My attention has been drawn to an error in our paper. At reference #3
we state that Addisson Yeaman was legal counsel to Philip Morris. He was
in fact legal counsel to Brown & Williamson. The mistake arose because
the document was in the Philip Morris collection and was misinterpreted as
being a Philip Morris document. Also, it dates from 1963, not 1964 as
stated.
After nearly two-fold efficacy over placebo in most clinical studies, NRT has proven no more effective than quitting without it in all real-world quitting surveys conducted since adoption of the June 2000 Clinical Practice Guideline (CPG): Minnesota 2002, California 2003, London 2003, Quebec 2004, Maryland 2005, UK NHS 2006, and Australia 2006.[...
After nearly two-fold efficacy over placebo in most clinical studies, NRT has proven no more effective than quitting without it in all real-world quitting surveys conducted since adoption of the June 2000 Clinical Practice Guideline (CPG): Minnesota 2002, California 2003, London 2003, Quebec 2004, Maryland 2005, UK NHS 2006, and Australia 2006.[1]
In the most recent survey, among smoking patients of Australian family practice physicians, patients quitting cold turkey doubled the rates of nicotine patch, gum, inhaler and bupropion quitters and accounted for a whopping 88% of all success stories (1,942 of 2,207).[1]
In fact, after more than two decades of use, NRT still cannot point to a single real-world performance victory in which those engaging in nicotine replacement prevailed over those engaging in nicotine cessation. The question we should all be asking ourselves is why?
On 10/27/06 the CDC reported that for the first time since 1997 the U.S. smoking rate failed to decline. I submit that intimidating physicians into betraying two decades of practice observations may increase profits for those marketing replacement nicotine, bupropion and varenicline but not without substantial needless loss of life.
Primary fault for our stalled U.S. rate is not with physicians. Whether nicotine or pain meds, it rests upon pharmacology dependent medical school curriculum developers who continue to ignore the core basics of chemical dependency recovery counseling. It also rests upon the very June 2000 Clinical Practice Guideline (CPG) here employed to coerce compliance by suggesting that physicians "might be hard pressed to defend" against civil malpractice liability if they fail to see CPG recommendations as imposing legal duties.
The authors' objective is clearly admirable. Far too many physicians ignore ever advancing circulatory, pulmonary and mental health carnage fostered by years of chemical dependency upon smoking the highly addictive super-toxin nicotine. Imagine 81 IARC identified cigarette carcinogens (including polonium) slowly building time-bombs throughout the body, when the only action taken by the average physician is to tell the patient what, to them, is already obvious - "you need to quit."
But in pounding the proverbial square peg into roundness the authors misstate the CPG's key objective, grossly overstate the document's credibility and, as already noted, confuse clinical efficacy with real-world effectiveness. As Professor Branzhaf notes, standards of care are born of consensus among impartial experts, rather than statements from hired guns. The CPG is anything but impartial. Although physicans have a duty to assist those dependent upon smoking nicotine they have no legal obligation to follow a pharmacology use directive that two decades of practical experience has convinced them is totally ineffective, a finding supported by all real-world evidence to date.
The authors fail to note that CPG recommendation seven (R7) totally consumes the remaining recommendations. It reads, "Numerous effective pharmacotherapies for smoking cessation now exist. Except in the presence of contraindications, these should be used with all patients attempting tobacco cessation." Not with "some" patients but "all."
PHS adoption of CPG R7 instantly discredited all non-pharmacotherapy counseling, support and behavioral cessation programs as being no longer in accord with U.S. cessation policy. Nicotine cessation programs that refused to integrate nicotine replacement found themselves in a state of policy illegitimacy with obvious financial and accreditation implications. Their choices were to stick with a true nicotine cessation format that within 3 days creates a nicotine free work space with the onset of full dopamine pathway neuronal re-sensitization (down-regulation), or amend the program to advocate use of chemicals which delay dopamine pathway re-sensitization for weeks or months.
Since 2000 the CDC's primary quit smoking web page has evidenced total government abandonment of support for the cessation efforts of the 80 to 90% of U.S. smokers whose natural instincts are nicotine cessation, not replacement. PHS policy does not treat CPG R7 as optional. Smokers visiting the CDC website are told that key to quitting is to "get medication and use it correctly."[2] The page lists seven pharmacotherapies that include five different NRT delivery vehicles. It then clearly suggests that clinical study efficacy findings are being mirrored in real-world effectiveness in asserting that "all of these medications will double your chances of quitting and quitting for good." The CDC knows or should know that this assertion is false.
