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We are mildly flattered that Philip Morris found it worthwhile to
have Peter Lee criticize our framework [1] for assessing the likely
population effects of aggressive promotion of smokeless tobacco as a harm
reduction strategy in the USA. Peter Lee is a longtime tobacco industry
consultant who has a history spanning decades criticizing important
studies demonstrating the harms of tobacco and secondhand smoke [2],
inclu...
We are mildly flattered that Philip Morris found it worthwhile to
have Peter Lee criticize our framework [1] for assessing the likely
population effects of aggressive promotion of smokeless tobacco as a harm
reduction strategy in the USA. Peter Lee is a longtime tobacco industry
consultant who has a history spanning decades criticizing important
studies demonstrating the harms of tobacco and secondhand smoke [2],
including the landmark Hirayama study [3-5] and publishing papers or
letters to the editor contesting the health effects of secondhand smoke on
cardiovascular disease [6], cancer [7], SIDS [8] and more recently the
health effects of smokeless tobacco [9, 10] and menthol [11]. Lee's role
in industry efforts to discredit the Hirayama study has been well
documented in the literature [12, 13]. As Lee notes, "one would
intuitively expect a substantial benefit if increasing snus promotion led
to many smokers switching to snus." The whole point of our analysis was
to move beyond "intuition" and make predictions based on data in a way
that explicitly accounts for the uncertainty in the data on tobacco use
behavior and the associated health costs. The fact that the likely health
cost ranges overlap is what leads to the conclusion that, accounting for
this uncertainty, the market changes likely to accompany aggressive
smokeless promotion would not confer population-level health benefits.
Lee, a statistician, simply ignores the uncertainty associated with
the estimates that form the core of the model.
He criticizes the fact that we do not account for the temporal
dynamics of changes in tobacco use behavior and the associated risks over
time. He is correct that our model is a steady-state, not a dynamic,
model. We considered a dynamic model, but doing so conflicted with our
fundamental goal of basing the results on data rather than the rhetoric
and "intuition" that have characterized the harm reduction debate to date.
We were unable to find the data necessary to model the dynamics Lee seeks.
It is noteworthy that Lee did not provide citations to the data that one
could use to develop the model he desires.
Lee found the justification for the health cost we used for snus as
11 to be "unclear." In our paper, we clearly stated that this estimate
came from an expert consensus panel estimate of the health effects,
reference 9 in our paper [14]. As we noted in our paper, the estimate
that this panel produced is probably low because subsequent research has
found higher risks for heart disease, that are larger than those
considered in this reference, a case that has only grown stronger as
evidence has continued to accumulate [15]. If anything, we are almost
certainly underestimating these risks.
Lee questions our assumption of a risk of 90 for dual use. He is
correct that there is little data available on dual use (a subject worthy
of study). The reason we assumed a modest reduction in risk was that
there might be less exposure to cigarette smoke, which could lower cancer
risk but would have little effect on heart disease risk because of the
highly nonlinear relationship between smoking and heart disease risk, with
most effect occurring at low levels of smoking.
Lee criticizes us for including what he sees as unacceptably high
levels of dual use (i.e., concurrent use of smokeless tobacco and
cigarettes) in our scenarios. (It is important to define "dual use" as
use of either product on some days rather than both products on all days.
This latter definition does not reflect actual dual use, particularly as
the snus products are being promoted for use when one cannot "light up",
and substantially underestimates dual use.) The base levels of dual use
we used in our model are from surveys of actual use patterns in the USA.
The fact that we model large increases in dual use reflects the actual
marketing of smokeless products by the tobacco companies, who are
promoting snus products as cigarette line extensions, packaging them
together, and explicitly promoting dual use in their marketing. Dr. Lee
could make a real contribution to the debate if he were to present an
analysis based on the market targets that his client, in this case Philip
Morris, has established for both Marlboro snus and dual use of Marlboro
snus and cigarettes together.
Finally, we were surprised that Dr. Lee did not simply put the health
costs he asserts are accurate into the model and present the results to
demonstrate that his assertions are correct and supported by actual data.
(The full model is available on the Tobacco Control website at
http://tobaccocontrol.bmj.com/content/19/4/297/suppl/DC1, something we
pointed out to him when he contacted us asking for a copy of the model.)
The whole object of this enterprise is to move beyond the "intuitive"
arguments Lee presents to making decisions based on quantitative estimates
of likely population effects: Lee failed to provide credible estimates
demonstrating that smokeless promotion would actually be likely to reduce
harm on a population level.
Adrienne Mejia
Pamela M. Ling
Stanton Glantz
University of California, San Francisco
San Francisco, CA 94143
REFERENCES
1. Mejia AB, Ling PM, Glantz SA. Quantifying the Effects of Promoting
Smokeless Tobacco as a Harm Reduction Strategy in the USA. Tob Control.
2010 Aug;19(4):297-305.
2. Lee PN. Many Claims About Passive Smoking Are Inadequately
Justified. BMJ. 1997 Feb 1;314(7077):371.
