Tobacco Harm Reduction as the Basis for Tax Policy in Indiana & Kentucky

On April 29, 2011, Indiana became the second state in the U.S. to officially recognize tobacco harm reduction. Governor Mitch Daniels signed into law HB 1004 (available here), which states: “The Indiana general assembly finds that the tax rate on smokeless tobacco should reflect the relative risk between such products and cigarettes.”

This is a landmark event. It sets the stage for the state to develop a rational excise tax policy for tobacco products -- something I have advocated since 2003. That year, I proposed that smokeless tobacco products and cigarettes should be taxed according to risk, in order to provide an economic incentive for smokers to transition from high risk/high tax cigarettes to very low risk/low tax smokeless products. My commentary was published by newspapers in Tallahassee and Tampa, Florida (here and here and St. Louis (here).

On March 23 of this year, I provided expert testimony at a hearing of the Indiana Senate Committee on Public Policy, which was considering HB 1405, a bill to appropriately classify dissolvable tobacco products. That legislation (here) was also passed by the legislature and signed by the governor. My prepared testimony is available here.

Indiana is the second state to recognize the roles that tobacco harm reduction and tobacco excise tax policy can play in promoting public health. In 2005, the Kentucky General Assembly passed and Governor Ernie Fletcher signed into law a bill recognizing that:

“increasing taxes on tobacco products should reduce consumption, and therefore result in healthier lifestyles for Kentuckians. The relative taxes on tobacco products proposed in this section reflect the growing data from scientific studies suggesting that although smokeless tobacco poses some risks, those health risks are significantly less than the risks posed by other forms of tobacco products. Moreover, the General Assembly acknowledges that some in the public health community recognize that tobacco harm reduction should be a complementary public health strategy regarding tobacco products. Taxing tobacco products according to relative risk is a rational tax policy and may well serve the public health goal of reducing smoking-related mortality and morbidity and lowering health care costs associated with tobacco-related disease.”

The idea of a rational risk-based tobacco tax is clearly gaining momentum in policy circles. Earlier this year, the National Center for Policy Analysis, a nonprofit, nonpartisan public policy research organization, issued a report titled “Taxing Tobacco By Risk.” That document, available on the NCPA website (here), discusses tobacco harm reduction as a basis for tax policy and concludes: “States that wish to pursue a consistent and science-based tobacco harm reduction strategy should examine the way in which they tax tobacco products and the amount of tax levied on these products.”

In 2003, I wrote: “When it comes to taxes there are no easy answers. But a rational tobacco tax strategy based on risk is as compelling as it is innovative, because it allows lawmakers to meet their fiscal responsibility while fulfilling their moral obligation to help smokers who are desperate to quit.”

Indiana and Kentucky have admirably adopted this compelling and innovative strategy; other states will be wise to follow.

Misinformation from the Dana-Farber Cancer Institute and the Massachusetts Dental Society

The list of prestigious medical organizations that exaggerate and distort the risks of smokeless tobacco is growing longer. On May 12, the Dana-Farber Cancer Institute, “a principal teaching affiliate of the Harvard Medical School and… among the leading cancer research and care centers in the United States,” and the Massachusetts Dental Society, “a 5,000-member professional association… dedicated to improving the oral health of the public in the Commonwealth,” released demonstrably false information about smokeless tobacco risks (article here).

The Dana-Farber article says that these organizations “are partnering to spread the word that chewing tobacco, otherwise known as spit, dip, chew, or smokeless tobacco, is not a safe alternative to smoking.” Using an “absolutely safe” straw-man standard is now standard fare among smokeless prohibitionists.

The most egregious misinformation comes from Dr. David P. Lustbader, an oral surgeon: “Chewing tobacco is the most dangerous form of tobacco because it comes in contact directly with the oral mucosa.” Dr. Lustbader ignores the reams of medical literature irrefutably identifying cigarettes as “the most dangerous” of tobacco products.

Dana-Farber’s Dr. Marshall R. Posner does no better, saying, “Nicotine and the other tars in chewing tobacco change the cells throughout the mouth and tongue and lead to cancer.” First, nicotine does not “lead to cancer.” Second, nicotine is not a “tar.” Third, there are no “tars” in chewing tobacco. What was he smoking?

I emailed the director and associate director of media relations at the Dana-Farber Cancer Institute, detailing the misinformation in the press release and requesting a correction. No response or correction was forthcoming.

Dana-Farber (here) claims to “pursue excellence relentlessly and with integrity in all that we do, adhering always to the highest standards of conduct,” and the Massachusetts Dental Society is dedicated to “promotion of the highest professional standards.” These values are betrayed by the pernicious pronouncements about smokeless tobacco by their purported experts.