Our government knows: (1) that nicotine is a psychoactive chemical producing an alert dopamine/adrenaline high with vasoconstriction, an increase in heart rate and blood pressure, heightened senses and an underlying "aaah" sensation; (2) that those with a quitting history are likely to have trained themselves to recognize their withdrawal syndrome; (3) that those seeking participation in pharmacology studies were not cold turkey quitters expecting to endure their withdrawal syndrome but instead those seeking "medications" that promised some degree of withdrawal syndrome reduction; (4) that a June 2004 review of NRT study blinding assessments concluded that NRT studies were generally not blind as claimed in that "subjects accurately judged treatment assignment at a rate significantly above chance";[3] and (5) that never once in any real-world quitting method survey to date has NRT use proven more effective than quitting without it.
How many nicotine cessation programs survived R7? Very few. But if your patients type "quit smoking" into any major search engine they should encounter one or more such programs as government abandonment of abrupt nicotine cessation education, skills development, counseling and support has fostered demand.
Ironically, a November 2003 persistent use study in this journal found that nearly 40% of nicotine gum users are chronic long-term users of greater than six months. Imagine R7 effectively banishing the very programs that could have aided those getting hooked on the cure. Under current policy where are they to turn to reclaim neurochemical control?
The authors paint a picture of the CPG having been created by an independent panel of experts. The authoring panel had 17 members of which 11 openly acknowledge financial ties to the pharmaceutical industry in CPG Appendix C.[4] The panel chairman, who was also the director of the Center for Tobacco Research and Intervention (CTRI), discloses that he "has served as a consultant for, given lectures sponsored by, or
has conducted research sponsored by Ciba-Geigy, SmithKline Beecham, Lederle
Laboratories, McNeil, Elan Pharmaceutical, and Glaxo Wellcome." In 1996 he was openly labeling himself "a consultant to Glaxo Wellcome."[5] In 2005 he testified that the Robert Wood Johnson Foundation (RWJF) provided CTRI with more than $8 million in funding since 1998, that he had served as director of the RWJF National Program Office Addressing Tobacco in Managed Care since 1996, and that since 1998 he had sat in a $50,000 a year university chair funded by GlaxoSmithKline.[6]
GlaxoSmithKline markets nicotine gum, a nicotine lozenge and nicotine patch. The RWJF clearly knows it could gain philanthropy credibility by severing financial and board member ties to Johnson & Johnson (J&J) and its product line, which includes a nicotine patch, nicotine inhaler and nicotine spray, but it hasn't. Instead it remains J&J's largest shareholder with a quarter of board members having been former J&J executives.
RWJF claims that in August 1998 it contributed $102,016 to CTRI as its share toward updating the CPG. It notes that on September 14-15, 1999, panel members met in Madison, WI, where they evaluated findings and prepared a draft of the new Guideline. It also asserts that "the final version was submitted to RWJF and the USPHS for approval."[7] Also of note, RWJF paid at least $235,654 toward CPG dissemination.[8]
The only fair conclusion is that pharmacology influence had major impact on the CPG. Stakeholders have no business managing the writing of U.S. cessation policy and the practice must stop. Imagine if the panel had included educators and counselors who had devoted their life to highly effective programs involving nicotine cessation, programs that RWJF and pharmaceutical companies would have zero interest in studying and promoting. Allowing more than one lone voice would likely have prevented R7 from consuming all other recommendations, and cost the pharmaceutical industry billions.
I seriously doubt that many reviewing the CPG in 2000 grasped that the document was effectively outlawing pharmacology's only serious competitor, cold turkey. How many today grasp why pharmacology seems so wonderful inside clinical trials yet so dismal once outside clinic doors?
How many smokers wanting to quit cold turkey would you expect to join a clinical trial offering a 50/50 chance of free medicine? For those seeking withdrawal syndrome diminishment, how many with a prior quitting history would be able to recognize full-blown withdrawal or, some degree of relief of withdrawal symptoms if assigned to the active group? How meaningful would clinical results be if frustrated or fulfilled expectations determined who survived and who relapsed? Real-world performace evaluations compel pharmacology quitters to at last go head-to-head with real cold turkey quitters. It's strange how the CDC relies upon surveys to establish every tobacco truth except the most effective quitting method.
Is it fair to blame the CPG and specifically R7 for bringing a decline in the U.S. smoking rate to a halt? I believe it is. Let me briefly explain why. First, think about two decades and hundreds of millions spent bashing and trashing quitter confidence in the most productive method the world has ever known, cold turkey. Still, this year it will generate more than 80% of all long-term successful quitters.
