New England Journal of Medicine Promotes Failed Policies for Smoking Control

The New England Journal of Medicine on September 29 published a commentary (here) promoting “total abstinence” with behavioral therapy and medicines, a strategy that has failed to help over 90% of smokers who tried to quit. The article, by Michael Fiore and Timothy Baker of the University of Wisconsin, reflects the nation’s dual obsession with smoking as a disease and nicotine- and tobacco-abstinence as the only cure.

Fiore and Baker use the terms “smoking” and “tobacco use” synonymously. They write, “more than 30% of deaths from cancer, 90% of cases of COPD and 30% of cases of cardiovascular disease in the United States are attributed to tobacco use…Tobacco use remains the chief avoidable cause of death in the United States…”

That is demonstrably false. Tellingly, in the next sentence they drop the phrase “tobacco use” and correctly use the word “smoking.” I have previously described the unfortunate consequences of such deliberate misinformation (here).

While Fiore and Baker advise health professionals to “note the effectiveness of seven FDA-approved medications for smoking cessation,” they acknowledge that a meta-analysis documented that the abstinence rate for nicotine medicines was a mere 9% at six months -- a 91% failure rate. Despite these dismal statistics, Fiore and Baker use the words “effective” or “effectiveness” at least 10 times in describing quit-smoking medicines. Interestingly, they write that patients don’t use medicines because they believe them to be “dangerous” and “ineffective.” Although smokers incorrectly believe that nicotine medicines are dangerous, they are correct in believing that they are largely ineffective.

Anti-tobacco extremists and most journal editors continue to ignore the scientific evidence for tobacco harm reduction, but some medical journals are putting it front and center (here). It is unfortunate that the New England Journal of Medicine devoted 10 pages to a misleading abstinence-only screed.

International Sports Monitoring Agency: Nicotine, Smokeless Tobacco May Enhance Performance

The World Anti-Doping Agency (WADA), an international agency composed and funded by sport organizations and governments, on September 27 announced it will “monitor the effects nicotine can have on performance when taken in oral tobacco products such as snus,” starting in 2012 (here). This followed publication of a report from the agency’s laboratory on over 2,000 urine samples from athletes in 43 sports. The report, by François Marclay and colleagues at the University of Lausanne in Switzerland, is abstracted here.

The research measured exposure to and active use of nicotine by athletes. While the prevalence of active use was only 15%, the authors noted high prevalence in some sports, included in this table:

Active Nicotine Consumption Among Athletes
Sport (No. of samples)	Active Consumers (%)
American football (19)	56
Basketball (24)	25
Biathlon (38)	18
Bobsleigh (38)	31
Football (soccer) (205)	19
Gymnastics (48)	29
Ice hockey (108)	32
Rugby (25)	28
Skating (41)	20
Skiing (143)	26
Volleyball (46)	20
Wrestling (31)	32

Marclay wrote that these results provide “alarming evidence” about nicotine consumption among athletes. But the report had no information about the athletes who were tested, and the number of samples was minuscule. For example, Marclay’s claim that 56% of American football players actively used nicotine was based on only 19 samples. There are over a million football players at the high school level in the U.S., thousands at the college level, and hundreds in the NFL, and there are 18 other countries with American football leagues. The most alarming aspect of this report is that it made sweeping claims based on very little evidence.

Marclay wrote that “…smokeless tobacco is a very attractive drug from a doping perspective, considering the performance enhancement pharmacological properties of nicotine and the absence of direct adverse effects on the respiratory tract.” Nicotine “exhibits a variety of pharmacological properties sought-after by consumers,” and it “results in vigilance and cognitive function enhancement together with relaxation, reduced stress, mood modulation and lower body weight.”

