Comments on the National Institutes of Health Conference on the State of the Science on Tobacco Use
On June 12-14, the National Institutes of Health hosted a conference in Bethesda, Maryland, titled "State of the Science Conference on Tobacco Use: Prevention, Cessation, and Control." Following the conference, according to the conference program, "an unbiased, independent, panel will prepare and present a State-of-the-Science statement addressing the key conference questions." A draft statement was released on June 14.
I arrived in Bethesda in time to hear the end of one presentation and all of two panels (the second one, the last of the day, addressed smokeless tobacco). Following are my notes from what I heard, some questions I was not able to ask the speakers, and some concluding remarks.
Joseph L. Bast
The Heartland Institute
Cathy Melvin, Ph.D., M.P.H., School of Public Health, University of North Carolina at Chapel Hill, was finishing a presentation on "Increasing Demand for and Use of Effective Tobacco Cessation Treatments Among Individuals." She then participated in Q&A with members of her panel.
What I found striking was her repeated statements that we "lack good research" showing that current methods of intervention with smokers are working. This is also reflected in the abstract of her comments in the conference book. While asserting that "individuals are trying to quit without assistance that can double their changes of success," [p. 59], her review of the literature turns up "very few studies ... no studies ... we did not identify sufficient studies ... very few studies..." on key aspects of which programs are effective, or why.
Most interesting was during Q&A, when she was asked if she supports employers telling their employees they may not smoke while away from work. She said no, that this would be "a violation of their privacy" and an over-extension of the authority of businesses over individuals. She sounded positively libertarian when she said we need to avoid giving institutions "more power over individuals."
Panel 3: What are the Effective Strategies for Increasing the Implementation of Proven Population-Level Tobacco Use Cessation Strategies, Particularly by Healthcare Systems and Communities?
Michael Fiore, M.D., M.P.H., University of Wisconsin, described how "Health System Changes" were necessary to support more cessation strategies. He explained how smokers should be identified in their medical records, hospitals should be required to offer treatment and insurers should be required to pay for it, and most of all how more money was needed to make cessation programs effective. His presentation was "all about the money."
Phillip Gardiner, Ph.D., University of California, lamented how the black community suffers from higher rates of tobacco-related illnesses than the white community. He held up the "California experience" as showing that a concerted and coordinated effort to demonize smoking and smokers could reduce smoking rates. He called for more restrictions on tobacco advertising.
Tim McAfee, M.D., M.P.H., Chief Medical Officer for an anti-smoking group called "Free & Clear," described telephone counseling for smoking cessation efforts ("quitlines"). Quitlines seem to increase the effectiveness of anti-smoking clinics, though it is hard to tell if it is any different from background rates of quitting without help. He lamented that only .5 to 1% of smokers have ever (?) used a quitline and said more money needs to be spent on this.
Panel 4: What is the Effect of Smokeless Tobacco (ST) Product Marketing and Use on Population Harm from Tobacco Use?
Dorothy Hatsukami, Ph.D., University of Minnesota, described new products being introduced, described NNK and NNN, known rodent carcinogens, and documented their presence in smokeless tobacco (ST) products, compared levels of NNK and NNN in conventional ST and the newer products. She documented how levels of NNK and NNN in urine fell when users switched to medicinal nicotine products. She concluded from this that medicinal nicotine products are superior, and said because the negative health effects of ST were probably significant, "regulation of ALL tobacco products" was needed before ST could be given a role in smoking cessation programs. She concluded with a long list of topics on which more research is needed, implying that "we need to know" all these things before allowing ST use to increase.
Critique: Most of her presentation was irrelevant to the policy debate. We know that the mere presence of carcinogens in food and other products is not evidence of a health risk: more than half of all products tested for carcinogens, including many fruits and vegetables, contain chemicals known to cause cancer in rodents. The issue is whether the level of exposure is high enough to constitute a health threat. She presented little or no evidence that it is, and most importantly, no comparison of that risk to the risk of smoking. Notsurprisingly, she did not acknowledge the possible life-saving effects of smokers switching to smokeless tobacco, or the implication of her advice -- that insisting that we must research and regulate ST before "allowing" it to be used as a cessation aide is like signing a death sentence for many life-time smokers.
