Attack on E-Cigarettes as Gateway Products Draws from Same Old Playbook

Tobacco opponents who falsely claim that e-cigarettes are a gateway to smoking dissuade smokers from switching to safer smokeless products, leaving smokers at greater risk of fatal disease.

The tobacco prohibitionists’ playbook was developed some 15 years ago, when Dr. Scott Tomar, of the CDC and the University of Florida, published a smokeless tobacco study (abstract here) with a pronounced gateway spin:

“Some men may use snuff to quit smoking, but U.S. men more commonly switch from snuff use to smoking. Some smokers may use snuff to supplement their nicotine intake, and smokers who also use snuff are more likely than nonusers to try to quit smoking but tend to have less success.”    

My letter to the editor (which was not published) noted:

“Recently Tomar reported that 1998 National Health Interview Survey data show that snuff users are 3 to 4 times more likely to have quit smoking than have never users.  However, he also suggested that more American men switched from snuff use to smoking than vice versa.  We disagree with some of Tomar’s interpretations of the available data and offer alternative explanations for his findings.

 

“Tomar suggests that the data show that snuff use is a ‘gateway’ to cigarette smoking among adolescents and young men because ‘former’ snuff users were current smokers in this adult survey.  However, Tomar has inferred causation solely from temporal patterns (post hoc, ergo propter hoc).  If snuff had been a ‘gateway’ to smoking for some individuals, they would have been much older when they started to smoke than smokers without a snuff history.  The survey shows no such difference, suggesting that snuff was merely an adjunct for some smokers.  More importantly, Tomar did not evaluate the gateway possibility for other forms of tobacco use.  For example, survey data also reveals that pipe smoking was much more of a ‘gateway’ than was snuff.  Yet it is obvious that few adolescents initiate tobacco use by smoking a pipe.  A more reasonable interpretation of all the available information is that there is a subset of smokers who additionally have used other forms of tobacco.

  

“Tomar interprets his findings as evidence that switching smokers to ST is not a workable public health strategy.  We point out that for over twenty years the dominant public health message from tobacco prohibitionists has been that ST use is as dangerous as smoking.  This erroneous, even dangerous, message is reinforced by the mandated warning on packages of ST (“This product is not a safe alternative to cigarettes”).  Most smokers have accepted this message and continue to smoke.  Tomar’s study only confirms this and suggests further, and unfortunately, that some ST users also accepted it and switched to cigarettes.  Tobacco users need to be told the truth, that ST use is associated with only 2% of the mortality risks of smoking, and that it is an effective form of nicotine substitution for smokers unable to achieve abstinence.  Only then can a harm reduction strategy be tested and judged.”

Prohibitionists today are using the same groundless gateway attack to vilify e-cigarettes, even as teen smoking is dropping at an unprecedented rate (here).

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.