These effects are well known among tobacco users, but Marclay cited no authority for the claim that these properties enhance performance to an extent that justifies prohibition in sports. In fact, Marclay acknowledged that “the frontier between recreational consumption and use for doping purpose is difficult to ascertain with social drugs, including nicotine, caffeine or tetrahydrocannabinol (THC)[marijuana].” Would Marclay and WADA ban caffeine along with nicotine?

In trying to tie smokeless tobacco to performance enhancement, Marclay offered a startling non-sequitur: “Since smoking may be responsible for noticeable respiratory effects and numerous health threats detrimental to sport practice at top level, likelihood of smokeless tobacco consumption for performance enhancement is a hypothesis of very serious concern.” Simply put: Smoking is very bad, so smokeless tobacco must be a performance enhancer. The association of these two very different products in this manner defies logic.

Marclay was especially concerned about athletes involved in winter sports. Citing his own work (abstract here), he wrote that “a recent study on the 2009 Ice Hockey World Championships brought alarming findings as active nicotine consumption before or/and during the games was highlighted for about half of the athletes.”

If WADA rules eventually that smokeless tobacco and nicotine enhance athletic performance, it will refute tobacco prohibitionists’ persistent claim that tobacco provides no tangible benefits to consumers. As I have written (here), “It’s time to be honest with the 50 million Americans, and hundreds of millions around the world, who use tobacco. The benefits they get from tobacco are very real… It’s time to abandon the myth that tobacco is devoid of benefits, and to focus on how we can help smokers continue to derive those benefits with a safer delivery system.”

British Government Endorses Tobacco Harm Reduction, E-Cigarettes

The British Cabinet Office’s Behavioural Insights Team (BIT), or the “nudge unit”, as the year-old high-level group is called, strongly endorsed tobacco harm reduction in its first annual report (read the report here).

The BIT’s mission is “to find intelligent ways to encourage, support and enable people to make better choices for themselves.” The unit reported that “smoking remains the biggest preventable cause of death in the U.K., killing over 80,000 a year in England alone,” and that “treating smoking-related diseases costs the [National Health Service] £2.7 billion each year in England.”

BIT observed: “A review by the [British] Medicines and Healthcare products Regulatory Agency concludes that ‘nicotine, while addictive, is actually a very safe drug.’ BIT is working with [the U.K. Department of Health] on how to encourage smokers to substitute to safer but nonetheless appealing sources of nicotine, noting that products that produce a fine vapour appear to reproduce the pleasant ‘hit’ without the harms associated with smoking.”

This statement is remarkable. It confirms what I have been reporting for over 17 years: Nicotine, “while addictive, is a very safe drug.” BIT observes that nicotine is a recreational drug that can be used safely, like caffeine and alcohol, and notes that there are efforts to get smokers to substitute “safer but nonetheless appealing sources of nicotine”. E-cigarettes are cited as potentially effective substitutes because of their behavioral attributes.

This positioning by such a high-level entity should significantly advance tobacco harm reduction initiatives on a global scale. U.S. regulatory authorities, in particular, should take note. For the British government, the challenge now is to translate concepts into practical applications. Although e-cigarettes are widely available in the UK, snus and other smoke-free products remain under an EU ban. As awareness of the benefits of tobacco harm reduction increases, British smokers will rightfully demand access to the full range of smoke-free products that are available in Sweden and the U.S.

State-Wide Smoking Bans: Little to No Impact on Heart Attack Deaths

My research group just published a study documenting that the implementation of state-wide smoking bans in California, Utah, Delaware, South Dakota, New York and Florida had little or no immediate measurable effect on deaths from heart attack (acute myocardial infarction, AMI). The study was published in the Journal of Community Health (here).

Nicholas Peiper, Phil Cole and I studied the AMI death rate in those states before and after smoking bans were implemented, comparing those rates to historical and national trends. The results are illustrated in the figure.

The state-wide bans had no effect in California, Utah, Delaware or South Dakota (the AMI death rate actually increased almost 9% in South Dakota during the target year). But after bans in Florida and New York in 2003, AMI death rates declined 9% and 12% respectively, which exceeded the expected declines based on historical trends in those states. However, they were not significantly different from the 10% decline in the 44 states that did not have smoke-free ordinances in 2004.

