Base Tobacco Taxes on Tobacco Risks – A Valid Strategy Is Revived

On August 13 the New England Journal of Medicine published a commentary (here) by three prominent tobacco research and policy experts challenging “national, state, and local policymakers” to “expedite the move away from cigarette smoking” by basing tobacco taxes on health risks.  They recommend high taxes on high-risk combustible products, and lower taxes on low-risk smoke-free products like e-cigarettes and smokeless tobacco. 

Economist Frank J. Chaloupka of the University of Illinois Chicago, attorney David Sweanor of the University of Ottawa and economist Kenneth E. Warner of the University of Michigan acknowledge that “the science supporting a difference in risk between combustible and noncombustible tobacco products is well established,” and they conclude that “Sizable public health benefits could derive from current cigarette smokers’ switching to [e-cigarettes] and other noncombustible products.”

I made the same argument in a Tampa Tribune op-ed on August 16.  12 years ago.

In 2003, many states were under pressure to raise tax revenues.  I submitted op-ed columns to newspapers in 16 states, noting: “Excise taxes on tobacco products may be inevitable, but they don’t have to be illogical.  A common sense approach is to tax tobacco products according to risk.  Cigarettes, widely acknowledged as the most dangerous products, are already taxed at high levels by most states, ostensibly to discourage consumption.  But the health impact of smokeless tobacco use is much lower; scientific and medical research has confirmed that smokeless tobacco use carries only about 2% of the risk of smoking.  A rational tobacco tax policy would set taxes on smokeless products at 2% those of cigarettes.” 

The Tampa Tribune published my proposal (click on the image to read it), which included this:

“Taxing tobacco products according to well-established risks will serve the public health goal of reducing the death toll from cigarette smoking.  Economic research shows that a large price differential encourages cigarette smokers to switch to smokeless tobacco.  A growing number of public health experts, including the prestigious Royal College of Physicians in Britain, recognize that smokeless tobacco may be an acceptable substitute for smokers who have been unable or unwilling to quit.  They point to evidence from Sweden where, over the past century, men have smoked less and used more smokeless tobacco than in any other Western country.  The result: Swedish men have the lowest rates of lung cancer -- indeed, of all smoking-related deaths -- in the developed world.

“How have the Swedes achieved this record-setting reduction in smoking?  First, placing tobacco discreetly inside the mouth is far safer than setting it on fire and inhaling the smoke, and the Swedes know it…Second, smokeless tobacco satisfies, because it delivers nicotine almost as efficiently as a cigarette.  Nicotine is addictive, but it causes none of the diseases associated with smoking.  Third, the “spitting image” of smokeless tobacco is history, because modern products, available in Sweden and the US, can be used invisibly and as easily as breath mints.  Finally, in Sweden the price of smokeless tobacco products is less than half that of cigarettes, the difference largely reflecting levels of taxation.”

Twelve years later, it is comforting to see this taxation strategy gaining wider currency.

Formaldehype vs. Fact: Levels Are Far Lower in E-Cigarettes Than In Cigarettes

Researcher Naoki Kunugita at Japan’s National Institute of Public Health recently fueled anti-e-cig hysteria with this unverifiable claim: “In one brand of e-cigarette the team found more than 10 times the level of carcinogens contained in one regular cigarette.”

The charge came not in a peer-reviewed study, but in comments to the press publicizing favorable e-cig research.  His group looked at 13 Japanese e-cigs and reported in the International Journal of Environmental Research and Public Health that they had lower levels of formaldehyde than cigarettes (here).

Formaldehyde is everywhere, even in the air we breathe.  Individuals inhale about 1,000 micrograms per day, according to the World Health Organization (here), and a microgram is a very small amount – one-millionth of a gram.

The Japanese researchers collected from 0 to 34 micrograms from 10 puffs of e-cigarettes – at most, about one thirtieth of normal daily exposure from air.  In contrast, 10 puffs of a cigarette deliver 150 to 200 micrograms.

Apparently, after the controlled research was completed, Kunugita recorded 1,600 micrograms (10 times the cigarette level) using another e-cig brand.  That single observation generated the worldwide headlines.  Not only is the finding completely out of range with respect to all other studies, the claim is unverifiable. 

Publishing a scientific report showing low formaldehyde levels and then publicizing an unsubstantiated claim of 10-fold carcinogenicity is irresponsible.  The announcement was rightfully condemned by e-cigarette expert Konstantinos Farsilanos in his research blog (here).

The unvalidated claim undercuts legitimate science and sends smokers a horrific message: keep lighting up, because e-cigarettes are more dangerous. 

An Absorbing Nicotine Lesson

Nicotine uptake from snus, cigarettes and medicinal gum varies significantly, new research shows.

Helena Digard of British American Tobacco is lead author on the work, joined by colleagues from her company and from Sweden’s Lund University; their research was published in Nicotine and Tobacco Research (abstract here).

