Motorcycles Aren't Cars and Cigarettes Aren't Smoke-Free Tobacco

What if the federal government told you that cars are as dangerous as motorcycles?  Well, you would be living – and dying – in TobaccoWorld.  Read my commentary that appeared in the Washington Examiner (here) and is reprinted below.

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Motorcycles are more dangerous than cars. We know this because a government agency, the National Highway Traffic Safety Administration, routinely provides data that confirms it.

For example, the NHSTA reports there were 0.85 auto-related deaths for every 100 million miles Americans drove in 2014. By contrast, the death rate for motorcycles was 22.96 for every 100 million miles, making motorcycles 27 times deadlier than cars.

What if the government ignored this difference in risk and assumed the motorcycle death rate applied to all vehicles? In other words, what if all vehicle manufacturers had to be governed by motorcycle regulations and what if insurance premiums for car owners were pegged at the much higher rates for motorcycles?

The effect of such irrationality would be intolerable, with cars priced out of reach, companies put out of business and consumers left without choice. Policymakers would never inflict such pain on the American driving public – at least, not on purpose.

But that's just the sort of irrationality being imposed on the nation’s consumers of smoke-free tobacco products, with tragic consequences. Federal agencies routinely conflate the risks of using smoke-free tobacco products with the risks of smoking, despite decades of scientific studies demonstrating that smoke-free products are vastly safer than cigarettes.

Smokeless tobacco products are required by the Food and Drug Administration to carry demonstrably inaccurate and misleading safety warnings. Companies that attempt to challenge those messages are held to the unnecessary and financially crippling standard of proving that their products would have virtually no health impact on the population.

Even when a company did provide irrefutable proof to change the warning labels in 2011, the FDA took four years to deny its citizen’s petition. Another company’s formal application from 2014 remains in FDA limbo.

The FDA ignores extensive evidence from federal surveys of the role e-cigarettes are playing in helping smokers to quit—including some 2.5 million successes—while the Centers for Disease Control and Prevention withholds evidence that smokeless tobacco is safer. 

The Affordable Care Act permits health insurers to charge higher premiums for any recreational nicotine use, not just smoking.  Most life insurance companies also fail to recognize established risk differences, as they charge higher premiums for users of all nicotine products, even medicines. 

No one confuses motorcycles with cars, just as no one, other than government officials, confuses cigarettes with e-cigarettes or cans of moist snuff. The risk differential between combustible and smoke-free tobacco products is proven and profound. It’s time to tell the public the truth, and to regulate accordingly. 

The Truth About Traffic: Putting Fatalities in Context

In my lectures, I often provide context about the risks associated with use of tobacco products by comparing those behaviors with the use of automobiles.  Putting risk in context is important, as can be demonstrated by focusing on traffic safety data alone.

The U.S. National Highway Traffic Safety Administration (NHTSA) recently reported that there were 35,092 traffic fatalities in 2015 – a small increase from the previous year (here).  Some media reports treated the incremental change as if it demonstrated a growing epidemic.  National Public Radio headlined their story, “Largest increase in decades” (here), and CBS called it the “Largest increase in a half century” (here).  Transportation Secretary Anthony Foxx said in a press release (here), “…far too many people are killed on our nation's roads every year…we're issuing a call to action and asking researchers, safety experts, data scientists, and the public to analyze the fatality data and help find ways to prevent these tragedies.” 

Reducing carnage is certainly a worthy goal, but NHTSA ought to kill the hype and present traffic fatality statistics in a meaningful fashion.  In past years, NHTSA framed fatality rates based on population (e.g., deaths per 100,000 residents) or on vehicle miles traveled (see Table 2 of last year’s report here).  Those rates are more meaningful than press release hyperbole such as, “2,348 more people died in traffic crashes compared to previous year.” (here) 

This year’s NHTSA report downplayed the miles traveled rate and omitted the population rate.  Fortunately, using Census Bureau data, one can calculate the latter.  The chart shows both rates since 2005.

Traffic fatality rates, after falling almost continuously for several decades, have been stable since around 2009.  The small 2014/2015 uptick to 11 deaths per 100,000 population or 1 billion miles traveled is not an increase of epidemic proportions.

The risk of traveling by automobile in the U.S. remains very small.

The Surgeon General on Teen Tobacco Use: Is She “Shocked,” or Shocking?

Surgeon General Regina M. Benjamin on March 8 released a report on teen tobacco use with the comment, “The numbers are really shocking.” What is truly shocking is that Dr. Benjamin apparently released the report only to a select group of media outlets that published unchallenging stories, precluding any immediate intelligent analysis of this important public health screed.

Stories published shortly after 12 am that day in the Washington Post (here) and USAToday (here) read like tobacco prohibition press releases. Wendy Koch distilled the theme in her USAToday lead: “Many of America's teens smoke cigarettes as well as use smokeless tobacco, and the tobacco industry's marketing fuels their addiction.”

The Surgeon General incorrectly stated in the report’s preface that “today nearly one in four high school seniors … smoke.” That was true eight years ago. According to the authoritative Monitoring the Future Survey, last year only 19% of high school seniors had smoked in the past 30 days, and only 10% smoked daily (here). These are the lowest numbers in the survey’s 36-year history. Before Dr. Benjamin uses the Surgeon General’s bully pulpit, she should get her facts right.

On tobacco industry marketing, the Surgeon General’s allegations strained scientific credibility.

Tobacco manufacturers have been prohibited from targeting children since the 1998 Master Settlement Agreement with 46 states (here). They cannot “take any action, directly or indirectly, to target Youth within any Settling State in the advertising, promotion or marketing of Tobacco Products, or take any action the primary purpose of which is to initiate, maintain or increase the incidence of Youth smoking within any Settling State.” If Dr. Benjamin can make a case against the industry, she should contact state attorneys general, who have expedited processes for policing and enforcing MSA provisions regarding children.

