A “News” Study on Smokeless Tobacco

A study published this month in Nicotine and Tobacco Research (abstract here) provides evidence that coverage of smokeless tobacco (ST) in the context of tobacco harm reduction was infrequent and negatively slanted during the period 2006 through 2010. The lead author was Dr. Olivia Wackowski from the University of Medicine & Dentistry of New Jersey, with coauthors from her institution and from the University of California San Francisco.

The authors searched for articles primarily about ST in the Wall Street Journal, the New York Times and USA Today, and in the top 2-4 newspapers in each state.  She also searched national news services (Associated Press, Reuters, UPI), the Winston-Salem Journal (home of RJ Reynolds), The Richmond Times (home of Altria) and health wire news services. 

Dr. Wachowski found 677 news articles, the largest group of which (n=191, 28%) were business-focused.  Other categories included prevention/cessation (11%), taxes (10%), use trends (9.0%), bans (8.1%), tobacco industry promotions (4.9%) and health risks (4.9%).

Only 130 ST articles focused on tobacco harm reduction (lumped with new products and product regulation), a low number considering the subject’s potential to save millions of lives.  Of these, only “…about 58%... referred to ST products as being [or] possibly being less risky or harmful than smoking.”  This category also had the highest percentage of articles (69%) with references to health risks, but it is likely that few of them were positive.  Tobacco hometown newspapers contributed the most articles to this category (38%), followed by state papers (35%) and national papers (23%). 

The researchers also found 176 “opinion” articles; 89 were letters to the editor, 70 were editorials and 17 were op-ed pieces.  Unfortunately, 64% were classified by the researchers as anti-ST, only 26% were pro-ST, and the remainder were neutral.  Of the 61 articles in the harm reduction category, 43% were pro-ST. 

One positive note: The use of the derogatory term “spit tobacco” was uncommon, except in state newspapers (15%).    

In short, coverage of ST has been scant and heavily biased against and tobacco harm reduction.  This is unsurprising, given the national misinformation campaign that I discussed previously (here).    

Indefensible Action By the U.S. Army Public Health Command

On February 28, I saw the “Great American Spit Out/ Tobacco Cessation” webpage (from my archive here), published by the Army Public Health Command (APHC) to “raise awareness of the dangers associated with smokeless tobacco.” The site was inaccurate and unprofessional with regard to smokeless tobacco use among army personnel.

After the ironic introductory statement, “Unfortunately, the myths concerning smokeless tobacco are still in existence,” the webpage contained this egregious claim: “Smokeless tobacco is as harmful as smoking tobacco.”

I contacted two APHC staffers and explained that this statement was factually incorrect and indefensible. A 2004 National Cancer Institute study concluded: … “[smokeless] products pose a substantially lower risk to the user than do conventional cigarettes. This finding raises ethical questions concerning whether it is inappropriate and misleading for government officials or public health experts to characterize smokeless tobacco products as comparably dangerous with cigarette smoking.” (abstract here).

To its credit, the APHC responded quickly. Less than 24 hours later, on February 29, the just-as-dangerous myth was removed from the website (here).

I also explained to the APHC that the word “spit” is demeaning, disrespectful and deplorable, as I pointed out in a previous post (here). Two years ago, I wrote to federal officials, strongly objecting to use of this term (here). The Centers for Disease Control, the Food and Drug Administration and the National Institute for Dental and Craniofacial Research responded by removing the offensive term from websites and other publicly available materials (here).

It’s time for the Department of Defense and the U.S. Army Medical Command to abandon this offensive language, treat smokeless tobacco users with respect, and provide accurate medical information, particularly on the subject of tobacco harm reduction.

Federal Agencies Agree: Phrase “Spit Tobacco” Is Inappropriate

Readers of this blog may remember my July 14 post (available here) describing the use of the derogatory term “spit tobacco” on websites run by the FDA and the National Institute of Dental and Craniofacial Research (NIDCR). At that time, I wrote to the directors of the agencies, asking them to remove this offensive language from their sites.