Those supporting R7 like to tell smokers that, "on average, it takes between three to five serious quit attempts before breaking free of tobacco dependence. Some may be successful on the first try, others may take three or more tries. I like to tell people to visit our clinic, that every time you make an effort, you're smarter and stronger, and you can use that information to increase the likelihood that your subsequent quit attempt is successful."[9]. What they fail to reveal is the precise lesson eventually learned or that the statistics they quote belong to nicotine cessation not nicotine replacement.
Reflect on the amazing influence upon the mind of a quitter who smokes nicotine just once after quitting, in generating a new salient dopamine "aaah" prefrontal cortex "pay attention" memory. It's an "aaah" that their missing dopamine killjoy enzyme (suppressed by nicotine) allows them to savor far longer than normal. It isn't just that their mind tasted another stolen dopamine "aaah" sensation but that it will not allow them to forget. Just one powerful puff is the single greatest predictor of full and complete relapse back to their old level of nicotine intake or higher.
We call it the "Law of Addiction."[10] This critical relapse lesson does not always come easy but eventually the failed quitter begins to see a bright line in the sand that says, "just one powerful puff of nicotine and I will again throw all this hard work out the window."
It should be obvious that toying with the very chemical that the school of hard-quitting-knocks was eventually supposed to teach them to leave alone muddies the learning waters. Renaming nicotine "medicine," labeling its use "therapy" and two decades of telling quitters that they need to replace missing nicotine has clearly interfered with a natural learning process.
Lastly, we know that unlike cold turkey quitting, where each new attempt actually increases the odds of success (unless the lesson becomes clouded by toying with pharmacology), with each subsequent NRT attempt the odds of success appears to decline. Shiffman's OTC NRT patch and gum meta analysis published here in TC in March 2003 found a 93% six-month relapse rate. But in the only two nicotine patch studies that have examined second time patch use rates, an average of 99% relapsed within six months. (100% Tonneson 1993, 98.4% Gourlay 1995). With second time NRT use rates climbing, this important yet little known finding should disturb all.
I submit that physicians have a legal duty to believe their ears and eyes above clinical study assertions that will never ever be duplicated in real-world use. I too encourage physicians to read and rely upon all aspects of the CPG except for pharmacology performance efficacy claims and use recommendations.
John R. Polito
Nicotine Cessation Educator
Editor WhyQuit.com
As the public interest attorney and law professor who first developed
the concept of using legal action as a weapon against the problem of
smoking (e.g., getting antismoking messages on TV and radio, driving
cigarette commercials off the air, starting the nonsmokers’ rights
movement, etc.), I was delighted to read a paper suggesting the
feasibility of using legal action to more effectively prod physicians to
warn patient...
As the public interest attorney and law professor who first developed
the concept of using legal action as a weapon against the problem of
smoking (e.g., getting antismoking messages on TV and radio, driving
cigarette commercials off the air, starting the nonsmokers’ rights
movement, etc.), I was delighted to read a paper suggesting the
feasibility of using legal action to more effectively prod physicians to
warn patients about smoking, and to assist them in quitting.
Actually, by way of full disclosure, my organization [Action on
Smoking and Health (ASH), http://ash.org] had made a similar suggestion in
2003, [http://ash.org/recommendations] and the New York City Health
Department warned even earlier that, "because physician intervention can
be so effective, failure to provide optimal counseling and treatment is
failure to meet the standard of care – and could be considered
malpractice." [City Warns Docs -- Help Patients Stop Smoking -- or Else,
New York Post (12/13/02)].
The Clinical Practice Guidelines referred to in the article greatly
strengthen such law suits because courts and juries are often confused by
– and therefore tend to throw up their hands regarding – testimony by
competing physicians as to the standard of what other physicians do.
Therefore they are increasingly likely to adopt, as a appropriate standard
of care, some official document which represents a consensus among
impartial experts, rather than statements from “hired gun” medical
witnesses. This is even more true where, as in the case of the tobacco
guidelines, they have been adopted and put into practice by prestigious
medical organizations.
Dr. Siegel makes some interesting observations but, as a physician
rather than an attorney, he appears to be out of his field, and – with
all due respect – perhaps out of his depth (despite his participation in
some tobacco litigation), in bluntly stating that the “legal reasoning in
[the] malpractice article is not sound.” As someone with almost 40 years
of experience with anti-tobacco litigation – and who has been called the
"Ralph Nader of the Tobacco Industry," an "Entrepreneur of Litigation,
[and] a Trial Lawyer's Trial Lawyer,” "a Driving Force Behind the Lawsuits
That Have Cost Tobacco Companies Billions of Dollars," and "The Law
Professor Who Masterminded Litigation Against the Tobacco Industry," let
me speak frankly in suggesting from a lawyer’s perspective why the legal
reasoning is sound and why the legal threat is very real.
