A Tainted Legacy

On August 19 David Abrams and Julia Cartwright wrote an article for the Huffington Post entitled “What’s Wrong With This Picture.” (here).

Dr. Abrams and Ms. Cartwright are what’s wrong with this picture.  They represent the Legacy Foundation, a billion dollar enterprise (here) aimed at “Helping people live longer, healthier lives without tobacco” (here).  This prohibitionist crusade is fueled by exaggerated claims of tobacco risks and gateway fantasies. 

For example, they write that “smokeless tobacco or ‘chew’ can also cause a long list of disfiguring and deadly oral cancers.”  This is false, as attested to in in the Legacy fact sheet on smokeless tobacco (here)*, which lists no specific health risks for those products. 

Asserting that “newer products have unknown risks and require more research,” Abrams and Cartwright ignore decades of research documenting that smokeless tobacco products produce barely measurable health risks. 

The writers of the column praise the European Union’s inclination to ban tobacco products, including snus, in every country except Sweden.  Yet they should know that snus use has been directly associated with record low smoking rates among men in Sweden: they smoke less and use more smokeless tobacco than in any other developed country.  And they have the lowest rates of lung cancer -- indeed, of all smoking-related deaths -- in the developed world.

Abrams and Cartwright claim that children are confused about “which products are candy and which ones are the real deal.”  This is a red herring.  The sale of tobacco products to children is prohibited in every state; FDA monitoring reveals that the vast majority of retailers are compliant (here).  If Legacy has evidence that tobacco manufacturers are marketing to children, those serious charges should be directed to states’ attorneys general.  Since the 1998 Master Settlement Agreement, tobacco manufacturers have been prohibited from directly or indirectly targeting children.  Legacy should produce evidence and file a complaint; otherwise their accusations are specious.

Abrams and Cartwright write that smoking “…robs us of more than 440,000 lives, $96 billion in healthcare costs and an additional $97 billion in lost productivity costs each year.”  Yet their prohibitionist prescription would rob 45 million American smokers of vastly safer smoke-free alternatives.  The eight million Americans who will die from a smoking-related illness in the next 20 years are not children, they are today adults.  Preventing youth access to tobacco is important, but that can be accomplished without condemning to premature death those parents and grandparents who are current smokers.

*The publication date of this post was August 21, 2013.  On August 27 Legacy produced a new smokeless tobacco fact sheet and gave it a new web address.  The new fact sheet lists no specific health risks for smokeless tobacco use.

Tobacco Trick or Treat by Florida’s Surgeon General

On Halloween, Dr. John Armstrong, Florida Surgeon General and Secretary of Health, launched an attack on flavored tobacco, ostensibly to protect children (I expressed concern three years ago about the crusade against tobacco flavors, here and here).  As I note in the attached letter, “the availability of flavored tobacco products is important for tobacco harm reduction among adults who smoke…” because “…these individuals [should] have access to appealing, vastly safer smoke-free alternatives to cigarettes.”  Furthermore, contrary to Dr. Armstrong’s claim, there is no evidence that tobacco flavoring is aimed at targeting youth.  The full text of my letter follows:

November 12, 2012

John H. Armstrong, MD, FACS

Surgeon General and Secretary of Health

State of Florida

Dear Dr. Armstrong,

I am a professor of medicine and hold an endowed chair in tobacco harm reduction research at the University of Louisville.  I read with interest an article in the St. Pete Patch entitled “Candy Flavored Tobacco: Trick or Treat” (here), which provided the following quote from you:

“Youth have always been a target for the tobacco industry, and our Department will not sit by and watch.  Companies perceive youth as an easy target, and develop products like flavored tobacco and marketing campaigns aimed at them.”

The 1998 Master Settlement Agreement (MSA) between the four largest American tobacco manufacturers and the attorneys general of 46 states (here) expressly prohibited the egregious actions you describe occurring in Florida.  Section IIIa of this agreement, titled “Prohibition on Youth Targeting”, specifies that “No participating Manufacturer may take any action, directly or indirectly, to target Youth within any Settling State in the advertising, promotion or marketing of Tobacco Products…” 

As you know, the state of Florida was not a party to the MSA.  Instead, Florida entered into an individual agreement with tobacco manufacturers (here) that appears not to have youth targeting and marketing prohibitions.  However, I believe that tobacco manufacturers have a moral obligation to follow the spirit of the MSA in Florida.   