Dr. Digard provided 20 Swedish dual users of snus and cigarettes with two loose and two pouched snus products with different nicotine levels; nicotine gum; and a cigarette, over the course of six sessions.  Snus was placed in the upper lip for one hour only and not moved; the cigarette was smoked ad lib for 5 minutes or until reaching a prescribed length; the gum was chewed every 2 seconds for 30 minutes, with juices swallowed once every minute. 

The chart from the journal illustrates critical nicotine absorption data:

1.  Cigarettes produced a rapid, but transient, nicotine spike.  Peak blood nicotine levels of around 12 nanograms (ng) per milliliter (ml) were seen seven minutes after starting to smoke, followed by a steep decline.

2.  Snus produced similar nicotine levels much more slowly, but they stayed higher longer.  The products produced varying nicotine levels (~ 10-17 ng/ml) that correlated with their nicotine concentrations; the peak occurred one hour after placement.  Subsequent declines were also slower; after two hours, nicotine levels ranged from 7 to 12 ng/ml.

3.  Nicotine gum produced low blood nicotine levels much more slowly.  The peak (8 ng/ml) at 45 minutes was similar to the cigarette level that had declined by one-third. 

These findings are similar to those reported 24 years ago in the New England Journal of Medicine (reference here); they are particularly relevant for cigarette smokers making the switch to smoke-free nicotine products. 

The big lesson: Snus delivers satisfying doses of nicotine, but not as quickly as cigarettes.  However, slower nicotine delivery means slower decline – a distinct advantage.  Switchers generally use fewer pinches or pouches of smokeless tobacco compared to the number of cigarettes they smoked, as documented in my published research in the U.S. (here and here) and in Sweden (here). 

When unit consumption drops, smokers save money, further incentivizing them to stick with their switch to safer smokeless products.

Banning Flavored Cigarettes…What’s Next?

Earlier this week the FDA implemented a ban on flavored cigarettes. According to FDA documents, the scientific basis for this action was essentially a 2008 study by Klein et al. in Nicotine and Tobacco Research.

Klein looked at the National Youth Smoking Cessation Survey (NYSCS), finding that 22-23% of smokers age 17-19 years had "used" flavored cigarettes, compared with 9-10% of smokers age 20-26 years and 11% of smokers age 25-39 years (the latter percentage is from another survey).

According to the manuscript, “most flavored cigarette users reported that they usually smoked a brand other than [a flavored one]. Over half of flavored cigarette users (51.1% in NYSCS…) reported use of a usual brand that was manufactured by Philip Morris,” a company that does not make flavored cigarettes. The report could have presented detailed information about use of flavored vs. non-flavored cigarettes; it didn't, probably because the information didn't sustain the authors' conclusion: “Uniquely flavored cigarette brands seem to be most attractive to the youngest smokers and should be prohibited.”

In summary, flavored cigarettes are used by, at most, 2 out of 10 young smokers and aren't even their usual brand, which is unflavored. The Klein report also provided no evidence that flavored cigarettes are tobacco initiation products among young smokers. Of course, anti-tobacco crusaders have two magical words for tobacco regulatory discussions: The children. Virtually any action can be portrayed as protecting youth, and providing a rationale for the action is entirely unnecessary.

Congress directed the FDA to remove flavored cigarettes, so the agency didn’t need to justify the ban. That was fortuitous, because but it appears the FDA had trouble producing a credible scientific rationale. The FDA’s action does serve one of the primary goals of the anti-tobacco crusade: make tobacco use a miserable experience. However, since smokers who occasionally enjoy flavored-cigarettes prefer unflavored brands most of the time, the ban is likely to have minimal to no effect on smoking prevalence. It’s the equivalent of banning wine coolers because they’re occasionally consumed by people who drink a quart of vodka daily.

The FDA “is currently examining options for regulating both menthol cigarettes and flavored tobacco products other than cigarettes.” The only “option” that will satisfy anti-tobacco extremists, who have been whining for years about flavored smokeless products, will be to broaden the ban.

Minnesota Researchers to Smokeless Users: You’re Better Off Smoking!

In mid August the American Chemical Society, “the world’s largest scientific society,” held its national meeting in Washington, DC. The ACS has an impressive media machine, and on August 16 it was mobilized to promote a presentation entitled “Analysis of 21 polycyclic aromatic hydrocarbons in smokeless tobacco by gas chromatography-mass spectrometry,” by Irina Stepanov, a research associate at the University of Minnesota Masonic Cancer Center. The ACS media blitz included a press conference with Stepanov, which you can watch here.

Stepanov made some utterly incredible claims during her presentation, which were reported in an article published on the website of U.S. News & World Report under the headline “Chewing Tobacco No Safer Than Smoking”:

(1) “Tobacco users who think it's safer to dip snuff or chew tobacco than smoke are dead wrong, researchers say.”

(2) “A study has found that taking one pinch of smokeless tobacco delivers the same amount of polycyclic aromatic hydrocarbons (PAHs) as smoking five cigarettes.”

