Zhu et al. reported that 0.3% of men who were exclusive current
smokers in 2002 became smokeless tobacco users at follow-up in 2003 (1).
Similarly, they reported that 1.7% of men who were former smokers of one
year or less duration and 0.3% of men who were former smokers for a longer
time were smokeless tobacco users in 2003.
These percentages are quite small, prompting the first author to
issue a statement in...
Zhu et al. reported that 0.3% of men who were exclusive current
smokers in 2002 became smokeless tobacco users at follow-up in 2003 (1).
Similarly, they reported that 1.7% of men who were former smokers of one
year or less duration and 0.3% of men who were former smokers for a longer
time were smokeless tobacco users in 2003.
These percentages are quite small, prompting the first author to
issue a statement in a press release that the research confirms that the
effects of smokeless tobacco use on smoking among Swedish men are unique
to Sweden (2). However, the study did not provide population estimates
for the American percentages.
Using SPSS statistical software with Complex Samples (Version 15.0
for Windows), I developed U.S. population estimates from the 2002 NHIS for
the number of male exclusive current and former smokers in that year, from
which I estimated the number who had switched to smokeless tobacco in 2003
as follows:
From exclusive current smokers in 2002: 70,416
From former smokers (<= 1 year): 52,058
From former smokers (> 1 year): 68,165
Total 190,639
Some might believe that 190,000 current or former smokers who became
smokeless tobacco users in this one-year period is an insignificant
number. But it is consistent with the results of a recent study using the
2000 National Health Interview Survey (3), in which 261,000 American men
had used smokeless tobacco to quit smoking. In that study switching to ST
compared very favorably with pharmaceutical nicotine, despite the fact
that few smokers know that the switch provides almost all of the health
benefits of complete tobacco abstinence. Taken together, these results
are proof of the concept that smokeless tobacco is a viable cessation
option for smokers in the U.S.
As long as American smokers are misinformed about the comparative
risks of ST and cigarettes, most will not consider trying to switch, or
will do so only reluctantly. A social and public health environment that
honestly informs smokers about comparative risks would provide many more
smokers with the opportunity to lead longer and healthier lives.
Conflict of Interest
Dr. Rodu is supported by unrestricted grants from smokeless tobacco
manufacturers (US Smokeless Tobacco Company and Swedish Match AB) to the
University of Louisville. The terms of the grants assure that the
sponsors are unaware of this work, and thus had no scientific input or
other influence with respect to its design, analysis, interpretation or
preparation of the manuscript.
References
1. Zhu S-H, Wang JB, Hartman A, et al. Quitting cigarettes
completely or switching to smokeless tobacco: do U.S. data replicate the
Swedish results. Tob Control 2008; in press.
2. UC San Diego News Center, available at:
http://ucsdnews.ucsd.edu/newsrel/health/01-09SmokelessTobacco.asp
(Accessed February 17, 2009)
3. Rodu B, Phillips CV. Switching to smokeless tobacco as a smoking
cessation method: evidence from the 2000 National Health Interview Survey.
Harm Reduction Journal 5: 18, 2008 (Open Access, available at
http://www.harmreductionjournal.com/content/pdf/1477-7517-5-18.pdf
Nitzkin and Rodu raise several interesting points about harm
reduction and how they would like to see the current FDA bill
(HR1108/S625) be improved [1]. However, the purpose of Zhu et al.’s paper
is not to advocate for or against harm reduction. It is simply to examine
whether current US data replicate the Swedish results [2].
If large numbers of US smokers could be induced to switch to
smokeless tobacco, tha...
Nitzkin and Rodu raise several interesting points about harm
reduction and how they would like to see the current FDA bill
(HR1108/S625) be improved [1]. However, the purpose of Zhu et al.’s paper
is not to advocate for or against harm reduction. It is simply to examine
whether current US data replicate the Swedish results [2].