National Cancer Institute Funds Camel Snus Quit-Smoking Study

Opponents of tobacco harm reduction have portrayed that public health strategy as a marginal approach to smoking cessation that is neither legitimate nor credible. Finally, that specious position may be convincingly undermined, by no less an authority than the National Cancer Institute. The NCI is funding a study, based at the Medical University of South Carolina, that will evaluate the impact of Camel Snus in a nationwide randomized clinical trial among 1,250 smokers who are not motivated to quit.

The trial will run for one year, although the grant is active until 2016 (description here); the NCI has provided over $400,000 for the current fiscal year. The research is being directed by Matthew Carpenter, a psychiatrist at MUSC who previously published a pilot study demonstrating that Ariva and Stonewall dissolvable tobacco products are effective cigarette substitutes (described in this blog last January, here).

As with any clinical trial, outcomes will depend on the trial’s design; so far, few details are available. Will participants be provided with accurate information about the vastly lower health risks of Camel Snus? The answer isn’t clear, because the public description of the trial uses ambiguous terms. For example, Carpenter states that “a comprehensive risk profile [for smokeless tobacco] remains unclear”, despite numerous epidemiologic studies documenting minimal risks. In addition, he states, “The tobacco industry has developed a number of novel smokeless tobacco products that are purported to offer reduced health risks as compared to conventional cigarettes.” This implies that “reduced health risks” are unsubstantiated industry allegations; in fact, they are established scientific fact.

Carpenter describes the trial: “A population-based, nationwide sample of smokers will be proactively recruited through established methods, consented to enroll in a telephone-based cessation induction trial, and randomized to either a) provision of Camel Snus, or b) not.”

We don’t know how smokers will be recruited or enrolled, but we do know they will be randomized to receive Camel Snus, or not. While it is routine to offer one “treatment” in a clinical trial, this presents many problems when the outcome is a behavior. How do you study a product that is already available in stores nationwide? Will smokers who don’t receive Camel Snus be denied a product that is 98% safer than cigarettes? Will smokers who receive Camel Snus know its name? Will the products be provided free, or will smokers have to buy them? Which flavor of Camel Snus will be used? What happens if participants prefer another flavor, or prefer another smokeless product?

Previously, Carpenter found that Ariva and Stonewall had great potential as smoking cessation aids, but now only Camel Snus is being tested. If this trial is not a success, it may mean only that smokers are not enamored of Camel Snus.

Despite these questions, this trial is a landmark development for tobacco harm reduction. Its funding by the National Cancer Institute sends an unequivocal message that informing smokers about safer smokeless substitutes is ethical, credible and worthy of serious consideration.

Huffington Post Suppresses Tobacco Truth

In his Huffington Post blog on April 18, Dr. Glenn Braunstein penned “Chew on This: The Real Dangers of Smokeless Tobacco.” (available here) Dr. Braunstein is professor and chairman of the Department of Medicine at Cedars-Sinai Medical Center in Los Angeles.

The “dangers” he described are demonstrably fictitious. Compounding this offense, Dr. Braunstein subsequently violated HuffPo blog moderating rules by removing my April 19 reasoned and fact-driven comment, which read:

“It is regrettable that Dr. Braunstein used the Huffington Post to misinform Americans about smokeless tobacco.

“Dr. Braunstein: ‘Contrary to popular belief, ingesting [smokeless] tobacco carries risks just as serious and severe as smoking.’ This ignores numerous scientific studies documenting that smokeless tobacco use is 98% safer than smoking. Smokeless does not cause lung cancer, heart disease or emphysema, and the risk for mouth cancer is far lower than with cigarettes. Statistically, smokeless users have about the same risk of dying from mouth cancer as automobile users have of dying in a car wreck.

“Dr. Braunstein goes even further, suggesting that ‘…ingested tobacco may be even more dangerous than cigarettes...’ because of nicotine. This is grossly misleading. All tobacco products have roughly the same nicotine content and produce about the same blood levels. More importantly, nicotine does not cause any smoking-related disease.

“Dr. Braunstein’s comments are at odds with the viewpoint of prominent tobacco research and policy professionals. A group of leading tobacco experts in 2004 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.’

“The established scientific and medical literature on tobacco harm reduction clearly refutes the major objections raised by Dr. Braunstein concerning modern smoke-free tobacco products.”