While it is technically true that the plaintiff must prove – and then
only by a “preponderance of evidence” and not “to a medical certainty” –
that he would have quit if only the physician has warned him and assisting
him in doing so, in practice this is not a major burden for several
reasons.
1. To survive the initial motion to dismiss – where the defendant
asks the court to throw out the law suit so that defendant (and his
insurance company) will not be put to the burden of defending it – the
judge must assumes all allegations in the legal complaint are true unless
they are clearly impossible on their face. Thus a judge would refuse to
dismiss any law suit which alleged that the plaintiff would have quit if
the physician had warned him to do so, even if such a proposition were
clearly against the great weight of evidence. This refusal to grant the
motion opens the door to pre-trial discovery – including depositions,
demands for the physician’s time, documents, and records, etc. – places
a blot on his record, and perhaps interferes with his ability to obtain
malpractice coverage at favorable rates. That threat alone may motivate
many physicians (and their medical organizations and insurance companies)
to settle or – better yet – to follow the guidelines next time.
2. In most jurisdictions, a judge will charge the jury that there is
a legal presumption that the plaintiff would have heeded a warning, and
this jury charge is usually given even regarding small-print routine
warnings on tools, drugs, etc. which were merely inadequate rather than
nonexistent. This presumption – which in effect shifts the burden on this
issue onto the defendant – is likely to be far stronger where the specific
face-to-face warning from a physician mandated by the guidelines was not
even given, since judges as well as jurors know that warnings from
authority figures in white coats are likely to be far more effective that
tiny-print warnings on jars or packages. The presumption and jury charge,
by the way, is generally given even if the defendant introduces strong
empirical evidence that the plaintiff would not have heeded the warning.
3. The question of whether the plaintiff would have heeded the advice
and assistance of the physician if he or she had given it is a factual
issue for the jury to decide, and the issue must be left to them if
reasonably people could possibly differ – as they obviously can on this
question. Experience clearly suggests that, faced with a sympathetic and
very ill plaintiff who swears that he would have heeded a warning if it
had been given, and a physician who (as his lawyer will argue) “thumbed
his nose at his professional obligation, ignored the simple guidelines of
a governmental commission and the unanimous advice of his peers,” the
jury’s sympathy for the plaintiff will incline them to award him some
damages, even if empirical evidence as well as common experience suggests
how hard it often is to quit.
4. The same is true with regard to the burden on the plaintiff to
prove that, had he quit, he would not have had the medical problem of
which he now complains. Sympathy may well be more important in a jury’s
consideration of this issue than dry empirical and statistical evidence
and related arguments put forth by “rich doctors and their greedy
insurance company lawyers.” Moreover, since juries are so firmly
convinced that smoking causes lung cancer, arguments about latency periods
– and just when the first cell turned from healthy to pre-cancerous and
then to cancerous – are not likely to be very persuasive. Plaintiff
attorneys may also try to sue in situations based upon other diseases and
medical problems triggered and/or exacerbated by smoking – e.g., heart
attacks – where arguments based upon early damage and long latency periods
will have less traction.
5. Antismoking lawyers do not have to win every case, most cases, or
even one out of every ten cases to put strong pressure on hospitals,
medical organizations, insurance companies, and ultimately on individual
physicians to begin complying with the guidelines to avoid the risk of
being sued and the possibility – however large or small it may appear –
of losing such a law suit. In this regard, many older physicians may
remember an interesting parallel.
6. Prior to 1975, it appeared that it was not the custom and
practice of psychiatrists to issue warnings when their patients made
threats in the presence of their doctor to do serious harm to spouses,
friends, and other third parties. When the Supreme Court of California
ruled in the Tarasoff case that such a failure to warn could give rise to
legal liability if the patient carried out the threat, most psychiatrists
reportedly changed their own policies quickly, without even waiting for
the subsequent jury verdict which found the physician liable. There are,
of course, many other instances where changes were quickly made in medical
practice and procedure in response to law suits, and sometimes even to the
threat of law suits. Indeed, it would be far better for those in the
profession who do not currently follow these guidelines to begin doing so
now, rather that waiting for one or more tests of this legal reasoning.