3. Hirayama T. Non-Smoking Wives of Heavy Smokers Have a Higher Risk
of Lung Cancer: A Study from Japan. Br Med J (Clin Res Ed). 1981 Jan
17;282(6259):183-5.
4. Lee PN. "Marriage to a Smoker" May Not Be a Valid Marker of
Exposure in Studies Relating Environmental Tobacco Smoke to Risk of Lung
Cancer in Japanese Non-Smoking Women. Int Arch Occup Environ Health.
1995;67(5):287-94.
5. Ong E, Glantz SA. Hirayama's Work Has Stood the Test of Time. Bull
World Health Organ. 2000;78(7):938-9.
6. Lee PN, Forey BA. Environmental Tobacco Smoke Exposure and Risk of
Stroke in Nonsmokers: A Review with Meta-Analysis. J Stroke Cerebrovasc
Dis. 2006 Sep-Oct;15(5):190-201.
7. Lee PN, Hamling J. Environmental Tobacco Smoke Exposure and Risk
of Breast Cancer in Nonsmoking Women: A Review with Meta-Analyses. Inhal
Toxicol. 2006 Dec;18(14):1053-70.
8. Lee PN. Passive Tobacco Exposure and Sudden Infant Death Syndrome.
Pediatrics. 1993 Sep;92(3):505-6.
9. Lee PN, Hamling J. Systematic Review of the Relation between
Smokeless Tobacco and Cancer in Europe and North America. BMC Med.
2009;7:36.
10. Sponsiello-Wang Z, Weitkunat R, Lee PN. Systematic Review of the
Relation between Smokeless Tobacco and Cancer of the Pancreas in Europe
and North America. BMC Cancer. 2008;8:356.
11. Werley MS, Coggins CR, Lee PN. Possible Effects on Smokers of
Cigarette Mentholation: A Review of the Evidence Relating to Key Research
Questions. Regul Toxicol Pharmacol. 2007 Mar;47(2):189-203.
12. Hong MK, Bero LA. How the Tobacco Industry Responded to an
Influential Study of the Health Effects of Secondhand Smoke. BMJ. 2002 Dec
14;325(7377):1413-6.
13. Yano E. Japanese Spousal Smoking Study Revisited: How a Tobacco
Industry Funded Paper Reached Erroneous Conclusions. Tob Control. 2005
Aug;14(4):227-33; discussion 33-5.
14. Levy DT, Mumford EA, Cummings KM, Gilpin EA, Giovino G, Hyland A,
et al. The Relative Risks of a Low-Nitrosamine Smokeless Tobacco Product
Compared with Smoking Cigarettes: Estimates of a Panel of Experts. Cancer
Epidemiol Biomarkers Prev. 2004 Dec;13(12):2035-42.
15. Piano MR, Benowitz NL, Fitzgerald GA, Corbridge S, Heath J, Hahn
E, et al. Impact of Smokeless Tobacco Products on Cardiovascular Disease:
Implications for Policy, Prevention, and Treatment: A Policy Statement
from the American Heart Association. Circulation. 2010 Oct 12;122(15):1520
-44.
Thomson and colleagues present a novel radical approach for national
tobacco elimination supported by cogent arguments and discussion of the
various pros and cons for such a policy (Tobacco Control 2010;10:431-435).
They discuss, albeit briefly, the importance of best practice cessation
support. However current best practice is not especially effective, and
just as they have argued for a radical policy approach, there sim...
Thomson and colleagues present a novel radical approach for national
tobacco elimination supported by cogent arguments and discussion of the
various pros and cons for such a policy (Tobacco Control 2010;10:431-435).
They discuss, albeit briefly, the importance of best practice cessation
support. However current best practice is not especially effective, and
just as they have argued for a radical policy approach, there similarly
needs to be a more radical and innovative approach to cessation treatments
in terms of access, public awareness and choices of delivery.
Firstly, cessation treatments, particularly Nicotine Replacement
Therapy (NRT) must be more visible and available. Despite strong subsidy
for NRT via prescription and the New Zealand Quitline it remains easier to
obtain a packet of cigarettes that it does to obtain the almost harmless
nicotine equivalent. Nicotine needs to be much more prominently displayed,
and available wherever tobacco is legally sold. When a smoker needs
nicotine they usually need it immediately at the corner shop not after an
appointment with their GP and a pharmacy prescription.. Nicotine needs
marketing in the same proportion that tobacco needs eliminating.
Secondly, there needs to be better education about the relative
safety of NRT compared to continued smoking. More than 50% of smokers
believe that nicotine is the dangerous component of smoking, and so it is
perhaps not surprising that NRT uptake is poor. The merits of NRT should
be discussed at every cessation encounter and much more widely
promulgated. For those unable to quit smoking, the long term use of
nicotine is infinitely preferable to continued smoking, and yet to date
there have been no long term studies designed to explore substitution as
an alternative to cessation.
