Not-So Fine Whine, From the Society for Research on Nicotine and Tobacco

 

The Society for Research on Nicotine and Tobacco (SRNT) bills itself as “the only professional association dedicated exclusively to the support of researchers, academics, treatment professionals, government employees, and the many others working across disciplines in the field of nicotine and tobacco research.” 

The organization claims that it advances the field of nicotine and tobacco research by working with groups including the FDA’s Center for Tobacco Control and Center for Drug Evaluation and Research, the National Cancer Institute (NCI), and the National Institute on Drug Abuse.  While those relationships are appropriate, SRNT’s bragging about its “close relationships” with the Truth Initiative, the Campaign for Tobacco Free Kids (CTFK), the Association for the Treatment of Tobacco Use Dependence, and the American Cancer Society is unseemly, given those groups’ open hostility to any research or data supportive of nicotine, tobacco or tobacco harm reduction.

Responding to the CDC losing $310 million for its Office on Smoking and Health (OSH), SRNT published a “Nicotine & Tobacco Research Community Call to Action.”

The call to action links to a CTFK letter, dated April 30, that argues for continued CDC OSH funding: “The elimination of CDC’s Office on Smoking and Health would have a profoundly negative impact on our nation’s efforts to reduce the death and disease caused by tobacco…OSH has provided grants to all 50 states and territories to support tobacco prevention and cessation programs. Comprehensive state and local tobacco control programs…OSH has provided funding to state quitlines…With $310 million, CDC will be able to address the challenges posed by e-cigarettes…”

Stated more accurately, if the CDC loses this funding, it will no longer be able to pursue its stated goal of achieving nationwide tobacco prohibition.

SRNT emphasizes the prime reason they support continued funding for their CDC piggybank: “More than ever, we need to explain how tobacco impairs health, why people continue to use tobacco, and what can be done to reduce tobacco-related deaths.”  

In reality

 The only tobacco use that impairs health is smoking;

2.  People use tobacco because it is pleasant and satisfying; and,

3   We can reduce tobacco-related deaths by reducing smoking. 

This bit of federal spending reduction may actually promote public health, “more than ever.”

 

Up in Smoke: The American Heart Association on Smokeless Tobacco

 

The American Heart Association published a policy statement in its journal Circulation, titled, “Impact of Smokeless Oral Nicotine Products on Cardiovascular Disease.” (here)  Below, I cite with permission excerpts from a review by Clive Bates, along with my comments.

The smokeless tobacco [ST] policy statement from the American Heart Association is too long to review in depth, but my main take outs are:

1. It’s a modest improvement on what came before and it has factually correct things in it, but it does not work as a basis for policymaking or risk communication.

Clive notes the biggest problem, the conclusion is preordained: “summarize implications of use for [the AHA’s] policy work toward ending tobacco and nicotine addiction in the United States.

So if your goal is a nicotine free society, no level of risk will ever be tolerable, and your search for harms (real, exaggerated or imaginary) will be driven by the need to support this conclusion.  We do not have this “elimination” philosophy with other common recreational drugs - caffeine, alcohol and cannabis, even though these are not risk-free.  We take the approach of managing risks to levels acceptable in society. AHA should also know by now that regulation and risk communication in this field is plagued by unintended consequences - adverse behaviour change (more smoking), illicit trade and risky workarounds - and these consequences can be more severely negative than the intended benefits.

Let me be clear - I am not recommending tobacco or nicotine use to anyone… this is better understood as a phenomenon in society driven primarily by its perceived or real benefits to users - it makes people feel better and feel as though they function better. No space was available in the paper to discuss this important aspect of nicotine use - why people use it. The demand for nicotine is not going to disappear and the availability of nicotine in much safer forms than smoking removes nearly all of the main deterrent for nicotine use - extreme harmfulness over the long term of inhalation of smoke. I suspect there would be a very different attitude to ST if the public had not been confused by years of deceptive risk communications [only 13.4% think ST can be safer than cigarettes - HINTS 2017]. There are no upfront statements that address this risk miscommunication.