Lynn Kozlowski, Ph.D., head of the Department of Biobehavorial Health at Pennsylvania State University, said there is consensus that ST poses a lower risk to health than smoking, but disagreement (often vehement, sometimes personal) over how or whether to use ST to help reduce the health hazards of smoking. ST products, he said, are already here, they are legal, and used. This is not a debate about whether to allow a "new" product on the market. Some smokers are and will use ST to quit smoking, "there's no doubt about it." We only debate how many, and whether there are off-setting risks. "If nicotine replacement therapy (NRT) works, ST works."
So why do some people oppose ST? He said there are several reasons. First, because of anti-tobacco convictions and strategies, basically an ideological commitment (he didn't use the word) to an anti-tobacco company mentality that puts this agenda ahead of smokers' health. He deplored that attitude and said we need to focus on the well-being of smokers. Second, the desire to avoid a repeat of the low-tar cigarette fiasco -- telling people low-tar cigarettes were "safer" only to see a large increase in people smoking light cigarettes. He said the ST phenomenon is fundamentally different, there is no parallel, because ST is so dramatically safer.
Third, some people want to wait until it is regulated and studied. He mentioned the "precautionary principle" and warned that delay costs lives, "there is urgent need for action now." Fourth, there are scientific concerns: will it lead to dual use? (not likely he says, and it hardly matters); will it entice new people to use nicotine? (an "off-point" argument, he said, we should focus on tobacco-related diseases; moreover, if ST is 95% safer than smoking, the population using ST would have to be 400% greater than the current population of smokers before the risk comes out the same ... impossible), will it be a gateway to smoking? (his own research says no, he thinks there is no agreement or consensus on this point, "there are data on both sides"), do we need more regulatory authority? (maybe, but what if the regulatory authority never comes? we should not wait for politics to resolve the matter).
His policy recommendations were to raise taxes on tobacco products but varythem according to risk, with cigarettes taxed most, ST less, and medicinal nicotine lowest or not at all. Doing so could make ST a gateway from cigarettes rather than vice versa. He also called for accurate and responsible information and labels, avoiding scare tactics; treating ST as one of several options for NRT; other NRTs, he pointed out, are not fun to use; we should not do nothing ... the cost of inaction is high.
He ended by saying "hypothetical, uncertain, and remote risks should not stand in the way" of advancing urgent public health policies.
Critique: I found myself agreeing with most of what Kozlowski was saying. He was the only speaker to explicitly address the dramatically different fatality rates for smoking and using ST, and to challenge the anti-tobacco first, pro-public health second attitude of so many self-proclaimed public health advocates. My only objection is to his call for higher taxes on tobacco products. W. Kip Viscusi and other experts observe that smokers already pay more, in excise taxes and through the MSA, than whatever cost they impose on the rest of society. Claims to the contrary ignore the fact that smokers assume the risk -- surveys show they actually over-estimate the risk to their health posed by smoking -- so the costs they absorb personally are not "social" costs -- or assume that smokers would NEVER DIE if they didn't smoke. Why, if tobacco products are already over-taxed, should they be taxed even more?
Scott Tomar, D.M.D., Dr.P.H., University of Florida College of Dentistry and Behavioral Science, said "the scientific evidence is strong that the use of snuff can cause cancer in humans," but never once compared that risk to the risk of smoking, or even translated the risk into current or projected fatalities. He repeatedly tried to rebut the "Sweden experience" (where rising use of ST was accompanied by dramatic reductions in lung cancer rates) by observing that women's smoking and lung cancer rates experienced a fall similar to that of men, but women did not use snus ("snus" is the most widely used type of ST in Sweden). He also cited survey data indicating that relatively few smokers say they used snus to stop smoking, or used it instead of smoking. He pointed to U.S. data also suggesting no correlation between ST use and less smoking, and in fact quite a lot of evidence to the contrary. A couple of times in a hurried presentation he acknowledged that snus seems to lead everyday smokers to become "someday" (less frequent) smokers ... and cited a study showing the percentage of smokers who became someday smokers was twice as high among snus users (14.6%) as non-snus users (6.3%). Also, people who used snus reported smoking fewer cigarettes per day -- 11 versus 18.