Lastly, we need fast acting nicotine formulations delivered in a
manner that is both acceptable to smokers and rapidly controls their urges
to smoke. The inhalation route is the obvious one but is more difficult
given the aversiveness of nicotine in the upper airway. Oral liquid
formulations may prove more effective than current NRT, and we should not
write off products such as snus without at least examining their potential
for harm reduction. In addition to considering a sinking lid for tobacco,
we need to take the lid off nicotine, convince smokers that it is not much
more harmful than coffee, and provide a much improved range of products
for cessation or failing that for lifelong use.
INTRODUCTION
Mejia et al1 argue that a harm reduction strategy based on promoting snus,
the form of smokeless tobacco widely used in Sweden, is unlikely to result
in any substantial health benefit to the US population. They divide the
population into five tobacco groups (never tobacco users, former tobacco
users, current cigarette smokers, current snus users, and current dual
users), attaching to each group an estimate of...
INTRODUCTION
Mejia et al1 argue that a harm reduction strategy based on promoting snus,
the form of smokeless tobacco widely used in Sweden, is unlikely to result
in any substantial health benefit to the US population. They divide the
population into five tobacco groups (never tobacco users, former tobacco
users, current cigarette smokers, current snus users, and current dual
users), attaching to each group an estimate of the "tobacco-related health
effect" (TRHE). By definition, TRHE is 0 in never smokers and 100 in
current cigarette smokers, with other smoking groups having intermediate
TRHE values, proportional to their relative excess disease risk. Mejia et
al consider various scenarios (e.g. "aggressive smokeless promotion")
which result in different predicted distributions by tobacco use, and
hence different estimates of the overall average TRHE for the whole US
population. For the "base case", with tobacco use distributions as they
currently are, this is estimated as 24.2, and under the various scenarios
considered the estimates lie between 19.2 and 30.5.
Their conclusion that snus promotion probably provides little health
benefit seems surprising. Given the strong evidence that health risks from
snus are much less than from smoking, one would intuitively expect a
substantial benefit if increasing snus promotion led to many smokers
switching to snus. It is useful therefore to look at the methodology used
and assumptions made.
FAILURE PROPERLY TO ACCOUNT FOR PATTERNS OF TOBACCO USE
There are some deficiencies in the approach. First, there are clealy
more than five relevant tobacco groups. Limiting attention to snus use
and cigarette smoking, there are nine main groups, representing each
combination of never, former and current use of each product. And within
some combinations, there are subgroups by sequence of events. Why, for
example, should TRHE be assumed similar in former tobacco users regardless
of whether snus or cigarettes were previously used, or similar in current
snus users who have or have not previously smoked cigarettes? Other
deficiencies include failure to consider age, sex, amount used, and other
tobacco products such as pipes or cigars. However, these are minor
compared to the failure to account for time in its various guises - time
since quit, time since switch, and time used snus or cigarettes. It is
unsound to assume TRHE is the same for all former users of tobacco
regardless of time quit, or the same for current snus users regardless of
previous smoking history. Failure to consider time undermines the validity
of the TRHE estimates for the different tobacco groups.
ESTIMATES OF TRHE BY SMOKING GROUP
Quitters
No justification is given for the TRHE estimate of 5 used by Mejia et al.
It seems very low. Relative all-cause mortality rates for current, former
and never smokers from the well- known CPS-II study2, indicates former
smokers have about 40% of the excess all-cause mortality rate of current
smokers, not 5%. The appropriate TRHE would be higher still for short-
term quitters. Was the value of 5 intended to relate to long-term
quitting?
Snus users
The justification for the TRHE estimate of 11 is unclear. It is much too
low, if applied to recent switchers from cigarettes, particularly
following long-term smoking. However, if intended only to quantify effects
of snus, it seems too high. Updates of published meta-analyses for snus
use for heart disease3 and cancer4 (details available on request) suggest
little or no increased risk, with combined relative risk (95% confidence
interval) estimates of 1.01 (0.91-1.12) for ischaemic heart disease, 1.05
(0.95-1.15) for stroke, 0.97 (0.68-1.37) for oropharyngeal cancer, 1.10
(0.92-1.33) for oesophageal cancer, 0.98 (0.82-1.17) for stomach cancer,
1.20 (0.66-2.20) for pancreatic cancer, and 0.71 (0.66-1.76) for lung
cancer. Given it is implausible that snus use might increase COPD risk,
given the lack of confirmed reports of increased risks for other diseases,
and given the much stronger relationships seen with smoking, the excess
risk from snus use is probably no more than 2% of that from cigarette
smoking and not as great as 11%.
Dual use
The estimated TRHE of 90 derived from INTERHEART 5 is not relevant to
snus, the smokeless tobacco use reported in that study being predominantly
in Asian and African countries. Though data are lacking, one might
imagine that if lifetime dual users get about half their required nicotine
dose from each source, a TRHE of about 50 might be appropriate. Again,
however, this would not apply to those changing from long-term smoking to
dual use.
HIGH ESTIMATES OF DUAL USE
The proportion of dual users predicted in some of the scenarios of up to
about 20% seem implausibly high. Recent Swedish surveys (e.g.6,7 give
estimates less than 3%. While adolescents in Sweden often try both
products, adults usually only use one. Models based on studies in
adolescents that do not take this into account may result in misleading
predictions of the tobacco use distribution, especially when the data
used8 relate to smokeless tobacco use, not snus.