2. No clarity on the place of ST on the nicotine risk continuum.

This is the only mention of ST in the AHA statement: “Although there are no safe tobacco products, a continuum of risk across tobacco and oral nicotine products exists, with the greatest risk associated with combustible products such as cigarettes and cigars.” 

Everyone agrees that there is no “safe” tobacco product, and that combustion and smoke produce the greatest risk, but it is unacceptable to ignore decades of evidence proving that ST is only about 2% as risky as smoking.

3. Nothing to correct huge false risk perceptions and more to add to them.

While many studies have found that ST use confers minimal to no increased risk for cardiovascular diseases, the AHA cherry-picked research that portrays ST badly and they ignored, or were ignorant of, those studies’ major flaws.  For example, the AHA cited a seriously defective 2014 Swedish study in Circulation showing increased deaths among snus users with heart attacks (here).  Using that study’s results, my colleague and I found that continuing snus users actually had a lower death rate than those who used neither snus nor cigarettes (here).  Our analysis was so persuasive that the journal published it for the record (here).

Every ST prohibition screed includes a section on oral cancer, and this report, ostensibly about cardiovascular disease, adheres to the formula by quoting an infamous 2016 study by Wyss and colleagues that claimed a positive association of ST use and oral cancer.  Still, in a rare nod to truth and clarity, the AHA authors opine:

“It is noteworthy that many meta-analyses included individuals who reported use of high-nitrosamine ST products from many years in the past. These differences need to be considered carefully when extrapolating to oral cancer effects among individuals reporting use of currently available products with lower nitrosamine levels.”

Kudos, because that is what I have been documenting since 1994.  Wyss revealed that American men had zero excess mouth cancers associated with [low-nitrosamine] dipping or chewing tobacco (Odds Ratio, OR = 0.9), while women, who mainly use[d] [high-nitrosamine] powdered dry snuff, had a 9-fold elevated risk (here).

4. Detailing the mechanisms behind minor risks in a way that conveys greater risk than exists.

Almost every study showing some sort of material risk has been open to confounding or other methodological weaknesses - the high level mortality data show no excess risk for exclusive smokeless use in the US.

The AHA studiously ignores published research that failed to show excess risk from ST use; the FDA took a similar tack in an internal report last year (here). 

5. Not presenting a simplistic approach to nicotine use, and why people use it.

The AHA dwells on nicotine chemistry, toxicity, pharmacology and physiology, but in the end, they focus on the harm of nicotine addiction.  In doing so, they ignore the fact that hundreds of millions of people worldwide consume combustible tobacco and nicotine products, despite the long-term increased risk of dying prematurely from a plethora of diseases that could easily be avoided.

6. Disregards interactions between different forms of tobacco use with radically differing risks.

The AHA repeatedly mentions dual use as a negative side effect of ST, yet the association perpetuates dual use by ignoring or downplaying the well-documented differential risks between smoke and smoke-free tobacco.  This has been going on for decades; in 1991, the CDC reported that at least 23% of ST users also smoked (here).  Imagine how many dual users’ lives would have been extended if health professionals had been honest about the risk differential.    

7. A naive policy platform based on weak evidence of impact and blind to unintended consequences.

This review does have some useful though equivocating text buried within it as the truth is essentially undeniable.

Nicotine is the proximate cause of all tobacco-induced disease because it drives dependence and compulsive use. However, most of the harm from tobacco use results from inhalation of tobacco combustion products, which delivers high levels of oxidizing chemicals, numerous toxic volatile organic compounds, and carbon monoxide. Because oral nicotine products do not expose users to combustion toxins, an important question is the intrinsic toxicity of nicotine.

No, the real question is about the magnitude of risk - how this compares with smoking and how it looks in absolute terms compared to other risks that are routinely tolerated in society. It should also draw attention to the likelihood that ST use is likely safer than vaping, as there is no lung exposure and no thermal processes -just because something contains tobacco doesn’t make it more harmful than something that doesn’t.