I have just received reply letters from both agencies. Susan Johnson, Director of the Office of Communications and Health Education at NIDCR, wrote that the institute “is in the process of substituting ‘smokeless’ (or product-specific terms) for ‘spit’ in our online materials; we anticipate these changes will be completed by the end of August 2010.”

In a separate letter, Anne Henig, from the Office of the Director of the FDA Center for Tobacco Products, advised: “NIDCR has updated its webpage and changed the title to Smokeless Tobacco: A Guide for Quitting” (here)...FDA has also updated its webpage to reflect NIDCR’s change. I hope these modifications will address your concerns.”

I appreciate the timely responses from NIDCR and FDA. I’m encouraged that officials at these agencies have joined the CDC in resolving to treat smokeless tobacco users with respect and dignity.

Federal Agencies Continue To Disrespect Smokeless Tobacco Users

Last week I presented my correspondence with the director of the federal Centers for Disease Control and Prevention, which resulted in a retraction of CDC’s use of the pejorative term “spit tobacco” in a formal report (read it here).

This week I am very disappointed to report that the FDA uses the demeaning term on a web page (here) that was last updated on July 8.

Although the offending page is supposed to present information about warning labels, it launches into an unnecessary and unsubstantiated attack on smokeless tobacco and, of course, its users:

“Smokeless tobacco is still tobacco. It is addictive and causes cancer. Quit today. For help, visit ‘Spit Tobacco: A Guide for Quitting’ or call 1-800-QUIT-NOW.”

It is unacceptable and irresponsible for the FDA to use such language to describe the product it is supposed to regulate in a balanced, fair and scientific manner. But it gets worse. The Spit Tobacco Quitting Guide is an embedded link to a document on the website of the National Institute of Dental and Craniofacial Research (here). The document exposes smokeless users to even more abuse:

“If the health effects don’t worry you, think of how other people see your addiction. The smell of spit tobacco in your mouth is not pleasant. While you may have become used to the odor and don’t mind it, others around you notice. Check out your clothes. Do you have tobacco juice stains on your clothes, your furniture, or on your car’s upholstery? Your tobacco spit and drool could be making a mess. Look at your teeth. Are they stained from tobacco juice? Brushing your teeth won’t make this go away.”

This is appalling language, and it is disgraceful that two federal agencies have officially adopted and endorsed it.

Three years ago, the director of the Centers for Disease Control rejected the use of the biased and pejorative term “spit tobacco.” Unfortunately, the practice persists today at two other federal agencies. I have written to Dr. Lawrence Deyton, director of the FDA Center for Tobacco Products, and to Dr. Lawrence Tabak, director of the National Institute of Dental and Craniofacial Research, asking them to remove these offensive website items and order professionals in their agencies to stop using this term in all official matters.

Users of smokeless products may want to call, write or email Drs. Deyton and Tabak, asking them to remove “spit tobacco” from their agencies’ vocabulary. Here is their contact information:

Dr. Deyton: 1-877-287-1373 (toll-free)
AskCTP@fda.hhs.gov

Dr. Tabak: 1-301-496-3571
Lawrence.Tabak@nih.gov

Health Professionals Who Disrespect Smokeless Tobacco Users

When I started conducting research on tobacco harm reduction in the early 1990s, I noticed a disturbing trend: replacement of the term “smokeless tobacco” with the demeaning and disrespectful term “spit tobacco.”

This degrading term was not only used by extremists at the margin of tobacco control; by 1994, health professionals were using it in medical journals. The first instances were in the Journal of the American Medical Association (citation here) and the Journal of the American Dental Association (abstract here). The latter article was the first of 10 by Margaret Walsh, a professor of dentistry at the University of California/San Francisco; her most recent publication was in 2009 (abstract here).

Other professionals who have used this terminology include John Ebbert and Lowell Dale of the Mayo Clinic (here, here and here) and Dorothy Hatsukami at the University of Minnesota (here and here). Dr. Hatsukami’s adoption of the loaded term is especially troublesome since she now sits on the FDA tobacco products advisory panel.

