

November 19 is the date when American smokers are supposed to experience GAS, which is the American Cancer Society’s annual Great American Smokeout.

The American Cancer Society (ACS) has been producing GAS for 34 years, during which time it has refused to acknowledge that tobacco harm reduction is a legitimate public health option. That’s the main reason GAS is just a lot of hot air.

ACS has even criticized other medical organizations that want to tell smokers the truth. In 2007, the Royal College of Physicians, one of the world’s oldest and most prestigious medical societies, issued a comprehensive report reviewing and corroborating the impressive scientific foundation for tobacco harm reduction. The report concluded “…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.”

The response from the ACS and its vice president for epidemiology Michael Thun to this thoughtful treatise was a disservice to the millions of inveterate smokers in the U.S. who can not achieve complete abstinence from nicotine and tobacco.

Dr. Thun dismissed the existence of inveterate smokers as a “false assumption,” even though over 13 million Americans have died from smoking-attributable illnesses in the 34-year history of GAS. His solution is to provide all smokers with “sufficient counseling and treatment.”

“Counseling” consists of giving smokers behavioral coping skills. ACS instructs smokers who are in desperate need of nicotine to “Take a walk, go get a drink of water.” In 1991, the National Cancer Institute told physicians to help their patients quit smoking by advising them to: 1) ”Keep your hands busy- doodle, knit, type a letter,” 2) ”Cut a drinking straw into cigarette-sized pieces and inhale air,” and 3) ”Keep a daydream ready to go.” I’ve never met a smoker who could daydream himself out of craving for a cigarette, and I’ve never met a physician who passes along these ridiculous tips.

“Treatment” refers to pharmaceutical nicotine. In a prior post I discussed why these products fail to help smokers. They’re expensive, unsatisfying and most smokers have no interest in using them. If any other medication had the dismal 7% success rate of pharmaceutical nicotine products, the FDA would remove it from the market.

The grim reality is that Dr. Thun’s approach is grossly inadequate. According to the 2006 National Institutes of Health (NIH) Consensus Conference on Tobacco Use, “…fewer than 5 percent [of smokers] succeed [in quitting] in any given year. Effective tobacco cessation interventions are available and could DOUBLE OR TRIPLE SUCCESS RATES…” (emphasis added). This means that providing Dr. Thun’s “conventional treatments” to all 45 million American smokers would help fewer than 15% – no more than 7 million – to quit. Dr. Thun has no plan for the other 38 million adult smokers, except denying them life-saving information about safer smokeless tobacco products.

Dr. Thun understands the difference in risk between cigarettes and smokeless use; he served on a review panel for a National Cancer Institute-sponsored study which concluded that the health risks from the latter are at least 90% lower than those from smoking. However, he withholds this information from smokers because it might “postpone quitting.” He fears that smokeless will repeat the “fiasco of ‘Light’ and ‘Mild’ cigarettes,” which he characterizes as an industry-driven conspiracy. But that is only part of the story.

ACS played a prominent role in the fiasco, publishing research in 1976 showing that light cigarettes were indeed safer. ACS investigators wrote that “total death rates, death rates from coronary heart disease, and death rates from lung cancer were somewhat lower for those who smoked ‘low’ tar-nicotine cigarettes than for those who smoked ‘high’ tar-nicotine cigarettes.” The ACS made a mistake with light cigarettes, but the scientific evidence for smokeless tobacco is unequivocal.

Prohibitionists routinely stifle discussion by transforming every tobacco topic into a children's issue. Dr. Thun’s claim that “apple, peach, and mint” flavored smokeless tobaccos target children sets a new standard of insincerity. If he really believes that these are children’s flavors, Dr. Thun should campaign to eliminate them from alcoholic beverages, another cancer-causing adult-only consumer product. As with alcohol, tobacco manufacturers ought to be free to make their ST products appealing to adult tastes. Carping about flavored tobacco products is not responsible tobacco control; it is unwarranted harassment of adult consumers and the manufacturers who serve them.

Tobacco initiation by young people should be stopped in its tracks, but the relative safety and palatability of ST isn’t a children’s issue. The 8 million Americans 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 the Thun/ACS position on tobacco harm reduction effectively condemns millions of smoking parents and grandparents to premature death. If any other consumer product was as dangerous as cigarettes, society would demand safer alternatives. It is scandalous that the Cancer Society is not telling smokers the truth.