7. Attorneys are likely to be eager to bring such cases since the
damages are likely to be high, and they will involve far less research and
preparation than traditional medical malpractice cases which often require
a very careful review of the patient’s entire medical record to find
examples of alleged errors, detailed medical research to be sure what the
standard of care is, and the need to find qualified medical witnesses
willing to testify that the named defendant violated the general standard
of care required in this specific situation. It’s obviously much easier
to find a plaintiff who had not been adequately advised and assisted to
quit, and to find a witness who will testify that the guidelines do in
fact represent an expert consensus as to the appropriate standard of care
which are followed by prestigious institutions. Also, remember the old
adage: “never underestimate the tenacity and creativity of an attorney on
a contingency fee.”
One final comment goes far beyond the narrow issue of liability for
failing to assist patients to quit smoking. Dr. Siegel seems to suggest
that any malpractice action based upon a physician’s failure to warn a
patient of a potential risk, or to suggest a treatment (medication,
operation, or other course of action), is doomed to failure if the
proposed treatment is less than 50% effective: “Until such time as there
is a truly effective treatment for smoking cessation (one that works most
of the time), there really can be no basis for establishing a causal
relationship between the breach of duty and the incurred injury.” In
other words, by this reasoning, it would appear that the medical community
would have no legally enforceable duty to do anything at all (including
refraining from negligence) where the chance of success – much less the
patient’s ultimate chance of survival – is less than 50%. But several
courts have ruled directly to the contrary, finding that even plaintiffs
whose conditions were so grave that their chance of survival was less than
50% still have a valid cause of action against a physician whose
negligence decreases those already poor odds. Good physicians should never
act negligently toward a patient, gambling that the dismal chance that a
proposed treatment will be effective will shield them from liability.
I find the argument provided in the paper to be non-compelling
because it fails to provide any reasonable argument for how the 3rd
showing in a medical malpractice case - that there is a causal
relationship between the breach of duty and the incurred injury - could
possibly be met in a smoking malpractice case. This would require proving
to the jury that the physician's failure to warn the patient to quit
smoking was th...
I find the argument provided in the paper to be non-compelling
because it fails to provide any reasonable argument for how the 3rd
showing in a medical malpractice case - that there is a causal
relationship between the breach of duty and the incurred injury - could
possibly be met in a smoking malpractice case. This would require proving
to the jury that the physician's failure to warn the patient to quit
smoking was the cause of the injury sustained by the patient.
This would imply that 3 things would have to be shown: (1) that the
patient would have quit smoking if only the physician had advised them to
quit and followed the PHS guidelines; and (2) that the reason the patient
did not quit smoking was that the physician failed to advise them to quit
and failed to follow the PHS guidelines; and (3) that if the patient had
quit smoking, he would not have developed the injury.
These seem to be unreasonable, if not impossible, points to prove.
How can we possibly know that a patient would have successfully quit
smoking if only the physician had followed the guidelines? Unfortunately,
the overwhelming scientific evidence cited in the paper supports a
conclusion that the patient would most likely not have quit smoking, even
if the physician had followed the guidelines. The data demonstrate that
the cessation success rate, even with physician treatment, is dismal. The
success rate does not even come close to approaching 50%; thus, it is more
likely than not that even with physician advice to quit smoking, the
patient would not have been successful in quitting smoking.
The success rates reported in the PHS guideline itself are generally
below 20%. This means that it is much more likely than not (in fact 4
times out of 5) that a patient who goes through the suggested intervention
will fail to quit smoking.
I view this as an intractable problem in the use of the PHS CPG in
medical malpractice lawsuits for failure to properly treat tobacco
dependence. Until such time as there is a truly effective treatment for
smoking cessation (one that works most of the time), there really can be
no basis for establishing a causal relationship between the breach of duty
and the incurred injury.
Finally, it is important to note that one would not only have to show
that the plaintiff would have quit smoking had only the physician advised
them to quit; one would also have to show that had the person quit
smoking, they would not have developed the injury. However, we know that
many former smokers still develop smoking-related injuries. It is not
clear that one could show that the plaintiff wouldn't have developed the
disease even if they had successfully quit smoking, especially for a
disease such as lung cancer where risk decreases slowly following smoking
cessation.
The paper by Henningfield, Rose and Zeller is an important
contribution to understanding the all-too-clever manipulation of language
by tobacco industry in defending its manufacture and marketing of an
addictive product. It is useful to note, as on the authors' Table 1, that
while the industry now publicly acknowldeges that cigarette smoking is
addictive, it never mentions nicotine as the principal addictive agent.
The...
The paper by Henningfield, Rose and Zeller is an important
contribution to understanding the all-too-clever manipulation of language
by tobacco industry in defending its manufacture and marketing of an
addictive product. It is useful to note, as on the authors' Table 1, that
while the industry now publicly acknowldeges that cigarette smoking is
addictive, it never mentions nicotine as the principal addictive agent.