Let’s be perfectly clear: Irina Stepanov was asserting not only that smokeless tobacco is not safer than smoking, but that it is five times more dangerous than smoking!

Readers of this blog are familiar with the epidemiologic evidence linking smokeless tobacco use and cancer: almost a big fat zero. Numerous research studies have established that the cancer risks from using smokeless tobacco are so low that they are barely measurable.

Irina Stepanov made her claims about smokeless tobacco at a very public national meeting, and the American Chemical Society was an enthusiastic partner in promoting her research to the media. Surprisingly, after launching this unsubstantiated attack on smokeless tobacco, both Stepanov and the Chemical Society have refused to share her presentation with this researcher.

On August 19, I emailed Stepanov requesting a copy of her presentation. Her response on August 22 was bizarre: “We are in process of publishing a full paper on this study. So, the abstract is the only material that is available for sharing.”

That excuse for withholding her data is unprofessional. Researchers routinely provide copies of their public conference presentations to others in academia, regardless of the pendency of publication of fuller texts.

Refusal to share a conference presentation may violate the spirit, if not the letter, of the National Institutes of Health grants policy on data sharing. NIH funds Stepanov’s research group, the University of Minnesota and the Masonic Cancer Center, which also promoted Stepanov’s Chemical Society presentation. The NIH position is crystal clear: “It is NIH policy that the results and accomplishments of the activities that it funds should be made available to the public. PIs and grantee organizations are expected to make the results and accomplishments of their activities available to the research community and to the public at large.”

This episode is simply the latest in a series of attacks on smokeless tobacco by Minnesota anti-tobacco extremists. Almost the same approach and rhetoric were used in these 2007 articles in the New York Times and Fox News.

The main objective of this blog is to “examine and comment on the scientific foundation for tobacco policies and fallacies.” But that examination and commentary is contingent upon the scientific information being made available. In this case, Irina Stepanov, assisted by the American Chemical Society, has made a mockery of the long-standing tradition of open communication of scientific information.

Heart Attack and Stroke Risks from Smokeless Tobacco Use: Next to Nil

The International Agency for Research on Cancer (IARC) is a component of the World Health Organization with a mission “to identify the causes of cancer so that preventive measures may be adopted and the burden of disease and associated suffering reduced.” It is therefore not surprising that IARC staff have played a prominent role in exaggerating the cancer risks of smokeless tobacco use. The IARC anti- smokeless tobacco campaign has been led by Paolo Boffetta.

Boffetta, a cancer epidemiologist, departed from his field of expertise to complete (with co-author Kurt Straif) a review of the risks for heart attack and stroke among smokeless tobacco users in the U.S. and Sweden. The analysis has just been published by the British Medical Journal.

Boffetta reported that the summary relative risk (RR) for heart attack among smokeless tobacco users was 0.99, with a 95% confidence interval (CI) of 0.89 to 1.10 (For a discussion on how to interpret RRs and CIs, see my recent post). For stroke, Boffetta reported a minimal increase in risk (RR = 1.19) that was not statistically significant (CI = 0.97 – 1.47). Thus, the main finding in this study is that smokeless tobacco users have no excess risk of heart attack or stroke.

Given the importance of that conclusion, why did the researchers (in their BMJ abstract) and subsequent media coverage ignore it, focusing instead on fatal heart attack/stroke, one of two subgroups? It is because smokeless tobacco users had very small elevations in risk for the fatal events. For fatal heart attack the RR among smokeless users was 1.13 (CI = 1.06 – 1.21), and the RR for fatal stroke was 1.40 (CI = 1.28 – 1.54). Boffetta was unable to demonstrate that the excess risks were related to how much or how long smokeless tobacco had been consumed, two important characteristics that would have strengthened the validity of the findings.

There is a serious omission in this study. Boffetta divided all heart attacks and strokes into two subgroups, fatal and non-fatal. Boffetta found that smokeless users had no significant risk for all heart attacks and strokes but had elevated risks for fatal cases. It logically follows that smokeless users probably had LOWER risks for NON-FATAL heart attacks and strokes. But Boffetta provided no information about these subgroups, and the reason is obvious: it wouldn’t add to the health hysteria.

Here is the take-home message for smokeless tobacco users: You do not have elevated risks for heart attack and stroke. Although your risk for heart attack and stroke is the same as that of non-users of tobacco, there is a slight increased chance that, if one occurs, it could be fatal. This may be due to the effects of nicotine on the circulatory system, or it could be due to some other undiscovered factor that is associated with smokeless use. As Boffetta acknowledged, “the magnitude of the excess risk is small.”

In the article’s introduction, Boffetta wrote that smokeless tobacco “products have been proposed as an alternative to cigarettes and other smoking products under the claim of a smaller, or negligible, risk to health.” This study adds to the scientific evidence that, compared with cigarettes, the risks from smokeless tobacco are indeed vastly “smaller, or negligible.”