Critique: Tomar relies to much on the male-female difference in use of snus in Sweden to offer a serious criticism of the Swedish experience. If women are reluctant to use snus, and so found other ways to quit smoking, that does not contradict the hypothesis that men are using snus to quit smoking or to smoke less. Like Hatsukami, Tomar also dodged the most obvious and important question in the ST debate: are the adverse health effects of ST greater than the positive health effects of reducing the number of cigarettes smoked per day? If widespread use of ST in the U.S. were to lead everyday smokers to smoke an average of 7 fewer cigarettes per day, as his own data suggest, my quick arithmetic suggests this would result in 100 billion fewer cigarettes smoked in the U.S. per year. Wouldn't that be a dramatic victory for public health?
Leah Ranney, Ph.D., a research associate at the University of North Carolina at Chapel Hill, presented a hurried report on her computer-assisted review of the literature and concluded there was little reliable evidence indicating that ST was being used successfully to encourage cessation. Part of her methodology was, apparently, to reject any case study that did not include six-month follow-ups in their abstracts.
Critique: One of the themes of this conference is that there is insufficient evidence to support most, maybe all, of the current techniques used to prevent or end the use of cigarettes, so it is
no surprise that the data on ST fails to reach that threshold. It seems to me that the threshold she sets for ST is higher than what is used to justify programs that currently involve hundreds of millions of dollars of spending per year.
I did not observe all of the panels, though I did read the abstracts submitted by all of the presenters. I recognized many of the names of people on the program as prominent researchers and anti-smoking advocates. I believe the conference lived up to its goal of showcasing the "state of the science" on tobacco use, prevention, cessation, and control. But my own summary of the conference's findings is much different from that of the "independent panel."
All told, billions of dollars are being spent every year trying to prevent and reduce tobacco use, yet we know relatively little about why some techniques work and some don't. We know that most techniques simply don't work, and only a small fraction of people who stop smoking avail themselves of "professional" assistance.
Like many other "public" interest groups, the smoking cessation movement has developed its own interests and agenda that are increasingly at odds with the people it professes to be helping. There was little apparent recognition of why smokers smoke, whether smokers recognize the health risks that smoking brings, or how taxes and higher prices affect their access to health care and other goods and services. I wasn't surprised, then, that the cessation advocates' preferred methods of intervention had such low success rates, or that most of their programs amounted to punishing smokers instead of helping them.
I do not doubt that there are many well-intentioned and talented people working to reduce smoking rates in the U.S. in order to extend lives and avoid pain and suffering due to smoking-related illnesses. But even talented people can overlook important facts and realities that stand in the way of ideological goals and career self-interest. The clearest evidence that this is occurring in the anti-smoking movement is in its response to smokeless tobacco.
Lynn Kozlowski was exactly right to say that if the goal is to advance public health, it is wrong to raise "hypothetical, uncertain, and remote risks" as reasons to oppose a product that is known with some certainty to be dramatically less dangerous than one now being widely sold and promoted. It is plainly the case that some anti-smoking advocates would rather see smokers die than switch to another tobacco product, rather than use their slightly safer "medicinal nicotine products" that aren't, as Kozlowski once again correctly said, fun to use.
About midway through the panel on smokeless tobacco, I fought the urge to step outside to smoke. I had smoked before passing through security at an airport early in the morning, and now it was 5:00 p.m. I popped into my mouth a little pouch of mint-flavored tobacco and tucked it up into my cheek with my tongue. It was so small as to be unnoticeable to the person sitting next to me in the lecture hall, and (I'm told) it delivered about as much nicotine as a cigarette. I enjoyed the flavor. With its help I didn't smoke again that day until late in the evening.
I wondered if I was the only person in that lecture hall using the very product being discussed by the "experts." I think I probably was. That's one reason the smoking cessation movement won't achieve its goals, and why smokers will continue to be punished rather than helped by their self-proclaimed saviors.
Joseph Bast is president of The Heartland Institute, a national nonprofit research and education organization based in Chicago. He can be reached at firstname.lastname@example.org.