The former attribution puts the onus on the smoker who can choose to be
addicted or not; the latter would require the industry to be responsible.
Table 1 contains two errors. The observed death rate from all
cancers combined among women in 1991 was 175.3 per 100,000 in 1991 (not
173.3). The percentage decrease in the death rate from 1991 to 2003 was
8.4%. We noted and corrected both errors in the galleys but the
corrections were not picked up by the copy editor.
The recent article by Gilpin, et al.,[1] reported the major initial
impact of California’s tobacco control efforts was to initially reduce
cigs/day among continuing smokers and this was followed by an increase in
quitting.[1] We would like to make three comments on this paper.
First, this study was one of the first to decompose the effects of
tobacco control into effects on initiation, cessation and reducti...
The recent article by Gilpin, et al.,[1] reported the major initial
impact of California’s tobacco control efforts was to initially reduce
cigs/day among continuing smokers and this was followed by an increase in
quitting.[1] We would like to make three comments on this paper.
First, this study was one of the first to decompose the effects of
tobacco control into effects on initiation, cessation and reduction. Such
analyses are crucial to understanding how tobacco control works. Second,
decreased tobacco sales data appeared to be an early indicator of later
declines in prevalence; thus, when tobacco control programs are pressed to
show changes in the first few years, sales data may be the most sensitive
measure to document progress or the lack thereof.
Third, although the authors did not state that reduction in cigs/day
caused later changes in quitting, some readers could interpret their data
to indicate this. An alternate explanation is that reduction in cigs/day
was simply an indicator of other processes such as denormalization of
smoking. However, other data suggest reduction may, in fact, cause
increased cessation. Our recent review found that among the 19 studies of
reducing cigs/day in smokers not trying to quit, 16 found reduction was
followed by increased cessation.[2] Importantly, among the 10 randomized
controlled trials of using medications or behavioral treatments to induce
reduction, 9 found reduction led to increased quitting. Although these
studies focused on interventions at the individual level, it may be that
reduction in cigs/day achieved by tobacco policies, taxes, community
interventions, etc. also lead to later cessation.
Gilpin, et al., [1] hypothesized a mechanism by which reduction might lead
to cessation; i.e., reduced cigs/day may lead to decreased dependence.
Although this is highly feasible, surprisingly, our review could not find
any studies that have tested this. Other possible mechanisms include
reduction increases self-efficacy or disrupts the association of smoking
with specific environmental cues.
If reduction leads to cessation, then when treatment programs observe
that some relapsed smokers return to lower cigs/day than prior to
attempting to quit, they should implement treatments to maintain this
reduction. In fact, the Lung Health Study undertook such a strategy (via
continued use of medication) in many relapsed smokers[3] and reported one
of the highest rates of long-term cessation in the literature.[4]
Reference List
1. Gilpin EA, Messer K, White MW et al. What contributed to the
major decline in per capita cigarette consumption during California's
comprehensive tobacco control programme? Tob Control, 2006;15:308-316.
2. Hughes JR, Carpenter MJ Does smoking reduction increase future
cessation and decrease disease risk? A qualitative review. Nicotine Tob
Res, in press
3. Hughes JR, Lindgren PG, Connett JE et al. Reduction of smoking in
the Lung Health Study. Nicotine Tob Res, 2004;6:275-280.
4. Anthonisen NR, Connett JE, Kiley JP et al. Effects of smoking
intervention and the use of an inhaled anticholinergic bronchodilator on
the rate of decline of FEV. JAMA, 1994;272:1497-1505.
Care is needed when using aggregate smokeless tobacco (SLT)
consumption data to examine the potential for SLT being used as a
potential reduced exposure product. As far as I am aware very few people,
if any, are suggesting that traditional chewing tobacco be used as an aid
to smoking cessation; any hopes in this area have been focused on moist
smokeless tobacco (MST).
Care is needed when using aggregate smokeless tobacco (SLT)
consumption data to examine the potential for SLT being used as a
potential reduced exposure product. As far as I am aware very few people,
if any, are suggesting that traditional chewing tobacco be used as an aid
to smoking cessation; any hopes in this area have been focused on moist
smokeless tobacco (MST).
Data from the US Alcohol and Tobacco Tax and Trade Bureau (TTB),
available at www.ttb.gov, show that MST and chewing tobacco have had very
different consumption patterns over the last decade. Using taxable
removals (in pounds) in the US, plus imports, as a proxy for consumption,
consumption of chewing tobacco seems to have declined at a rate of 5.2% a
year between 1997 and 2005, while consumption of MST grew at a rate of
3.6% a year over the same period. Aggregate SLT consumption over the
period declined at 0.1% a year.
