How Dangerous Is Snus? Don’t Ask New York Times Editors

The New York Times has added more fuel to the anti-tobacco-harm-reduction fire with a December 4 editorial (here) rehashing the somewhat slanted reporting that appeared in the paper’s news pages on November 30.  In two stories that day, the Times explored issues surrounding Swedish Match’s FDA application to change the warnings on its snus products.  As I noted (here), “The Times and their quoted experts did a major disservice to their audience; they failed to report the simple truth, that mouth cancer risk for Swedish snus is next to nil.”

The original warning labels that Congress ordered for tobacco product packages in 1986 were factually wrong and fatally misleading to smokers, chewers and dippers.  Congress didn’t make the warnings more accurate when  it ordered the FDA to regulate tobacco in 2009, it just made them cover more of the package – an action it didn’t take with cigarettes. 

The Times editorial acknowledged that snus is “is less harmful than smoking tobacco,” but it painted Swedish Match’s application as a marketing ploy.  That ignores the critical need to terminate government’s lie about products’ health risks.

The editors echoed tobacco prohibitionists in denying that snus played a role in the Swedish experience.  Said the Times, “reduced smoking rates and lower rates of tobacco-related diseases such as lung and oral cancer” in Sweden since the 1970s “is debatable,” attributing the successes to “various bans, restrictions and public health campaigns.”  The editors failed to consider that the reductions are exclusively seen in men – who use snus and have the lowest lung cancer rate in Europe – not in women, who rank fifth in Europe for lung cancer.

The Times acknowledged that their reporters had “cited independent experts who found that snus is not nearly as lethal as cigarettes,” but it added the qualifier “[snus] is not risk-free either, especially for users who also smoke.”  It is patently obvious that smoking is risky for anyone, including snus users.  It should also be obvious that a smokeless tobacco can labeled “this product is not a safe alternative to cigarettes” encourages smokers to stick with their habit.

The Times editors revisit the discredited gateway theory (“the danger is that snus might lead some nonsmokers and former smokers to…progress on to cigarette smoking”), but they ignore substantial evidence that this has not happened in Sweden (here) or in the U.S. (here).

Summing up, the Times observes: “abstention would be the safest approach.”  That might work in Neverland, but in the U.S., abstention was impossible for the 8 million smokers who died in the 20 years since I first described our government’s warnings as bogus.  That is no one’s definition of safe.

How Dangerous is Swedish Snus? Don’t Ask The New York Times

The New York Times has published (here) a reasonably accurate portrayal of the Swedish snus experience that I have chronicled for over a decade (here,  here,  and here).  Reporters Matt Richtel and David Jolly examined Swedish Match’s FDA application to remove the federally mandated mouth cancer and not-safe-alternative warnings from snus products.  I have discussed this landmark filing previously (here). 

In a companion piece (here) the paper tried to answer two important questions about snus and mouth cancer: “How accurate is the current warning? How dangerous is Swedish snus?” 

Despite a wealth of available information, the Times unfortunately failed to nail the answers, even after acknowledging that “Many studies have been done on the question (sic),..." but fretting that "...but as in many fields that involve complex questions and human subjects, the research is imperfect.” 

How is the research imperfect?  “For instance, some research concluding virtually no oral cancer risk from snus was funded by Swedish Match itself.”  The Times fell back on the old canard – the funder influenced the finding, despite total disclosure and high-quality peer review.  The paper failed to note that numerous studies, regardless of funding, show “virtually no oral cancer risk” for Swedish snus and American chew and dip.

The Times asked Kristin L. Sainani, a Stanford epidemiologist not involved in tobacco research, to examine the science.  She was remarkably indecisive:   “‘The weight of the evidence suggests a small increase’ in the risk of oral cancer with snus.  In Sweden, users of Swedish snus see virtually no increase in the rates of lip and oral cancer.”  In the end she made the correct call: virtually no increase. 

Dr. Sainani attempted to provide an anti-snus slant using double negatives: she said that “it is inconsistent with the evidence” to suggest that there is “absolutely no harm to an individual” from snus.  In essence, she repeated the no-win argument that snus can’t be proven absolutely safe.  That’s an irrational standard that many common foods couldn’t meet.

Dr. Sainani was asked by the Times to resolve the mouth cancer question, yet she is quoted on an entirely different matter: “In fact, she said, Swedish snus users face a doubling of risk of pancreatic cancer…”  It appears that Dr. Sainani exclusively used a 2008 review by Boffetta et al., which has been exposed as relying on cherry picked data (here). 

Is a snus pancreas cancer risk real?  No.  Five years ago I detailed how Boffetta fabricated the risk in 2008 (here), and, in 2011, Boffetta acknowledged that his earlier finding was wrong (here).  Sainani would have discovered this if she had compared the faulty Boffetta analysis with the most authoritative and comprehensive meta-analysis by Peter Lee and Jan Hamling (here), which found no pancreas cancer risk, in addition to no mouth cancer risk.