I reviewed the Tobacco Free Florida website on candy-flavored tobacco (here), which claims that flavors include “berry, vanilla, chocolate and green apple, orange, cherry and coffee” and that tobacco products are presented in “colorful and playful packaging.”  I do not believe that this constitutes evidence that manufacturers are “directly or indirectly” targeting youth. 

The availability of flavored tobacco products is important for tobacco harm reduction among adults who smoke. From a public health standpoint, it is important that these individuals have access to appealing, vastly safer smoke-free alternatives to cigarettes.  The flavors highlighted by Tobacco Free Florida have no special appeal to youth, so there is no reason they should not be used in adult tobacco products.  Banning tobacco flavoring is no more logical than banning flavored beer, wine and mixed drinks on the grounds that those products appeal to youth.

As a state official, you have made specific allegations that tobacco manufacturers are targeting youth and have “marketing campaigns aimed at them.”   The mere use of flavoring in tobacco products does not warrant such a claim. 

I share your interest in preventing initiation of tobacco use by youth, and would appreciate your sharing with me any specific evidence of unlawful tobacco marketing to this protected class.

Sincerely,

Brad Rodu

Professor

Endowed Chair, Tobacco Harm Reduction Research

School of Medicine

University of Louisville

                                                                     

The True Impact of Snus in Sweden: Smoking Cessation Up, Initiation Down

It is a widely accepted myth that snus use among men in Sweden has only served as a quit-smoking aid. While my published studies from 2002 to 2005 (described here, here, and here) and many others (here, here, and here) have documented that male smokers in Sweden have used snus as a gateway to a smoke-free life, that is only part of the story.

Snus use has also played a valuable role in steering tobacco initiators away from more dangerous cigarettes. In 2005, I authored a study of tobacco use among Swedish boys and girls age 15-16, which was published in Tobacco Control (here). The results are impressive: “During the period 1989 to 2003, the prevalence of tobacco use [in Sweden] declined both among boys and girls. For boys, regular smoking declined after 1992 from 10% to 4%. Their snus use was about 10% in the 1990s but increased to 13% by 2003. Regular smoking among girls was 20% in early years and declined to 15%. Smoking among girls was always double that among boys. Patterns of occasional tobacco use were similar to those of regular use.”

I also observed that “…specific patterns of tobacco use differ strikingly between Swedish boys and their EU counterparts…In 2002 the World Health Organization reported that the average prevalence of daily smoking among 15 year old boys in 25 European countries (excluding Sweden) was 18%.7. In that report boys in Sweden had the lowest smoking prevalence of all countries (5.7%), at about one third of the EU average. The next highest prevalence was in Greece (9.2%). All other countries reported prevalences from 12% (Wales) to 27% (Lithuania). Thus, high prevalence of snus use by Swedish boys may be a factor in low smoking prevalence.

“In contrast, smoking rates among 15 year old girls in Sweden do not differ from those among girls in other European countries. In the 2002 WHO report smoking prevalence among Swedish girls was the fifth lowest in Europe (14%), but still close to the average for all other countries (19%, range 11% in Greece to 29% in Germany).”

I want to be absolutely clear: I strongly support all measures to keep tobacco away from children. However, a tobacco-free world, for adults and children, is as likely as an alcohol-free world was in 1920 (here). Teenagers will use tobacco, no matter what measures are taken to stop them. The remarkable story from Sweden is that most boys choose snus, the product their fathers use. This fact is well-received by health and policy professionals who understand that snus users lead lives that are virtually indistinguishable (in measures of years and health) from those of their abstinent peers.

Finally, the “Swedish Snus Experience” is not only about men. Recently, more women in Sweden are also using modern snus products (evidence here), which are spit-free and socially acceptable. This may represent the first time in recorded history that women have adopted a healthier behavior – from their husbands.