The picture of steady growth in annual MST volumes – contrasting with
declines for cigarette consumption – is also corroborated by industry
data. Data from Swedish Match, based on AC Nielsen figures, suggest that
consumption of MST grew at 3.7% a year between 1997 and 2005, as measured
per can (available in investor presentations section of
www.swedishmatch.com).
Both the TTB and the industry data suggest that MST consumption may
have accelerated in recent years. Measured by weight, MST consumption grew
at an annual rate of 3.3% from 1997 to 2002, and by 4.0% a year from 2002
to 2005 according to TTB data. Measured in cans, MST consumption grew at
2.3% a year from 1997 to 2002, and by 6.2% annually from 2002 to 2005,
according to Swedish Match. The latest Nielsen figures also seem to be
indicating that the MST category is growing by volume at 6-7% in the first
half of 2006.
I have not seen a definitive study of why this apparent acceleration
of consumption is happening. Part of the explanation is down to the fairly
rapid growth of discount snuff brands, which may be encouraging existing
MST users to consume more product. But industry leader UST also believes
that the number of adult consumers has increased recently.
According to UST survey data (see its December 2005 Annual Investor
Meeting presentation at www.ustinc.com) the number of adult consumers of
MST grew from 4.7mn in 2001 to 5.4mn in 2004. If we take US Census Bureau
(www.census.gov) estimates for the population size in July of each of
those years (285.1mn in 2001 and 293.7 in 2004), that would mean MST
prevalence grew from 1.65% to 1.83% over the period. The same UST survey
from 2004 also suggests that 63% of those MST users who had been using MST
for less than a year had used cigarettes or roll-your-own tobacco as their
first regular tobacco product.
Disclosures:
Deutsche Bank and/or affiliates own one percent of more of the common
equity of Swedish Match, expects to receive, or intends to seek,
compensation for investment banking services in the next three months, and
received non-investment banking related compensation from this company
within the past year.
The eletter entitled "A Personal Experience with Goza and Shisha
Smoking is authored by only FOUAD A. Al-BELASY. The names of other co-
workers were mistakenly entered during submission from below the bar
displaying how to enter other colleagues.
Shisha, Goza, Hashish and Street Children: What the
Egyptian Scene Teaches Us
For historical,
sociocultural and health reasons, Egypt is certainly the most important country
in the world regarding shisha smoking (*). So, many thanks to Pr Fouad
Al-Belasy and his colleagues for the very rich comments about the Egyptian Goza
and Shisha. This showed, once more, the complexity of the issue and how different
from the cigarette world it is. It is not everyday that we have a scientist with such hands-on experience and whose studies, particularly the last one in the Journal
of Oral and Maxillofacial Surgery, definitely reflects such qualities.
MOLLASSES. In his contribution, the
tobacco-mollasses mixture (mu‘assel; and “maassel” in Egyptian Arabic…) is said
to be unflavoured. I would like to inform him that in other countries,
particularly Arab countries, the same word is employed for the flavoured
product as well. And when the unflavoured product is used, it is sometimes
called jurâk.
BOURY. “Boury” can be used synonymously for
Shisha, he says. I would like to note that in a country like Yemen, such a
word represents the clay bowl of the madâ‘a (the national narghile) filled with
tumbak (raw tobacco)(*). I assume that this is a metonymic description
as it often happens in this field. For instance, “hookah” is literally an
Arabic word (for “urn”, e.g. of water) and similarly “shisha”, which means, in
Persian, something like a “bottle” (sise in Turkish). In Asia,
the same linguistic transfer seems to occur where “chillum” may mean the bowl
but sometimes, also, the hookah itself (*).
GOZA. What Pr Al-Belasy states about the
Goza (take care with the different spellings – perhaps we should keep “Goza”
and forget about “gooza” and “gûza”), and the description he gives of its
material details (from the valve to the reed and from the lighter to the
“bilya”…), and how they are used (body techniques), are indeed very important
because of their deep consequences on the related biomedical studies. I would
like to add that, my own work also contains similar descriptions of the Goza
and its users. For instance, I quote a popular song by M. Sêlem (‘El-Kîf) where the whole atmosphere of a Goza party is depicted as in Pr
Al-Belasy’s input (*). I have also carried
on an analysis of a book by Egyptian Nobel Prize Naguib Mahfûz (Tharthara fawqä n-nîl) in which the Goza is used as a mere pretext (a
relevant key sociological notion), being described in almost every page of the
novel (*). To close this chapter, thank you for recalling Salem, a pioneer in
research on Goza smoking, author of so many valuable studies on it (see our
Tetralogy)(*).