Since 2004 several published reports have claimed that smoking bans in small cities result almost immediately in reductions in heart diseases. For example, in Helena, Montana hospital admissions for acute myocardial infarction (AMI) declined 40%, from 40 before to 24 after implementation of a smoke-free ordinance (here). In Pueblo, Colorado, AMI admissions dropped 27%, from 399 before to 291 over a 1.5-year period following a ban, and the authors reported that the decline occurred “within months” of implementation (here). In Bowling Green, Ohio, hospital admissions for ischemic heart disease and heart failure fell from 36 before to 22 after a ban (here), and in Monroe County Indiana, hospital admissions for AMI among non-smokers declined from 17 before to 5 after a ban (here).

But there are two problems with these claims. First, it’s dangerous to make big claims based on tiny numbers. Phil Cole and I presented evidence that the Helena and Pueblo findings “are consistent with random variation because of the small number of observations on which they are based.” (here).

Second, none of the previous reports accounted for the long-term downward trend in heart disease in the U.S. In our study smoking bans might have taken the credit for the 9% decline in Florida and the 12% drop in New York if the historic drop in AMI that occurred throughout the U.S. in 2004 was ignored. The figure above shows the impressive decline in American heart attack deaths since 1991.

We concluded that “Smoke-free ordinances may serve public health objectives by providing non-smokers with indoor environments that are free from irritating and potentially harmful pollutants. However, this study does not provide evidence that these ordinances result in a measurable immediate reduction in AMI mortality of the magnitude claimed by reports based on very small incident numbers.”

Switch and Quit Owensboro (Kentucky)

A University of Louisville public health initiative is reaching out to thousands of adult smokers in Owensboro, encouraging them to quit with assistance from the unlikeliest of sources — tobacco. The “Switch and Quit Owensboro” campaign is based on scientific evidence that switching from cigarettes to smoke-free tobacco products provides almost all of the health benefits of complete tobacco abstinence.

Switch and Quit Owensboro is the first community-based quit smoking program based on principles of tobacco harm reduction. Switching to a safer form of tobacco that satisfies smokers’ addictive desire for nicotine helps smokers quit cigarettes, and gain longer and healthier lives.

The campaign includes print, radio, billboard, social media and cinema public service messages. It is aimed primarily at adult inveterate smokers -- those who are unable or unwilling to quit using conventional approaches that emphasize total tobacco abstinence.

At the start of the campaign, an astounding 15,000 cartons of cigarettes were sold per week in Owensboro/Daviess County. Cigarette sales should decline when smokers learn about safer, satisfying smoke-free substitutes. Visit the campaign website here.

Switch and Quit Owensboro is a program of the University of Louisville James Graham Brown Cancer Center, which is committed to the prevention and treatment of cancer. The campaign aims to prevent the estimated 220 smoking-related deaths that occur in Owensboro and Daviess County, Kentucky every year.

How Many Americans Smoke?

Surprisingly, the answer is either 45.3 million or 52.7 million in 2010, depending on which federal agency does the counting. This wide variance underscores the discordant findings from government smoking data.

National statistics on smoking are provided by two federal surveys, the National Health Interview Survey (NHIS) and the National Survey on Drug Use and Health (NSDUH). I have conducted research on the differences between these two surveys (here) and I previously wrote a blog on the topic (here).

Federal officials released fresh data from both surveys last week, making the discrepancies even more stark.

The Office on Smoking and Health at the Centers for Disease Control and Prevention (CDC) counted 45.3 million American smokers, using the NHIS (available here). This number has not changed much in over 20 years. In 1990, the CDC reported that there were 45.8 million adult smokers. But as the U.S. population has grown, the percentage of smokers has declined. In 1990, smokers made up 25.5% of the adult population; by 2010, prevalence had declined to 19.3%.