My comment appeared just long enough on HuffPo to elicit a supporting comment from another reader: “I agree with Dr. Rodu. I'd like to see Dr. Braunstein's reponse to Dr. Rodu's points, though we probably won't. As a dentist, I encourage those who use smokeless to quit, but not by giving them false information. The information in this article is very very misleading.”

According to Dr. Braunstein’s HuffPo biography, he is an endocrinologist with an interest in the treatment of thyroid cancer and in male and female reproductive endocrinology; he has no apparent expertise in tobacco issues. His blog entry on the subject closely aligns with smokeless tobacco misinformation issued in the past by the leading tobacco-prohibitionist organizations (Campaign for Tobacco Free Kids and others).

HuffPo says on its site that its mission is “to promote an open and transparent conversation.” But allowing Dr. Braunstein to erase a fair and factual rejoinder to his unfounded remarks violates that tenet, and disserves the public interest.

Kudos to the FDA: E-Cigarettes Are Tobacco Products

On April 25, the FDA abandoned its claim that e-cigarettes are drug delivery devices. In an open letter published on the agency’s website (here), Tobacco Center Director Lawrence Deyton and Drug Center Director Janet Woodcock acknowledged that e-cigarettes are tobacco products and would be subject to regulations under the 2009 Tobacco Act. This is consistent with the January 2010 decision by federal judge Richard Leon (discussed here).

This is a victory on several counts for smokers and for our nation’s public health. First, the FDA decision guarantees that e-cigarettes, which have helped many smokers quit, will remain on the market.

Second, as the Deyton-Woodcock letter indicates, FDA regulation of e-cigarettes will subject them “to general controls, such as registration, product listing, ingredient listing, good manufacturing practice requirements, user fees for certain products, and the adulteration and misbranding provisions, as well as to the premarket review requirements for ‘new tobacco products’ and ‘modified risk tobacco products.’” These requirements will promote the marketing of safe and quality-controlled products.

Finally, this decision could allow pharmaceutical companies to reposition nicotine medicines as recreational alternatives to cigarettes. Today, these products are sold with a therapeutic claim for smoking cessation, but they are expensive, unsatisfying and FDA-approved only for temporary use (10-12 weeks). That accounts for their dismal success rate of only seven percent among smokers (evidence here). I believe pharmaceutical companies should enter the recreational nicotine market with products that satisfy smokers indefinitely and are cheap enough to compete directly with cigarettes. Clearly, the tobacco industry is poised to compete in this new market -- Reynolds American owns Niconovum (here) and British American Tobacco recently formed Nicoventures (here).

In my 1995 book “For Smokers Only” (description here), I shared my perspective on recreational nicotine for smokers:

“Smokers derive a lot of pleasure from smoking tobacco. You may be reading this book because you or your loved one actually enjoys lighting up a cigarette and taking several deep puffs. A smoke may be especially welcome when you are in a stressful situation or when you need to relax. Or you may enjoy smoking when you need to concentrate on a difficult problem at work or at home. Cigarette smoking can activate that mental pressure-relief valve, which is followed by the feeling that the problem can be solved, the crisis will pass. These feelings are real, and not just a figment of your imagination.

“Many tobacco opponents claim that these sensations are not truly pleasurable, but are merely the satisfying of induced cravings and avoidance of withdrawal symptoms. One of the big advantages of the smokeless tobacco solution is that it addresses either view of smoking equally well. That is, it doesn't matter if you are a smoker who is unwilling to quit because you enjoy tobacco, or if you are unable to quit because of nicotine craving and withdrawal. Because in either case you recognize the potential life-shortening effects of this nicotine delivery system. In either case the smokeless tobacco solution can work for you.”

Smoking has been the problem; smoke-free tobacco and nicotine can be the solution. In making the right call on e-cigarettes, the FDA has facilitated that solution.

Nicotine Delivery and Satisfaction: Snus is Superior

In a small, but impressive, clinical study just published in Nicotine & Tobacco Research, Drs. Erik Lunell and Margareta Curvall demonstrate that snus is a superior substitute for delivering satisfying nicotine doses to smokers (abstract here). Dr. Curvall is a scientist employed by Swedish Match.

Lunell and Curvall recruited 15 smokers (9 men, 6 women) who had never used snus or nicotine gum to use two snus 1-gram snus products (in packets) and 4-milligram nicotine gum during three visits to a clinic in Helsingborg, Sweden. The subjects abstained from smoking for 12 hours the night before each visit.

The researchers measured the amount of nicotine in the used products and found that a higher proportion was extracted from the gum than from the snus products. This is understandable, because the gum was chewed, while the snus was simply placed under the upper lip. Nevertheless, blood nicotine levels from snus were higher after 30 minutes than those from the gum, and the increases were also faster for snus. The snus products took less time than the gum to deliver the maximum nicotine level (37 versus 46 minutes), but the differences were not statistically significant.