The FDA has said there is virtually no evidence that tobacco manufacturers are marketing to children through retailers. The agency’s extensive multi-state monitoring program shows that 96% of retailers are compliant (discussed in my blog here). Retailers in several states, including Alabama, Idaho, Kansas, Maryland and Maine, have compliance rates of at least 99%.

If the Surgeon General holds the tobacco industry responsible for the 19% of high school seniors who smoke, then what industry does she blame for the 23% of high school seniors who use marijuana (evidence here)? Does she blame the alcohol industry for the 40% of seniors who use alcohol, or for the 25% of high school seniors who had been drunk in the past 30 days (evidence here)?

According to Dr. Benjamin, “Cigarette smoking by youth and young adults is proven to cause serious and potentially deadly health effects immediately…” This appears to be a new line of attack aimed at teens: If you smoke, you are now at risk for disease and death. Dr. Benjamin should reconsider the veracity of this statement. While teen smoking is unacceptable and troubling, it is not a death sentence.

To put the numbers in context: Every year, there are 33,000 deaths among U.S. teenagers and young adults (age 15-24 years); 25,000 of those are due to “external causes,” including 11,000 road accidents, 5,300 homicides and 4,100 suicides. Illnesses of all kinds account for 8,000 deaths.

The Surgeon General has an obligation to focus on the real and tragic causes of death among our youth. She would be wise to adhere to the facts.

Measuring Misperception About Smokeless Tobacco Health Risks

Consider an American addiction: automobile travel. Driving around town or around the country, we recognize and accept a small but measurable risk of dying in an accident. We take comfort in the fact that our cars’ seat belts and airbags will protect us.

Now imagine a world in which the American Automobile Association, the Fraternal Order of Police and the National Highway Traffic Safety Administration declared that cars with seat belts and airbags are just as dangerous as cars without these devices, and that the only way to avoid dying in an auto accident was to avoid automobiles altogether.

This is an outrageous scenario. We wouldn’t tolerate the dissemination of such demonstrably false information by non-profit groups, professional organizations and government agencies. It is well established that these harm reduction measures (seat belts and airbags) have helped reduce automobile accident deaths to record-low numbers (34,000 in 2009).

So why do we tolerate misinformation about smokeless tobacco, a harm reduction measure for smokers that could prevent over 400,000 deaths per year?

My research group just published a study documenting that misinformation about the risks of smokeless tobacco use has led to widespread misperception among highly educated university faculty, even those in health-related schools. The first author of our study was Nicholas Peiper, a doctoral student in epidemiology at the University of Louisville. Ramona Stone and Riaan van Zyl of the U of L Kent School of Social Work were our collaborators. The study was published in Drug and Alcohol Review (abstract here).

We conducted a survey that quantified the risk perceptions of cigarette smoking and smokeless tobacco use with respect to general health, heart attack/stroke, all cancer, and oral cancer among full-time faculty. We compared the results from faculty on the health science campus with those in schools not related to health.

We found that misperception was common among this highly educated group. For example, 51% of all faculty incorrectly believe that smokeless tobacco use confers general health risks that are equal to or greater than smoking. The misperception rate was lower for heart attack/stroke risk (33%) but higher for cancer (61%).

The misperception rate for oral cancer was stunning: 86% of all faculty incorrectly believe that smokeless tobacco use confers risks that are equal to or greater than smoking. Although faculty on the health science campus had a somewhat lower rate than others (81% vs. 91%), our survey provides evidence that most health professionals have a poor understanding that smokeless tobacco use is vastly safer than smoking.

Why are these highly educated people, especially those in health-related professions, so wrong about the risks of smokeless tobacco use? We offer some reasons in the manuscript:

“First, deficiencies in health education may exist with respect to tobacco use and health consequences. Numerous U.S. studies have shown that medical, nursing and dental school graduates may have inadequate training to provide effective tobacco education or intervention.”

However, we believe that misperception results from misinformation from “…anti-tobacco advocates and organizations. A 2005 review found that websites providing health advice and information tend to conflate the risks of smokeless tobacco with the risks associated with cigarettes, using either direct or implied statements. This misinformation came from respected international and American federal health agencies like the World Health Organization, the U.S. Department of Health and Human Services and the National Cancer Institute, as well as nongovernmental organizations like the American Cancer Society and the Academy of General Dentistry. Another systematic review of over 48 medical brochures from some of the same organizations (e.g., NCI and ACS) found that the risk of oral cavity cancer and of other conditions associated with smokeless tobacco use was frequently overemphasized, ‘reaching beyond the scientific data.’”

Here is an excellent example of misinformation from respected health organizations. The Canadian Cancer Society and the Canadian Heart and Stroke Foundation sponsor the quit-smoking website I Will Succeed. Look at question 4 of the simple quiz, “Chewing tobacco is safer than smoking it. True or False?” It is pitiful that these organizations consider False the correct answer, and their explanation is either completely misleading (“the exposure [to nicotine] is similar; a tin of snuff equals roughly 60 cigarettes”) or absolutely false (smokeless “can boost the chance of cheek or gum cancer times fifty”). These societies are misinforming Canadian smokers and health professionals.

Modern smokeless products, which satisfy smokers and can be used invisibly in any social situation, are as widely available in the U.S. as seatbelts. Thus there is no barrier to their widespread adoption as safer nicotine delivery substitutes for cigarettes by inveterate smokers. Still, large scale tobacco harm reduction will not happen in the U.S. until smokers are provided truthful information about the low health risks of smokeless products.