Scaremongering’s Forever Effects

 

With the emergence of nicotine pouches, claims from the 1980s about the health risks of smokeless tobacco (ST) use have reappeared. Nicotine pouches are an important addition to smokers’ options for reducing harm, but it is inappropriate to devalue them by overstating the risks of ST use, such as opining that it causes leukoplakia and periodontal disease.  This is not the case, and I wish to set the record straight.

Leukoplakia

In 1995, my research group published an article, “Tobacco Use and Cancer,” that discussed leukoplakia: “Oral leukoplakia was originally defined in 1978 by the World Health Organization as a ‘white patch or plaque that cannot be characterized clinically or pathologically as any other disease.’ This definition was recognized as overly broad, and in 1984 a revised definition excluded white lesions such as frictional keratoses and also specified tobacco-induced leukoplakias as a distinct category. Furthermore, [ST keratosis, STK] was separated from smoking-related leukoplakia on the basis of presentation with additional differences in prevalence, frequency of dysplasia, and rate of malignant transformation. STK is common; it occurs in up to 60% of ST users.” (references omitted)

While anti-tobacco zealots never adopted the accurate terminology, preferring the scarier term leukoplakia, findings from 92 biopsies in one of these scaremongering studies were consistent: “All lesions were benign, but one specimen had mild epithelial dysplasia.”  The term mild dysplasia is subjective, so it’s likely that none of the findings were significant.

When our article was published, we were unaware that the infamous study by Winn et al. in the New England Journal of Medicine involved only women who had used powdered dry snuff (here).  That misleading study led nearly everyone, including health professionals, to mistakenly believe that moist snuff (dip) and chewing tobacco use among men causes mouth cancer.  For confirmation of that fallacy, see the October 2016 report by Annah Wyss of the National Institute of Environment Health Science and 20 government-funded coauthors (discussed here) that found that American men had no excess mouth cancers associated with dipping or chewing tobacco (Odds Ratio, OR = 0.9), while women, who mainly use powdered dry snuff, had a 9-fold elevated risk (here). 

Periodontal Disease

The CDC describes gum or periodontal disease as “mainly the result of infections and inflammation of the gums and bone that surround and support the teeth.”  The same scaremongering study cited above also reported that “gingival recession and attachment loss [4 mm or more] were greater in sites adjacent to lesions in [ST] users.”  These findings aren’t the same as infections and inflammation in and loss of the supporting bone, which is periodontal disease.  In fact, a comprehensive review by Kallischnigg et al. in BMC Oral Health concluded, “Two of four studies report a significant association of snuff with attachment loss and four out of eight with gingival recession. Snuff is not clearly related to gingivitis or periodontal diseases. Limited evidence suggests chewing tobacco is unrelated to periodontal or gingival diseases.” (emphasis added)

These two conditions, leukoplakia and periodontal disease, pale in comparison to lung cancer and heart attacks, so why am I focusing on them?  Because misinformation, particularly about safer smoke-free cigarette substitutes, has a dangerously long shelf-life.

I have dedicated the past 30 years to setting the record straight about ST use, but the American public remains grossly misinformed due to misinformation published decades ago.  For example, the National Cancer Institute Health Information National Trends Survey documents that 86% of Americans don’t believe – or don’t know – that ST use is less harmful than smoking (here).  Similar fake science now inundating the medical literature about newer smoke-free products, if not stopped, will have the same long-term effects. Public health and tobacco experts need to approach misinformation about tobacco risks as seriously as physicians counter quackery in medicine. 

 

Intolerable False Statements by FDA’s Mitch Zeller

Mitch Zeller, director of the FDA Center for Tobacco Products, should stop making false statements about smokeless tobacco.

The FDA earlier this week expanded its smokeless tobacco campaign, arranging a series of interviews for Zeller (example here), whose script included two provably false statements.

   “Every year more then [sic] 2,000 new [mouth or throat] cancer [cases] are diagnosed in the United States solely caused by smokeless tobacco use.”