If large numbers of US smokers could be induced to switch to
smokeless tobacco, that would certainly help to increase the population
smoking cessation rate. However, our study shows that very little
switching has occurred in the US population, unlike the Swedish
population. Smokeless tobacco has been promoted in both countries for a
long time, without a focus on relative risk. In light of these findings,
we sound a cautionary note. Tobacco control policymakers face difficult
choices, and our hope is that these new results might be helpful.
Nitzkin and Rodu’s arguments for the merits of harm reduction are
well known because there has been so much debate on this topic. Some are
convinced of such arguments while others are not [3,4]. Our paper aims to
inject empirical data into what sometime seems like an endless logical
exercise without new information. The debate is often filled with
hypothetical scenarios on how things might work this or that way. Some of
these hypotheses may turn out to be correct. Our paper does not say that
the hypotheses for harm reduction are wrong. It simply says that new
results from the US are quite different from the Swedish results and do
not support the idea that promoting smokeless tobacco necessarily leads to
increased smoking cessation on a population level. We believe that the
field needs more such empirical research.
That research can be misused, however, as in Nitzkin and Rodu’s
extrapolation of our finding that US men quit smokeless tobacco products
at three times the rate of quitting cigarettes. They suggest that this
means that “encouraging American smokers to switch to smokeless products
will increase the number that eventually quit all use of tobacco and
nicotine.” They ignore our larger finding that US smokers are not
switching to smokeless in the first place, and they fail to understand
that the differential quit rates suggest that, mathematically speaking, US
men tend to quit smokeless before quitting cigarettes. Are Nitzkin and
Rodu necessarily wrong, then, in suggesting such a hopeful scenario? We
would not say that. One can easily imagine various scenarios in which
smokeless tobacco helps smokers quit cigarettes or even all forms of
tobacco. But however enticing those scenarios may be, the US data do not
yet support them.
1. Nitzkin JL, Rodu B. Promoting snus will save lives in the USA. Tob
Control eLetter published online February 6, 2009.
2. Zhu S-H, Wang JB, Hartman A, Zhuang Y, Gamst A, Gibson JT et al.
Quitting cigarettes completely or switching to smokeless: do U.S. data
replicate the Swedish results? Tob Control; in press.
3. Rodu B, Godshal WT. Tobacco harm reduction: an alternative
cessation strategy for inveterate smokers. Harm Reduction J 2006;3:37.
Open access, available at:
http://www.harmreductionjournal.com/content/3/1/37 (Accessed February 10,
2009).
4. Tomar SL, Fox BJ, Severson HH. Is smokeless tobacco use an
appropriate public health strategy for reducing societal harm from
cigarette smoking? Int J Environ Res. Pub Health 2009, 6(1), 10-24;
doi:10.3390/ijerph6010010
Zhu, et al., when comparing tobacco-related behaviors in the U.S. and
Sweden concluded that “promoting smokeless tobacco for harm reduction in
countries with ongoing tobacco control programs may not result in any
positive population effect on smoking cessation.” [1]
We believe that this conclusion is too pessimistic.
Promotion of snus in the U.S., as a low-risk alternative for smokers
unable or unwillin...
Zhu, et al., when comparing tobacco-related behaviors in the U.S. and
Sweden concluded that “promoting smokeless tobacco for harm reduction in
countries with ongoing tobacco control programs may not result in any
positive population effect on smoking cessation.” [1]
We believe that this conclusion is too pessimistic.
Promotion of snus in the U.S., as a low-risk alternative for smokers
unable or unwilling to quit has great potential to substantially reduce
tobacco-related illness and death. Snus and selected other smokeless
nicotine delivery products can eliminate all risks from fire, second hand
smoke, all pulmonary disease, most cardiac disease and most cancer
attributable to smoking. These products are up to 1000 times less
hazardous than cigarettes.[2,3] Thus, if large numbers of smokers replace
some or all of their cigarettes with low-risk alternatives, a substantial
reduction in tobacco-related illnesses and death will occur. This will be
true even if large numbers of non-smokers initiate use of these smokeless
products.