 

The Times article ended with Dr. Deborah Winn, deputy director of the division of cancer control at the National Cancer Institute.  Readers of this blog know that Dr. Winn launched the smokeless tobacco mouth cancer scare in 1981 (here and here).  While she is the NCI’s top authority on smokeless tobacco and cancer, she demonstrated an appalling disregard of facts in a 2010 congressional hearing (here).  In the Times article, her obfuscation continued:  “[Winn] considered Swedish snus to be ‘a form of smokeless tobacco,’ which, in general, she said, is generally ‘linked to mouth cancer…Swedish snus in the past has given you cancer, and at the current low levels, I don’t know,’ she said. ‘There could be some risk there.’”

The one data point Winn provided to the Times is false.  “She said studies done in the 1990s showed that users of Swedish snus in the 1970s faced a twofold increase in the risk of oral cancer.”  There were two studies of Swedish snus and mouth cancer published in 1998.  They concluded:

1.  “[Snus] was not found to be a risk factor for oral cancer in our study.” (here)

2.  “No increased risk [for head and neck cancer, including oral cancer] was found for the use of Swedish [snus].” (here)

The Times and their quoted experts did a major disservice to their audience; they failed to report the simple truth, that mouth cancer risk for Swedish snus is next to nil. 

New York Times’ Call for Marijuana Legalization Advances Harm Reduction

A milestone in the fight for harm reduction was reached on July 28, when the New York Times formally endorsed the legalization of marijuana.  A Times editorial, “Repeal Prohibition, Again,” called for reversal of the government’s 40-year ban on the popular weed (here).  Legalization is overdue, as use of this psychoactive substance that is less dangerous than alcohol has led to the senseless prosecution of hundreds of thousands of Americans.

In 1994, as I was developing my tobacco harm reduction strategy, I read a brilliant article on drug policy reform in the prestigious scientific journal Science.  Entitled “Drug prohibition in the United States: costs, consequences, and alternatives” (abstract here), the article was written by Ethan Nadelmann, a pioneer in drug harm reduction.  Later that year, I described my strategy in a letter to Whitney Taylor of the Drug Policy Foundation (now the Drug Policy Alliance, here):

“Thanks for taking my recent phone call.  First, the proposal: that smokers unable or unwilling to quit consider switching to smokeless tobacco, which is far safer than smoking.  Smoking-related cancers, heart diseases and lung disorders are responsible for 419,000 deaths every year in the U.S.A.  In contrast, if all 46 million American smokers instead used smokeless tobacco, annual tobacco-related deaths (from a small risk of oral cancer) would number only 6000 [references here and here].  In fact, smokers who switch to smokeless tobacco reduce their risk for all smoking-related illnesses, including oral cancer.  Newer smokeless tobacco products deliver the nicotine kick smokers crave and they can be used almost invisibly; spitting, once the stigma of smokeless tobacco use, is minimal or nonexistent with these products.  Smokeless tobacco is already working for many Americans.  Statistics from the Centers for Disease Control and Prevention (CDC) show that 1.5 to 2 million former smokers have chosen this option on their own [reference here].

“I realize that your organization is only concerned with illicit drugs.  However, the current tirade against tobacco use(rs) demonstrates alarming parallels to the long-term crusade against other drugs.  First, as tobacco use is increasingly characterized as not just unhealthy but immoral and criminal, users are now experiencing an alienation process similar to that of narcotics users in the first three decades of the century.  Health professionals with ideas on the medical management of nicotine addiction are being ignored or attacked.  A cadre of prohibition-minded anti-tobacco activists has insisted on increased federal regulation (FDA, OSHA, EPA etc.) of tobacco use, which is endorsed without a hint of dissent by all major medical organizations.  In fact, tobacco use is the only major medical issue in which there is no debate whatsoever.  Prohibition may not be imminent, but smuggling from low to high tax states and the disastrous effects and ultimate reversal of the recent Canadian tax increase offer a great preview of where the crusade is headed and what the consequences will be.

“This proposal has much in common with harm reduction models proposed for illicit drug use with one important exception: smokeless tobacco is legal.  No new regulatory or legislative measures will be required.  Only interested and informed smokers.”

Mr. Nadelmann invited me to share my observations at drug policy reform conferences in 1999 and 2001.  Tobacco harm reduction has been explored at various other drug policy meetings over the last decade. 