This number is a pure fabrication.  No medical authority, including the FDA, has ever produced such a figure, which is more than 50% higher than the agency’s estimate of two years ago (here). Even that number was a gross exaggeration, due to a serious technical error confusing the historical risks of dip and chew (essentially zero) favored by American men with the higher risks of dry powdered snuff preferred by women (here).

The Zeller number is further undercut by last year’s American Cancer Society report which omitted smokeless tobacco as a cause of cancer (here).   

Zeller also produced this false statement in his latest publicity tour:

2.     …“a white spot inside your lip or gum that you know if you’re seventeen eighteen years old and you see that and you don't pay any attention to it, it can progress to things like cancer.”

A white patch, as I have documented (here), is simply a reaction to the irritating effect of the tobacco, similar to the development of calluses on a worker’s hand.  The link between white patches and cancer is virtually zero for dippers and chewers.

As director of an FDA center, Zeller has a profound responsibility to enhance public health and adhere to scientific truth.  He damages his own credibility and that of his agency by making false statements. 

Through with Chew Week: Don’t Be Fooled

Chewers and Dippers: It’s the third week in February, which means it’s time for you to be badgered by the annual Through with Chew public relations campaign.  Across the nation, tobacco prohibitionists are publishing unscientific and unsubstantiated claims about smokeless tobacco.  Here are recent examples from Fallon County, Montana and Boone County, Iowa, followed by the facts

Claim 1: “chew products deliver a higher dose of nicotine than cigarettes, making the product more habit forming.”

The Facts: The amount of nicotine that smokeless tobacco “delivers” is irrelevant, because chewers and dippers use products in ways that satisfy them.  In fact, there is evidence from one of the world’s foremost authorities on nicotine addiction that smokeless tobacco is less habit-forming than cigarettes (here and here).  Most Americans are badly misinformed about the absence of significant health effects of nicotine (here).  

Claim 2: “Smokeless ‘Spit’ tobacco contains over 2,000 chemicals.”

The Facts: Every natural product, including coffee contains thousands of chemicals (here).  A product’s chemical composition is unimportant if it carries little or no risk.  Like coffee, smokeless tobacco fits in that category.

Claim 3: “Chew contains at least 28 chemicals that have been found to cause cancer…”

The Facts: Almost everything we eat contains cancer-causing chemicals, but they are in trace levels that present no risk.  Again, coffee is a prime example (here).  Numerous scientific studies prove that there are vanishingly small levels of carcinogens in modern smokeless tobacco products (here, here, here, here, here). 

Claim 4: “Harmful effects of smokeless tobacco include mouth, tongue, esophageal, and throat cancer…stomach and pancreatic cancer”

The Facts: According to dozens of published epidemiologic studies (reviewed here), the risks for these cancers are not elevated.

Claim 5: “Harmful effects of smokeless tobacco include increased risk of heart disease, heart attacks and stroke.”

The Facts: Among the many risk factors for heart disease and stroke, smoking is one of the biggest.  That is not the case with smokeless tobacco.  When the American Heart Association conducted an extensive investigation of smokeless tobacco and heart disease, it found almost nothing (here).  Large studies from Sweden show that snus users do not have risk for heart attacks (here) and strokes (here), and snus use may even offer benefits for heart attack survival (here).

Claim 6: “Harmful effects of smokeless tobacco include leukoplakia (white sores in the mouth that can become cancer).”

The Facts: White patches are common in chewers and dippers, but they are nearly always benign.  The link with mouth cancer is virtually zero (here).

Claim 7: “Harmful effects of smokeless tobacco include receding gums, bone loss around the roots of the teeth, abrasion (wearing down) of teeth.”

The Facts: There is virtually no scientific evidence that smokeless tobacco is a risk factor for any dental problem (here, here).  In fact, one study shows that snus and moist snuff (dip tobacco) might be protective against cavities (here).

Don’t be fooled by bogus smokeless tobacco health claims.