The CDC notes that, “If current patterns continue, smoking prevalence is projected to fall to approximately 17% in 2020, and the national Healthy People objective to reduce smoking prevalence to < 12% will not be met.” That’s an understatement. In 1998, the government set 2010 as the target for 12% smoking prevalence (available here). That proved to be a pipedream, and the 2020 goal will prove equally unattainable. One is reminded of Albert Einstein’s definition of insanity: doing the same thing over and over again and expecting different results.

Last week, the Substance Abuse and Mental Health Services Administration, which administers NSDUH, released “selected” 2010 survey information (here). They estimated the number of smokers at a whopping 70 million, including teenagers, but they did not break out the number of adult smokers. The 2009 NSDUH survey reported 52.7 million adult smokers; the 2010 estimate likely will be similar.

It is unacceptable that two federal surveys differ by over 7 million in their adult smoking counts. Even worse is the way the government uses the divergent data to spin different stories about smoking. They use the lower NHIS numbers to boast about declining smoking rates, which they attribute to higher taxes and smoking bans. They use the higher NSDUH numbers to argue for even more onerous anti-tobacco measures.

My research (here) has explored why the NHIS and NSDUH estimates are so divergent. I have called for officials to investigate and resolve these problems so that national tobacco policy can be guided by accurate smoking data.

Insights From E-cigarette Users

When e-cigarette enthusiasts held a Vapefest in Philadelphia in March, Jonathan Foulds, a tobacco researcher at the Penn State University College of Medicine in Hershey, collected information from 104 attendees, using a 55-question survey. Dr. Foulds is the lead author on the resulting manuscript, published by the International Journal of Clinical Practice (abstract here).

About three quarters of the users were men, with an average age of 34 years; almost 80% had not used a traditional tobacco product in the past 30 days. The average duration of smoking was 16 years, and they had smoked an average of 25 cigarettes per day. The average number of quit attempts was nine. Nearly two thirds of e-cigarette users had unsuccessfully tried FDA-approved smoking cessation medications, and three quarters had tried to quit “cold turkey.” Over half had used e-cigarettes for over one year. Most participants planned to continue using e-cigarettes for at least another year; they reported that the average weekly cost was about $13.

The event attendees were e-cigarette enthusiasts, so it is not surprising that few of them used major brands that are widely available in convenience stores (such as NJOY and Smoking Everywhere). These brands have rechargeable batteries and replaceable cartridges. Instead, there was a preference for brands that have larger batteries with an extended life expectancy (eGo, Joye and Riva); the most experienced users preferred even more exotic hardware (Omega, Silver Bullet, Helix).

The findings are informative but not necessarily representative of e-cigarette users generally. However, it is likely that Philly Vapefest participants were inveterate smokers who, by switching to a form of smoke-free tobacco, substantially reduced their risk of contracting a smoking-related illness. Foulds and colleagues acknowledge that “the health risks from smoking are large and are known with certainty. Comparatively, the health risks from e-cig use are likely much smaller (if any) and temporarily switching to e-cigs will likely yield a large health benefit.” However, they inexplicably conclude that “current smokers who are interested in quitting smoking should be strongly directed towards evidence-based treatments (counseling, and approved medicines like nicotine replacement, bupropion or varenicline), rather than to e-cigs.”

Foulds and colleagues write that “we do not know enough about e-cigs to recommend them to patients.” Still, they must know that the “evidence” for evidence-based treatments is not compelling. Nicotine medicines have a 93% failure rate (here), and bupropion and varenicline are fraught with potentially serious side effects (here).

Many health professionals wrongly believe that smoking is an illness requiring treatment. In fact, smoking is a lifestyle choice – albeit an addictive and risky one – for which people need satisfying and safer substitutes. This is the core philosophy of tobacco harm reduction, and of this blog.