The most egregious use of the spit terminology has been by the American Cancer Society and the CDC. The Cancer Society published research studies in 2005 and 2007, prominently using “spit” (here and here). The CDC institutionalized the practice in a 2006 federal report in collaboration with the National Center for Health Statistics (here).

The 2006 CDC report was especially deplorable, because it treated smokeless tobacco use differently than three other adult health risk behaviors -- cigarette smoking, cigar use and alcohol consumption.

On February 19, 2007, I wrote to CDC Director Julie Gerberding and NCHS Director Edward Sondik (available here). I pointed out that “the report’s use of [‘spit’ tobacco] is clearly inconsistent with its use of other terms relating to tobacco use and drinking behaviors. Furthermore, I believe that the use of ‘spit’ tobacco violates NCHS and CDC guidelines for ensuring the quality of information disseminated to the public. The NCHS and CDC guidelines are identical with respect to this matter, as it is each agency’s policy to ‘ensure and maximize the quality, objectivity, utility, and integrity of information that it disseminates to the public.’”

I strongly urged “CDC and NCHS to issue a corrected version of the Advance Data Report Number 378. Furthermore, I am asking that CDC/NCHS officials and staff to avoid the use of the term ‘spit’ tobacco in future official government publications, and to remove the term from existing web pages. This term is inappropriate because it is inaccurate, biased and unobjective. In addition, its use is inconsistent with the fully appropriate and non-pejorative terms ‘cigarettes,’ ‘cigars’ and ‘alcohol’ used in this and other government documents.”

In April, I received a response from Dr. Gerberding (read it here). She acknowledged that “an inappropriate term was used in this report. We agree that the term ‘smokeless tobacco’…would provide a better description of the information and we will take swift action to make that change. A revised version of [the report] will be posted on NCHS’ website. The printed version of this report will be changed should we reprint in the future.”

In May 2007, I wrote to John Seffrin, CEO of the American Cancer Society. I included a copy of Dr. Gerberding’s decision, and I listed several specific publications in which Cancer Society officials had used “spit tobacco”. I made the following key points:

“In a March 27 Wall Street Journal article, American Cancer Society Vice President Dr. Michael Thun summarized a growing consensus among tobacco research and policy experts regarding the vast difference in risk between smoked and smokeless products: ‘There's no question that switching to spit tobacco and quitting tobacco altogether are both far less lethal than continuing to smoke.’ Recognizing these differential risks is consistent with the American Cancer Society mission, which includes ‘preventing cancer, saving lives, and diminishing suffering from cancer.’ Describing all tobacco products in objective and professional terms would enhance the essential humanity of your mission by treating all tobacco users with dignity and respect.

“I believe that the American Cancer Society strives for high standards in its professional reports and communications, and I request that Society officials describe tobacco use in a non-pejorative, unbiased and objective manner consistent with the change made by the CDC. Specifically, I ask that Cancer Society officials and staff not use the term ‘spit tobacco’ in future reports and communications, and that the term be removed from existing web pages and other electronic reports and documents.”

In July 2007, Dr. Seffrin wrote back: “Thank you for sharing your concerns regarding the use of the term ‘spit tobacco’ by health and policy professionals at the American Cancer Society. I have forwarded your letter to the appropriate staff for further review and any appropriate action.”

I don’t believe that Cancer Society officials at the national level have used “spit tobacco” since that time.

Use of the phrase “spit tobacco” shows that anti-tobacco extremists are completely out of touch with contemporary use of smokeless products. The “Swedish miracle” has shown the world that smokeless tobacco can be an effective substitute for cigarettes, resulting in population-level health improvement. Swedes have also shown how to use smokeless tobacco without spitting. They place smokeless products in the upper lip, reducing or eliminating the need to spit.

Modern dissolvable products (here and here), which are about the size of small breath mints, can also be used invisibly in any social situation. No tobacco juices are produced when these products are used, so spitting is as unnecessary as the derogatory terminology.