SNUS AND INITIATION OF SMOKING
Some Swedish retrospective studies9,10 claim snus users are less likely to
initiate smoking than never tobacco users. While these claims are
questionable (failing to adjust for time available to initiate), evidence
that few Swedish smokers used snus before they started smoking9,10, and
that most dual users started on cigarettes, suggest snus can be at most a
minor determinant of smoking.
SNUS AND QUITTING SMOKING
In theory snus use might discourage rather than encourage quitting. No
published study in Sweden suggests discouragement, but many 9,11-15suggest
encouragement. Although these studies have some limitations, concern
regarding discouragement seems unjustified.
FURTHER THOUGHTS AND A SIMPLER APPROACH
The approach of Mejia et al is complex and does not validly allow
assessment of the effect on health of the various scenarios considered.
One problem is that promotion of snus cannot affect the risk
resulting from past smoking (particularly so for those who quit before
the promotion started), so that inclusion of this risk in the overall TRHE
estimates obscures estimation of the effects of the various strategies
discussed. It would seem better to compare the decline in risk for the
given scenario of snus promotion with that in a comparable scenario where
those assumed to switch to snus quit instead.
A second problem is that while their approach is complex, it ignores
many factors, such as time quit or switched, age, sex, and quantity used.
However, attempting to improve the model to account for these would likely
be valueless, given the uncertainties involved.
Also Mejia et al do not define what they call a substantial health
benefit. The strategy "aggressive promotion with most new users from
smokers" reduces the overall TRHE from 24.2 to 19.2, i.e by about 20%.
This seems quite substantial, especially so if it is a relatively short-
term effect. Would strategies directly encouraging quitting do better?
To my mind, they have obscured a simple situation. Complete
switching to snus seems likely to have a health effect virtually
equivalent to quitting, with partial switching (dual use) having an
intermediate effect. For smokers unwilling or unable to give up their
nicotine, switching to snus is clearly a much better health alternative
than continuing smoking. Promoting snus may produce some new tobacco
users, but these will have little or no excess risk of disease, and be no
more likely to take up smoking than are those who have never used tobacco.
(WORD COUNT: 1213)
REFERENCES
1. Mejia AB, Ling PM, Glantz SA. Quantifying the effects of
promoting smokeless tobacco as a harm reduction strategy in the USA. Tob
Control 2010;19:297-305.
2. US Surgeon General. Reducing the health consequences of smoking.
25 years of progress. A report of the Surgeon General. Rockville,
Maryland: US Department of Health and Human Services; Public Health
Services; 1989. DHHS Publication No. (CDC) 89-8411.
http://www.surgeongeneral.gov/library/reports/index.html
3. Lee PN. Circulatory disease and smokeless tobacco in Western
populations: a review of the evidence. Int J Epidemiol 2007;36:789-804.
4. Lee PN, Hamling JS. Systematic review of the relation between
smokeless tobacco and cancer in Europe and North America. BMC Med
2009;7:36:
5. Teo KK, Ounpuu S, Hawken S, Pandey MR, Valentin V, Hunt D, et al.
Tobacco use and risk of myocardial infarction in 52 countries in the
INTERHEART study: a case-control study. Lancet 2006;368:647-58.
6. Persson J, Sj?berg I, Johansson S-E. Bruk och missbruk, vanor och
ovanor. H?lsorelaterade levnadsvanor 1980-2002 (Health related habits of
life 1980-2002). Statistiska centralbyr?n; 2004, (Accessed Oct 2010).
(Levnadsf?rh?llanden (Living conditions).) 105.
http://www.scb.se/statistik/le/le0101/1980i02/le0101_1980i02_br_le105sa0401.pdf
With additional data supplied by E H?gstorp, Statistiska centralbyr?n,
2005.
7. Wadman C. Levnadsvanor - Tobaksvanor. Statens Folkh?lsoinstitut;
2009, (Accessed Oct 2010). http://www.fhi.se/sv/Statistik-
uppfoljning/Nationella-folkhalsoenkaten/Levnadsvanor/Tobaksvanor/
8. Severson HH, Forrester KK, Biglan A. Use of smokeless tobacco is
a risk factor for cigarette smoking. Nicotine Tob Res 2007;9:1331-7.
9. Furberg H, Bulik CM, Lerman C, Lichtenstein P, Pedersen NL,
Sullivan PF. Is Swedish snus associated with smoking initiation or
smoking cessation? Tob Control 2005;14:422-4.
10. Ramstr?m LM, Foulds J. Role of snus in initiation and cessation
of tobacco smoking in Sweden. Tob Control 2006;15:210-4.
11. Lindstr?m M, Isacsson S-O. Smoking cessation among daily
smokers, aged 45-69 years: a longitudinal study in Malm?, Sweden.
Addiction 2002;97:205-15.
12. Lundqvist G, Sandstr?m H, ?hman A, Weinehall L. Patterns of
tobacco use: a 10-year follow-up study of smoking and snus habits in a
middle-aged Swedish population. Scand J Public Health 2009;37:161-7.