Sadly, if predictably, there are no clear statements in this policy statement that aim to reset the public, medical or political misunderstanding of relative risk.  Even on cardiovascular risk there are statements that suggest minimal risk in the American context, but buried deep within

The policy proposals are poorly supported with policy impact evidence and are more like an uncritical shopping list… Given it is a policy paper, it is completely dominated by largely irrelevant biomedical findings, with policy proposals made as if they are somehow obvious, rather than a perturbation of a complex adaptive and interconnected market-based system for nicotine use

The question is what happens to demand for nicotine when you try to adjust behaviour against smokless tobacco use? We have already seen that excessive FDA regulation has caused the vast majority of the vape market to be traded through unauthorised and/or illicit channels. 

If the demand for nicotine is robust, the policy problem is to move to ways of using it that are much less harmful than the dominant method, smoking tobacco. ST, responsibly manufactured and marketed, is one such option.

Amen.

 

 

 

 

 

Current Tobacco Prohibition in U.S. Prisons Would Violate the Geneva Convention, As It Treats Incarcerated Americans Worse than Wartime POWs

 

The U.S. Federal Bureau of Prisons in 2015 finalized a rule prohibiting inmate “possession of smoking apparatus and tobacco in any form.”  Nine years earlier, the Bureau had discontinued tobacco sales at prison commissaries.  

Announcing the final rule, Bureau officials discounted the issue of black market activity, saying that the agency’s staff was already trained to intercept contraband, so the addition of tobacco involved zero “additional burden.” They promised to increase searches of Bureau employees to assure that they don’t become contraband sources, and to impose “more severe inmate sanctions for violations” to deter “possession of tobacco products.” 

Such measures are destined to fail, as the Mississippi Department of Corrections discovered.  Three years ago, that agency abandoned its tobacco ban (here), reporting that prohibition had created an underground market that saw inmates paying “as much as $500 a pound” for cigarette tobacco.  The new policy, the commissioner said, “will save [them] money and the state will make money,” and, “By selling [cigarettes], we are breaking the contraband tobacco trade, designating smoking areas outside, clearing the air inside for the majority of inmates who don’t smoke, reducing inmate contraband violations, and recouping for taxpayers some of the dollars it takes to run prisons.”

The Federal Bureau of Prisons wrongly claimed that its rule would not affect prisoners with mental illness, citing a 2002 review that it said found, “It was no more difficult for the mentally ill to quit smoking than it was for someone with no mental disorder.”  To the contrary, the authors of that study acknowledged, in a gross understatement, that “quit rates of psychiatric populations may be lower than those of nonpsychiatric populations.”  There is overwhelming evidence that people with serious psychological disorders smoke more and have great difficulty quitting (here, here, here, here, and here). 

Clearly, prison bans of tobacco products ignore both science and economics, but the Bureau’s prohibition, as well as countless local and state prison tobacco bans, would also violate international humanitarian standards if the bans were applied to prisoners of war.

According to Army Lt. Colonel Frank Rosenblatt (Ret), military law expert and Assistant Professor at the Mississippi College School of Law, the Third Geneva Convention of 1949 is an international treaty regarding the treatment of prisoners of war, and it was ratified by nearly every nation, including the United States. Here's what it says about tobacco:

“Canteens shall be installed in all camps, where prisoners of war may procure foodstuffs, soap and tobacco and ordinary articles in daily use. The tariff shall never be in excess of local market prices.”

If enemy combatants are entitled to tobacco as an element of humane treatment, why shouldn't the same standard apply to incarcerated Americans?   

A second aspect to the Bureau’s prohibition also violates human rights.  The Bureau’s rule banned snuff and chewing tobacco on the grounds that they “are also harmful to health in the same way that ‘lighted’ tobacco products are.” (emphasis added)  Not only was this proven false 30 years ago (here and here), but eminent tobacco researcher Lynn Kozlowski demonstrated two decades ago that “no safe tobacco product” themes widely promoted by anti-tobacco extremists “are so uninformative that they constitute a violation of [a fundamental] right to health relevant information on tobacco.”   

The sweeping and pervasive prohibition of all tobacco products across federal, state and local penal institutions violates international humanitarian standards and the rights of 1.8 million incarcerated Americans.