The Times editorial board echoed the principals of harm reduction in its marijuana statement, as it weighed the relative risks of using various substances: “We believe that the evidence is overwhelming that addiction and dependence are relatively minor problems, especially compared with alcohol and tobacco.  Moderate use of marijuana does not appear to pose a risk for otherwise healthy adults.  Claims that marijuana is a gateway to more dangerous drugs are as fanciful as the ‘Reefer Madness’ images of murder, rape and suicide.  There are legitimate concerns about marijuana on the development of adolescent brains. For that reason, we advocate the prohibition of sales to people under 21.”

Advocates of tobacco harm reduction will recognize several themes in this passage.  First, there are no apparent health risks for moderate marijuana use (and even fewer health risks for smoke-free forms versus combusted), just as there are no significant risks related to the use of smoke-free nicotine/tobacco products.  Second, the “fanciful” gateway claim is as illegitimate for smoke-free tobacco as it is for marijuana.  Finally, while it is appropriate to protect children from substance use, there is no credible reason to deny adults access to alcohol, tobacco or marijuana.   

The Times has effectively advanced the cause of harm reduction, perhaps to the ultimate benefit of tobacco users and of public health generally.

               

The New York Times Plays Patsy for Anti-Tobacco Voices

In the tabloid tradition of “If it bleeds, it leads,” The New York Times ignored the lack of peer review and wasted no space on critical analysis when it ran a May 3 article by Matt Richtel titled “Some E-Cigarettes Deliver a Puff of Carcinogens.” (here). 

Based on two unpublished studies, the Times reported that “the high-power e-cigarettes known as tank systems produce formaldehyde, a known carcinogen, along with the nicotine-laced vapor that their users inhale.  The toxin is formed when liquid nicotine and other e-cigarette ingredients are subjected to high temperatures... This finding suggests that in certain conditions, [e-cigarettes] might expose their users to the same or even higher levels of carcinogenic formaldehyde as tobacco smoke.” 

The Times also said the new research shows that when users are “dripping” – placing drops of e-liquid directly onto an e-cig’s heating element – “formaldehyde and related toxins ‘approach the concentration in cigarettes.’”

The studies are the work of Roswell Park Cancer Institute assistant professor Maciej L. Goniewicz, and Alan Shihadeh at Virginia Commonwealth University and the American University in Beirut, respectively.  Goniewicz’s article will reportedly appear in the May 15 edition of Nicotine & Tobacco Research, while Shihadeh’s has not been accepted or peer-reviewed anywhere (the Times says it “is being prepared for submission to the same journal”). 

The Times story represents a deeply troubling development: the global publicizing of research before publication or even submission to a medical journal.

This high-profile pre-release tactic has become commonplace for anti-tobacco pronouncements from the CDC and other federal agencies.  Media outlets give these biased stories wide distribution free of critical analysis or balance.    

Historically, release of findings prior to a journal’s publication date was grounds for cancelling an article.  In a recent post I suggested that peer review of tobacco research is nearly nonexistent at some journals (here).  It is further disappointing that journals are active partners in the selective release of research findings to the public.

Jane Brody and the New York Times: Counting Smokers Badly

Jane Brody falsely reported in her November 12 New York Times “Personal Health” column that, according to the National Survey on Drug Use and Health (NSDUH), the smoking prevalence among young adults (age 18-25 years) is 40% (here).  The error was picked up by the American Council on Science and Health (here), and the Times later posted a correction, noting that the rate is 34%. (The original number was the prevalence of all tobacco use, rather than the prevalence of smoking.)  

But is 34% the accurate figure?  Perhaps; it depends on which federal survey is used. 

Anti-tobacco forces have for years selectively used two sets of numbers based on two federal surveys in a manner that recalls the schoolyard taunt, “Are you bragging or complaining?”  When zealots brag about how regulation, legislation and litigation have driven down smoking rates, they use the CDC-supported National Health Interview Survey (NHIS).  According to the 2010 NHIS, the prevalence of smoking among young adults (18-24 years) was 20% (here).  But when they complain that smoking rates are too high, and demand more regulation, legislation and litigation, they use the NSDUH, which produces higher estimates than NHIS – in this case 34%.

Why does this matter?  Using Jane Brody’s corrected percentage from NSDUH, the number of young adult smokers (18-24 years) in the U.S. is 10,489,854; using NHIS, the number is 6,165,090. 

With respect to variability, this difference of 4.5 million smokers is huge, and here’s why. 

NSDUH estimates are higher because it counts as a smoker anyone who answers “yes” to this question: "During the past 30 days, have you smoked part or all of a cigarette?”  The comparable question in the NHIS is, "Do you now smoke cigarettes every day or some days?"  

I published a formal study of this problem in 2009 (abstract here), and I wrote a blog post about it (here).  At that time, I calculated that there were 9 million more smokers of all ages nationally in NSDUH compared with NHIS.  

How can the federal government develop effective policies to help American smokers when the government can’t even develop and employ consistent estimates of how many Americans smoke? 

I am grateful to Jane Brody for bringing attention to this egregious problem.