13. Rodu B, Stegmayr B, Nasic S, Cole P, Asplund K. Evolving
patterns of tobacco use in northern Sweden. J Intern Med 2003;253:660-5.
14. Gilljam H, Galanti MR. Role of snus (oral moist snuff) in
smoking cessation and smoking reduction in Sweden. Addiction 2003;98:1183
-9.
15. Ramstr?m L. Is snus a model for harm reduction: the scientific
evidence from Sweden. In: The 13th World Conference on Tobacco OR Health:
Building capacity for a tobacco-free world, The 13th World Conference on
Tobacco OR Health: Building capacity for a tobacco-free world. Washington
DC, July 12-15 2006. 2006;
Conflict of Interest:
I am a long-term consultant to the tobacco industry, and this work was supported by Philip Morris
Could this in fact be a violation of your stated company policy to
not "use social networking sites such as Facebook to promote our tobacco
product brands."
Thank you for clarifying.
Becky
---
BECKY FREEMAN | Researcher and PhD Candidate
School of Public Health | Sydney Medical School
THE UNIVERSITY OF SYDNEY
Snus is threatening not only for Sweden also other parts of Europe. We have anecdotal information that UK tourists in Sweden(who are
smokers) are trying Snus quite frequently. Therefore, there
is a threat of cross-border transmission of Snus addiction. Some of the
reports claim that Snus is less injurious to health comparing smoking,
but, the evidence shows there is a higher risk for the occurrence of
oral cancer (OSCC)...
Snus is threatening not only for Sweden also other parts of Europe. We have anecdotal information that UK tourists in Sweden(who are
smokers) are trying Snus quite frequently. Therefore, there
is a threat of cross-border transmission of Snus addiction. Some of the
reports claim that Snus is less injurious to health comparing smoking,
but, the evidence shows there is a higher risk for the occurrence of
oral cancer (OSCC) and development of Metabolic Syndrome [MS] (MS=Central
Obesity, hypertriacylgycerolemia, low HDL cholesterol concentration,
elevated BP and fasting glucose concentration). To date, a couple of studies have been published on Quid chewing related metabolic
syndrome (1-3). Therefore, we cannot ignore the similar potential consequences of
Snus consumption. Again, the claim regarding an antioxidant effect of wet-
Snus to prevent cancer is misleading information. Obviously, such
information is again misleading for a person who wants to consume Snus,
and that needs to be stopped by removing the vested information
deliberately quoted by the manufacturers to promote their Snus business in
Europe, and probably extending to the other parts of the world.
Therefore, any form of the Smokeless Tobacco (SLT) whether it's
Indian/Chinese/Taiwanese/Japanese- is a major public health concern today.
It needs to be mentioned that in 2010 Japan started marketing a new
form of SLT: 'Zerostyle mint' targeting adolescents. And also for the smokers who wants to
switch from smoking to 'Zerostyle Mint'- a refillable cartridge (4).
It may be incorrect to say that Quid Chewing, Snus consumption or
Zerostyle mint will be less injurious than smoking, because it is established that any form of SLT may contribute to the higher risk of oral
and oro-pharygeal cancer and Metabolic
Syndrome (MS). Therefore, Chewing Quid, Zerostyle Mint or Swedish
Snus needs to be properly controlled under the WHO FCTC framework
convention (5). We have undertaken an interventional study
on Quid/Snus consumption and development of metabolic syndrome especially
among the cases suffering from Quid induced oral sub-mucosal fibrosis
(OSF)- a cause of high rate of morbidity and mortality in the risk group
population.
References.
1. Amy Ming-Fang Yen, Yueh-Hsia Chiu et al. A population-based study of
the association between betel-quid chewing and the metabolic syndrome in
men. Am. J Clin Nutr. 2006; 83:1153-60.
2.Boucher BJ, Mannan N. Metabolic effects of consumption of Areca
catechu. Addiction Biol 2002;7: 103-10.
3. Boucher BJ, et al. Betel nut (areca catechu) consumption and induction
of glucose intolerance in adults CD 1 mice and in their F1 and F2
offspring. Diabetologica 1994;37: 49-55.
4. JT to Launch New Style of Smokeless Tobacco Product "Zerostyle Mint"
http://www.jt.com/investors/media/press_releases/2010/0317_01/index.html
5. WHO Framework Convention on Tobacco Control
http://www.who.int/fctc/en/
Link/Contact:
Professor Chitta R Choudhury, PhD, MPH, FFDRCS, FRSPH, BDS, DND
Lead : OPCL/OSF study team
International Centre for Tropical Oral Health, PHT NHS Dept Max Fac,
England
& Oral Biology, Genomic Studies, Nitte University, Mangalore, India.
President, Institute of Health Promotion & Education (IHPE), UK
cr_choudhury@yahoo.co.uk
ASH Ireland very much welcomes the comprehensive article on cigarette
waste by Smith and McDaniel. This is an issue ASH Ireland has been
actively engaged with. In November 2009 ASH Ireland met with the Minister
for the Environment, Heritage and Local Government (Leader of the Green
Party in Ireland) and outlined the scale of the problem to him and his
department. Cigarette waste accounts for nearly half of all the litter...