Zhu et al. concede that “…in the U.S., smokeless tobacco has not been
promoted as a safer alternative to cigarettes.” But the American
environment is even worse: current federal tobacco policy incorrectly
labels a smokeless tobacco product as “not a safe substitute for
cigarettes,” which has left most Americans – even healthcare professionals
– with the misimpression that smokeless products are as hazardous as
cigarettes.[4,5]
The popularity of “light” and “low tar” cigarettes in the U.S. has
clearly demonstrated that large numbers of American smokers will switch to
products that appear to be of lower risk, if encouraged to do so. While
the implied health claims for “light” and “low tar” cigarettes were
fraudulent, the well established differences in risk between cigarettes
and smokeless tobacco products are not.[6]
One of the more intriguing findings in the Zhu paper is that “men
quit smokeless tobacco products at three times the rate of quitting
cigarettes (38.8% vs. 11.6%, p<0.001).”[1] This raises the possibility
that encouraging American smokers to switch to smokeless products will
increase the number that eventually quit all use of tobacco and nicotine.
Many opposed to such an approach claim that “conventional nicotine-
replacement therapies…have been tested extensively and shown…to be
effective.”[7] Such statements, however, rarely show the quit rates. One
recently published study boasts that nicotine gum more than doubles the
quit rate. The data show 6-month quit rates of 2.1% in controls and 5.9%
in study subjects.[8] The authors fail to mention that the therapy failed
for 94% of study subjects. We need to do much better than that if we are
to achieve substantial reductions in tobacco-related illness and death.
Zhu et al. acknowledge – then gloss over – the fact that the rate of
tobacco-related illness and death are far lower in Sweden, where snus is
popular, than in the U.S., where cigarettes are dominant. Data from the
World Health Organization and the International Agency for Research on
Cancer show that lung cancer rates among both Swedish men and women were
well under half the rates for their American counterparts from 1980 to
2002.[9] But the data reveal another amazing fact: since 1989 lung cancer
among Swedish men has been lower than that among American women. This is
evidence that snus use suppresses smoking, with the important context that
per capita nicotine consumption is nearly identical in both countries.[10]
Furthermore, the Swedish government neither promotes snus for harm
reduction nor vilifies it as “not a safe substitute for cigarettes.”
The time has come for American legislators and public health leaders
to educate smokers as to the differences in risk profiles between
cigarettes and other tobacco products. This will empower smokers who are
unable or unwilling to quit to reduce their risk of tobacco-related
illness, even while locked into their nicotine addiction. The potential
public health benefit is substantial.
Those opposed to such an approach theorize that smokeless tobacco
manufacturers “will inevitably target susceptible adolescents,”[7]
creating users who may then transition to cigarettes. They also point out
that there is no empirical evidence that such a policy (helpful
information to smokers) will generate the projected public health
benefits. Whether or not such a program results in increases in teen
tobacco use will depend entirely on how it is framed and how it is placed
in the context of other tobacco control efforts. As to the projected
public health benefits, there will be no way to know for sure without
implementing the policy, then carefully tracking the results. A national
program in the U.S. that includes helpful health education, effective
regulation, and robust surveillance and research programs should be able
to make the mid-course corrections needed to assure optimal outcomes from
a public health perspective.