HASHISH.As for the use of hashish
in the goza, Pr Al-Belasy’s anthropological description (in the true sense of
the word) of its smokers is also very interesting. In my chief work, I also
provide extensive narrative depictions of situations where such odd
characters as the Me‘ellem (Sultan), his wife the Me‘ellema, and other
colourful actors of the “gurez” (secret smoking rooms) “sign” their goza
by placing the substance inside the bowl (*).
CHILDREN SMOKING. What Pr Al-Belasy tells us about
children and smoking in his country is very useful because there has been a lot
of confusion in this respect. He is a personal witness of how poverty may
transform the “commonly accepted traditions” that maintain children away from
smoking. In the poor countries, not only shoe-shine boys at work are
commonplace scenes but also children selling cigarettes in the streets. For
them, the cafés are a natural and important place because there are many
potential clients. They are also a place where they can rest a little. Now, if
you were such a street child, probably in charge of several brothers and
sisters, you would feel that you have quickly become an adult simply because
you spend a great part of the day working in adult environments such as the
above cafés.
Consequently, from
time to time, you may try to reward yourself because the child is still in you.
Why not ask for a delicious “apple, peach, banana, or cherry shisha” since
nobody in society cares for you and your brothers and sisters anymore ? Neither
the walkers nor the employees of the coffee-shops would try to exert any kind
of moral or social control over you. You see, if these children were normal,
i.e. if they were not poor, of course their parents would never let them ask
for such a product and would let them clearly understand that this is
forbidden. Alternatively, they could find out that it is a kind of “rite of
passage” to the world of men and grown-ups. In these conditions, they would
learn, instead, to ask for an ice-cream flavoured with the same above fruits...
My attention has been drawn to an error in our paper. At reference #3 we state that Addisson Yeaman was legal counsel to Philip Morris. He was in fact legal counsel to Brown & Williamson. The mistake arose because the document was in the Philip Morris collection and was misinterpreted as being a Philip Morris document. Also, it dates from 1963, not 1964 as stated.
After nearly two-fold efficacy over placebo in most clinical studies, NRT has proven no more effective than quitting without it in all real-world quitting surveys conducted since adoption of the June 2000 Clinical Practice Guideline (CPG): Minnesota 2002, California 2003, London 2003, Quebec 2004, Maryland 2005, UK NHS 2006, and Australia 2006.[...
As the public interest attorney and law professor who first developed the concept of using legal action as a weapon against the problem of smoking (e.g., getting antismoking messages on TV and radio, driving cigarette commercials off the air, starting the nonsmokers’ rights movement, etc.), I was delighted to read a paper suggesting the feasibility of using legal action to more effectively prod physicians to warn patient...
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The paper by Henningfield, Rose and Zeller is an important contribution to understanding the all-too-clever manipulation of language by tobacco industry in defending its manufacture and marketing of an addictive product. It is useful to note, as on the authors' Table 1, that while the industry now publicly acknowldeges that cigarette smoking is addictive, it never mentions nicotine as the principal addictive agent. The...
Table 1 contains two errors. The observed death rate from all cancers combined among women in 1991 was 175.3 per 100,000 in 1991 (not 173.3). The percentage decrease in the death rate from 1991 to 2003 was 8.4%. We noted and corrected both errors in the galleys but the corrections were not picked up by the copy editor.
The recent article by Gilpin, et al.,[1] reported the major initial impact of California’s tobacco control efforts was to initially reduce cigs/day among continuing smokers and this was followed by an increase in quitting.[1] We would like to make three comments on this paper.
First, this study was one of the first to decompose the effects of tobacco control into effects on initiation, cessation and reducti...
Care is needed when using aggregate smokeless tobacco (SLT) consumption data to examine the potential for SLT being used as a potential reduced exposure product. As far as I am aware very few people, if any, are suggesting that traditional chewing tobacco be used as an aid to smoking cessation; any hopes in this area have been focused on moist smokeless tobacco (MST).
Data from the US Alcohol and Tobacco Tax an...
The eletter entitled "A Personal Experience with Goza and Shisha Smoking is authored by only FOUAD A. Al-BELASY. The names of other co- workers were mistakenly entered during submission from below the bar displaying how to enter other colleagues.
Shisha, Goza, Hashish and Street Children: What the Egyptian Scene Teaches Us
For historical, sociocultural and health reasons, Egypt is cer...
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