ASH Ireland very much welcomes the comprehensive article on cigarette
waste by Smith and McDaniel. This is an issue ASH Ireland has been
actively engaged with. In November 2009 ASH Ireland met with the Minister
for the Environment, Heritage and Local Government (Leader of the Green
Party in Ireland) and outlined the scale of the problem to him and his
department. Cigarette waste accounts for nearly half of all the litter
pollution in Ireland over many years. This is due to the indifference of
both smokers and the tobacco industry as to how to dispose of cigarette
waste. ASH Ireland has also submitted its analysis of the problem to the
public consultation process for a new waste policy. In addition ASH
Ireland has asked that 50 cent be levied directly on the tobacco industry
for every pack of 20 cigarettes that they seek to sell and that it be paid
at source by the tobacco industry. The tobacco industry could then pass on
the levy to their customer base should they so wish. The key point here is
that the State, which has to clean up cigarette waste, would put the
responsibility on the tobacco industry to pay for the waste problems
caused by their products rather than putting the responsibility on the
consumer. The revenue raised by such a levy could then be used to support
local government in their efforts to prevent and clean up after cigarette
waste pollution. Some of the funding could also be used to raise awareness
among young people as to the environmental harm that tobacco use causes
both at home and abroad. ASH Ireland would urge other tobacco control
organisations to raise this issue with their respective governments so as
to broaden our tobacco control activities and involve a wider discussion
on the negative effects of tobacco use.
Dr Fenton Howell
ASH Ireland
Denshaw House
Dublin 2.
The approach by Ayo-Yusuf and Connolly (2010) to evaluate cancer
risks of smokeless tobacco products (STP) addresses issues that could be
relevant to modified risk claims for Swedish snus tobacco products. We
disagree with the authors' conclusions, and in some cases they simply have
the facts wrong. Nonetheless, the issues presented warrant consideration
by the tobacco science community, including the FDA Center for Tobac...
The approach by Ayo-Yusuf and Connolly (2010) to evaluate cancer
risks of smokeless tobacco products (STP) addresses issues that could be
relevant to modified risk claims for Swedish snus tobacco products. We
disagree with the authors' conclusions, and in some cases they simply have
the facts wrong. Nonetheless, the issues presented warrant consideration
by the tobacco science community, including the FDA Center for Tobacco
Products and the newly formed Institute of Medicine committee on modified
risk.
The authors' use of the EPA risk assessment process is intriguing. In
the hands of someone familiar with the process it may have resulted in a
useful contribution to the scientific literature. Unfortunately the
authors do not seem to understand the process because they did not follow
the well documented EPA guidance.
Recently a National Academy of Sciences committee issued a report
examining the EPA risk assessment process (Science and Decisions:
Advancing Risk Assessment, 2009). The committee cited the importance of
making risk assessments data driven, and when data are unavailable
ensuring that default assumptions are accurately characterized. When
there is an abundance of information - particularly epidemiological data -
the credibility and utility of the risk assessment increases
significantly.
There is extensive health-related information available for Swedish
snus. That is why an EPA risk assessment approach is worth pursuing.
However, the authors did not use all the available data, particularly not
the epidemiological documentation. EPA scientists have some flexibility in
choosing "critical" studies, but they must justify their decisions, and
use "all the relevant and available scientific information." EPA
scientists cannot disregard data simply because of personal biases.
Also, instead of comparing life-time use of STP with only 12-weeks
medicinal nicotine, the authors should have made a comparison with long-
term cigarette smoking. This could then be expanded to comparisons with
selected smoke components. It would be enlightening, for example, to
determine risk assessment values for the carcinogenic potential of such
components as 1, 3-butadiene compared with the authors' claims for tobacco
-specific nitrosamines and benzo(a)pyrene.
In summary, we support the application of risk assessment in the
regulatory science process. However, if the EPA risk assessment model is
used to evaluate potential modified risk tobacco products, it should be
done so by scientists experienced in the EPA process who have an
understanding and appreciation of the available data.
References:
Ayo-Yusuf, O., A., Connolly, G., N. Applying toxicological risk assessment
principles to constituents of smokeless tobacco products: implications for
product regulation. Tob Control, published online Oct 5, 2010. doi:
10.1136/tc.2010.037135
Science and Decisions: Advancing Risk Assessment. Committee on
Improving Risk Analysis Approaches Used by the U.S. EPA. Board on
Environmental Studies and Toxicology. Division on Earth and Life Studies.
National Research Council of the National Academies. National Academic
Press, Washington D.C., 2009.
Conflict of Interest:
Lars E. Rutqvist is employed by Swedish Match AB. Chris Coggins acts in a consulting role to the company.
In economic terms anti tobacco have created a faux market. In
economic terms there are significant barriers to entry to any new tobacco
manufacturer and distributor with the ban on advertising.
Good heavens you even admit it: "These problems have been exaggerated
by unintended consequences of tobacco control policies."