The most important finding was that the snus products had higher subjective scores than the gum for overall “product strength” (also referred to as “head rush”, “buzz” or “hit”). This means that the snus products were more enjoyable than the gum, even though all products reduced the craving or urge to smoke to about the same extent. Another interesting finding is that snus resulted in significantly less mouth and throat burn than the gum five minutes after use.

Lunell and Curvall concluded “that Swedish snus produces a higher maximum blood nicotine concentration, in shorter time and with a quicker onset of ‘head rush’ in smokers naïve to snus, compared with the 4 mg [nicotine] chewing gum in spite of a smaller ingested dose…The quicker onset of ‘head rush’ and supposedly higher satisfaction from snus may partly explain the widespread use of snus in Sweden in attempts to stop smoking.”

This study is additional proof that smokeless satisfies smokers.

Smoking Gun: Manipulating Definitions

A report just published in Nicotine & Tobacco Research (abstract here) draws an obvious conclusion: How surveys define cigarette smokers and smokeless tobacco users influences the prevalence rate of dual use (consumption of both products).

Robert Klesges and colleagues used information obtained from Air Force recruits to show that if dual users are defined as using both products daily (a narrow definition), prevalence of dual use will be low. However, if dual users are defined as using either product once in the past month (a broader definition), prevalence of dual use will be high.

It is not surprising that Dr. Klesges found that defining tobacco use influences survey results. In 2001, he co-authored a study (with first-author C. Keith Haddock, abstract here; hereafter called Haddock-2001) that perfectly demonstrates how definitions can be manipulated to produce desirable results. Haddock-2001 purported to show that smokeless tobacco use is a gateway to smoking among Air Force recruits; it has been widely cited in American prohibitionist attacks on smokeless tobacco. In fact, its results are based on manipulation of definitions.

Haddock-2001 studied 14,340 men (average age, about 20 years) who had never smoked when they reported to Air Force basic training in 1995 and 1996. After one year, Dr. Haddock followed up with 7,865 subjects, finding that 1,099 of them were smoking. That’s a 14% smoking initiation rate among 20-year old men after one year in the Air Force! At one year, Haddock-2001 also found that, compared with recruits who had never used tobacco before basic training, recruits who were current smokeless users were 2.33 (95% Confidence interval = 1.84 – 2.94) times more likely to be smoking.

First, how did 14% of first-year never-smoking Air Force recruits start smoking? It turns out that this number is grossly inflated. In 1999, Drs. Klesges and Haddock had published a study of these same recruits (abstract here; hereafter called Klesges-1999), in which they reported that only 8% of never smokers had started to smoke after one year in the Air Force.

The discrepancy between Haddock-2001 and Klesges-1999 is due to differences in the category definitions of smoking, summarized in this table.

Different Definitions of Smokers in Klesges-1999 and Haddock-2001
Category	Klesges-1999	Haddock-2001(%)
At Enrollment
Never Smoker	Never smoked a cigarette	Never Smoked regularly
Experimental Smoker	Smoked on one or two occasions, never regularly	Not mentioned
Ex-smoker	Smoked regularly, but quit	Smoked regularly, but quit
Current Smoker	Smoked regularly, at least one cigarette per day	Smoked regularly, at least one cigarette per day
At One Year
Current Smoker	Smoked even a puff in last 7 days	Smoked even a puff in last 7 days

At enrollment, Klesges-1999 identified a group of “experimental smokers,” 26% of whom became smokers at the one-year follow-up. But Haddock-2001 never mentioned experimental smokers, which means that they were in the “never-smoking” group at enrollment; that significantly accounts for the 14% initiation rate, instead of the 8% rate found in the Klesges-1999 report.

It is likely that many Haddock-2001 smokeless tobacco users were also experimental smokers. The only apparent reason to eliminate the experimental smoker category and effectively shift those subjects to the never-smoking category was to bolster the case for labeling smokeless tobacco use as a gateway to smoking.

Dr. Haddock also defined current smoking differently at enrollment than after one year of follow-up. Good practice in scientific investigation is to establish definitions and stick with them throughout a research project. As the table shows, Haddock-2001 defined a current smoker at enrollment as smoking at least one cigarette per day, but then defined a current smoker at one-year as someone who smoked even a puff in the last 7 days.

The manipulation of smoking definitions in Haddock-2001 casts considerable doubt on its claim that smokeless tobacco use is a gateway to smoking.