Your paper says "...market failure, excess profits..wherein a cap is
placed on the ma...
In economic terms anti tobacco have created a faux market. In
economic terms there are significant barriers to entry to any new tobacco
manufacturer and distributor with the ban on advertising.
Good heavens you even admit it: "These problems have been exaggerated
by unintended consequences of tobacco control policies."
Your paper says "...market failure, excess profits..wherein a cap is
placed on the manufacturers' price but not on the retail price that
consumers face."
Could you define "excess profits?" Pension funds I am very sure are
grateful for the dividends and the pensioners whose income is dependent on
fund performance and receipts. I am sure the 80,000 people in th UK
employed directly and indirectly in the tobacco industry are happy that
they have an income that can put bread on the table.
"Such a system would increase government revenue by transferring the
excess profits from the industry to the government purse."
After 13 years of socialism under Labour, surely it lays bare how
wasteful government spending is. Are you seriously suggesting that the
?5.8 trillion, if you include public sector public pension liabilies, that
the government can spend my money better than I can?
"..market its products and lobby against tobacco control measures
would be curtailed."
So tobacco companies are to be denied their democratic rights? People
like you and public funded bodies like ASH can?
"Finally, it could offer a means of preventing down-trading to
cheaper tobacco products and controlling other unwanted industry practices
such as cigarette smuggling, price fixing and marketing to the young."
I get all my tobacco from erm... a mate of mine who has a white van
and coincidentally happens to pick up the odd packet when in Belgium, like
64% of other roll your own smokers in the UK and and 24% of cigarette
smokers. This will only increase with your measures.
You tobacco control policies will turn tobacco into the new crack
cocaine and heroin. Gangs will fight over their "manor" with guns and
violence in the supply of illegal tobacco. In Ireland the Real IRA are the
main "importers" of smuggled tobacco, elsewhere it is the Mafia, Triads
even the Taliban.
Even hope may fail to fly out of Pandora's box.
Conflict of Interest:
I receive no remuneration from tobacco companies in any shape or form.
Smokers will smoke more cigarettes and inhale more deeply should the
nicotine content of cigarettes be reduced. It is the burning tobacco which
kills - not the nicotine. Each smoker has his own comfortable level of
nicotine. Perhaps high nicotine cigarettes are safer?
The speculation that dependence can result from smoking 1 - 2
cigarettes a day is at odds with the more extreme claims by anti tobacco
campaigners...
Smokers will smoke more cigarettes and inhale more deeply should the
nicotine content of cigarettes be reduced. It is the burning tobacco which
kills - not the nicotine. Each smoker has his own comfortable level of
nicotine. Perhaps high nicotine cigarettes are safer?
The speculation that dependence can result from smoking 1 - 2
cigarettes a day is at odds with the more extreme claims by anti tobacco
campaigners about passive smoking. Is 5 hours a day in a smoky atmosphere
equivalent to 10 cigarettes a year as measured directly by independent
scientists or is it several cigarettes a day as is often claimed? If so,
why don't non smoking pub-goers become nicotine dependent?
Joel L Nitzkin and Elaine Keller did an excellent job of identifying
problems with this study so I shall not endeavor to duplicate their
suggestions. Instead I wish to speak as a 43 year, at the end 2 to 3
pack, smoker who used Swedish snus 6 months ago to completely stop
smoking.
I attempted smoking cessation for over 30 years using just about
every NRT product except Chantix. I tried hypnosis twice, group a...
Joel L Nitzkin and Elaine Keller did an excellent job of identifying
problems with this study so I shall not endeavor to duplicate their
suggestions. Instead I wish to speak as a 43 year, at the end 2 to 3
pack, smoker who used Swedish snus 6 months ago to completely stop
smoking.
I attempted smoking cessation for over 30 years using just about
every NRT product except Chantix. I tried hypnosis twice, group and
individual, and herbal remedies. Nothing worked. I was persuaded by my
girlfriend to purchase an electronic cigarette over a year ago. That
immediately got me down to a half dozen cigarettes a day plus the ecig.
However, I was unable to stop smoking completely.
If it had not been for an electronic cigarette forum, I would never
have tried any smokeless tobacco product. I was told decades ago that
these were no better than smoking. In addition, the only vision I had of
smokeless tobacco was the type that you had to spit the juices which I
still would not do. That being said, I'm sure that there are many that
would even consider that form of smokeless if they didn't feel it was just
as dangerous as smoking.
Even after being directed to Swedish snus, I had serious doubts
ingrained from bad science and worse publicity. It wasn't until I started
investigating on my own that I realized what most of the 44 million
smokers in the US don't know. Smokeless is anywhere between 90 and 99%
safer than smoking. I was shocked and angry that I might have quit a
quarter century ago if this information was provided by those that were
supposedly trying to get people to stop smoking.
In her response, Elaine Keller wrote, "What if the government changed
the warning labels to read "THIS PRODUCT IS NOT A 100% SAFE ALTERNATIVE TO
SMOKING"? See what a difference one tiny change can make? This would lead
folks to ask, "Well if it's not 100% safe, how much safer is it?" "
I shall take her thought one step further. How about a warning 25
years ago that read "THIS PRODUCT IS ONLY 95% SAFER THAN SMOKING", or
whatever the right percentage is. Six months ago I had my first portion
of Swedish snus. Six months ago I had my last cigarette with absolutely
no desire to smoke since. For me, the electronic cigarette is still
useful in certain circumstances, but it currently sits mostly unused as
about four portions of Swedish snus have replaced cigarette smoking
entirely.
Now you produce a modeling study using parameters that draw a
conclusion that selling the idea of smokeless won't make a difference in
the smoking rate. Had the industry been honest 25 years ago, your study
wouldn't have needed to be done. We'd have the answer. My guess is that
the number of smokers would have seriously been reduced. Of course that
would not have aligned well with the goal of Big Pharma in providing the
answer and that makes me angry.
How the industry and the "health" associations could continue to push
products that have a success rate only a couple percent better than cold
turkey after a year is beyond my comprehension. I know that 25 years less
smoking would have improved my odds health wise in the future and that
does not make me happy.
My last point is that the only snus mentioned was the American
versions that have come out over the last year or so. These are not
Swedish snus. I have difficulty even accepting that they can be
considered snus. Whether it's nicotine content or the other tobacco
alkaloids that are missing, I'm not sure. The product has to be adequate
to fulfill the needs of the smoker.
Conflict of Interest:
I hold quite a few shares of Pharmaceutical shares, many with companies that sell NRT products.
We are mildly flattered that Philip Morris found it worthwhile to have Peter Lee criticize our framework [1] for assessing the likely population effects of aggressive promotion of smokeless tobacco as a harm reduction strategy in the USA. Peter Lee is a longtime tobacco industry consultant who has a history spanning decades criticizing important studies demonstrating the harms of tobacco and secondhand smoke [2], inclu...
Thomson and colleagues present a novel radical approach for national tobacco elimination supported by cogent arguments and discussion of the various pros and cons for such a policy (Tobacco Control 2010;10:431-435). They discuss, albeit briefly, the importance of best practice cessation support. However current best practice is not especially effective, and just as they have argued for a radical policy approach, there sim...
INTRODUCTION Mejia et al1 argue that a harm reduction strategy based on promoting snus, the form of smokeless tobacco widely used in Sweden, is unlikely to result in any substantial health benefit to the US population. They divide the population into five tobacco groups (never tobacco users, former tobacco users, current cigarette smokers, current snus users, and current dual users), attaching to each group an estimate of...
Ms Murphy,
I am hoping that you may be able to answer a query for me? Does BAT sponsor or promote BAT cigarette brands at the MODERNITY festivals in Switzerland?
It seems a BAT employee is promoting MODERNITY events through Facebook - I have provided the relevant links below for your information.
Profile of Matthieu Kowalczyk - BAT employee National HoReCa Event Manager
http://www.f...
Snus is threatening not only for Sweden also other parts of Europe. We have anecdotal information that UK tourists in Sweden(who are smokers) are trying Snus quite frequently. Therefore, there is a threat of cross-border transmission of Snus addiction. Some of the reports claim that Snus is less injurious to health comparing smoking, but, the evidence shows there is a higher risk for the occurrence of oral cancer (OSCC)...
ASH Ireland very much welcomes the comprehensive article on cigarette waste by Smith and McDaniel. This is an issue ASH Ireland has been actively engaged with. In November 2009 ASH Ireland met with the Minister for the Environment, Heritage and Local Government (Leader of the Green Party in Ireland) and outlined the scale of the problem to him and his department. Cigarette waste accounts for nearly half of all the litter...
The approach by Ayo-Yusuf and Connolly (2010) to evaluate cancer risks of smokeless tobacco products (STP) addresses issues that could be relevant to modified risk claims for Swedish snus tobacco products. We disagree with the authors' conclusions, and in some cases they simply have the facts wrong. Nonetheless, the issues presented warrant consideration by the tobacco science community, including the FDA Center for Tobac...
In economic terms anti tobacco have created a faux market. In economic terms there are significant barriers to entry to any new tobacco manufacturer and distributor with the ban on advertising.
Good heavens you even admit it: "These problems have been exaggerated by unintended consequences of tobacco control policies."
Your paper says "...market failure, excess profits..wherein a cap is placed on the ma...
Smokers will smoke more cigarettes and inhale more deeply should the nicotine content of cigarettes be reduced. It is the burning tobacco which kills - not the nicotine. Each smoker has his own comfortable level of nicotine. Perhaps high nicotine cigarettes are safer?
The speculation that dependence can result from smoking 1 - 2 cigarettes a day is at odds with the more extreme claims by anti tobacco campaigners...
Joel L Nitzkin and Elaine Keller did an excellent job of identifying problems with this study so I shall not endeavor to duplicate their suggestions. Instead I wish to speak as a 43 year, at the end 2 to 3 pack, smoker who used Swedish snus 6 months ago to completely stop smoking.
I attempted smoking cessation for over 30 years using just about every NRT product except Chantix. I tried hypnosis twice, group a...
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