A piece of legislation was introduced into the recently concluded
110th U.S. Congress. The bill (HR1108/S625) was known as the “Family
Smoking Prevention and Tobacco Control Act.” Unfortunately, this bill, as
seen by the American Association of Public Health Physicians, is a total
failure with regard to the desired health education. It also fails to
effectively regulate tobacco products and strongly favors currently
marketed cigarettes. We hope it will be possible to amend the bill in the
current Congress so that it will provide the needed health education,
effective regulation, surveillance and research.[11]
The relative safety of snus and the latest generation of alternative
smokeless nicotine delivery products is not a children’s issue. The eight
million Americans who will die from smoking-related illnesses in the next
twenty years are now 35 years of age and older. Preventing youth access
to tobacco is vitally important, but should not be used as an excuse to
condemn smoking parents and grandparents to premature death, especially
within socially and economically disadvantaged sub-populations. If
implemented as an addition to otherwise effective tobacco control
programming, the helpful information to smokers should not significantly
increase the numbers of teens initiating tobacco use.[11]
Conflict of Interest
Dr. Nitzkin has never sought nor secured any financial or other
support from any tobacco-related enterprise. Dr. Rodu is supported by
unrestricted grants from smokeless tobacco manufacturers (US Smokeless
Tobacco Company and Swedish Match AB) to the University of Louisville.
The terms of the grants assure that the sponsors are unaware of this work,
and thus had no scientific input or other influence with respect to its
design, analysis, interpretation or preparation of the manuscript.
References
1. Zhu S-H, Wang JB, Hartman A, et al. Quitting cigarettes
completely or switching to smokeless tobacco: do U.S. data replicate the
Swedish results. Tob Control 2008; in press.
2. Royal College of Physicians of London. Protecting smokers,
saving lives: the case for a tobacco and nicotine authority. London,
England, 2002. Available at:
http://www.rcplondon.ac.uk/pubs/books/protsmokers/index.asp (Accessed
February 5, 2009).
3. Nitzkin JL, Rodu B. The case for harm reduction for control of
tobacco-related illness and death. Resolution and White Paper, Adopted by
the American Association of Public Health Physicians, October 26, 2008.
Open access, available at:
http://www.aaphp.org/special/joelstobac/20081026HarmReductionResolutionAsPassedl.pdf
(Accessed February 5, 2009).
4. O’Connor RJ, Hyland A, Giovono G, et al. Smoker awareness of and
beliefs about supposedly less harmful tobacco products. Am J Prev Med
2005;29:85-90.
5. O’Connor RJ, McNeill A, Borland R, et al. Smokers’ beliefs about
the relative safety of other tobacco products: findings from the ITC
Collaboration. Nicotine Tob Res 2007;9:1033-1042.
6. Rodu B, Godshall WT. Tobacco harm reduction: an alternative
cessation strategy for inveterate smokers. Harm Reduction J 2006;3:37.
Open access, available at:
http://www.harmreductionjournal.com/content/3/1/37 (Accessed February 5,
2009).
8. Shiffman S, Ferguson SG, Strahs KR. Quitting by gradual smoking
reduction using nicotine gum: a randomized controlled trial. Am J Prev
Med 2009;36:96-104.
9. World Health Organization Mortality Database. Accessed through
the Descriptive Epidemiology Group, Biostatistics and Epidemiology
Cluster, International Agency for Research on Cancer, Lyon, France at:
http://www-dep.iarc.fr/
10. Fagerström K. The nicotine market: an attempt to estimate the
nicotine intake from various sources and the total nicotine consumption in
some countries. Nicotine Tob Res 2005;7:343-350.
11. Analysis and Recommendations for Amendment of FDA/Tobacco Bill.
American Association of Public Health Physicians, November 5, 2008. Open
access, available at:
http://www.aaphp.org/special/2009/20081105_AnalRcommendFDATobcBill.pdf
(Accessed February 5, 2009).
A recent article in Tobacco Control 1 reported that 33% of cigarettes
are consumed by smokers who had a current mental disorder. The title,
abstract and discussion of that article stated that this 33% represented
how much “mental disorders contribute to tobacco consumption in New
Zealand.” This statement is misleading for at least two reasons. First,
although 33% of smokers had a current mental disorder, 21% of nonsmok...
A recent article in Tobacco Control 1 reported that 33% of cigarettes
are consumed by smokers who had a current mental disorder. The title,
abstract and discussion of that article stated that this 33% represented
how much “mental disorders contribute to tobacco consumption in New
Zealand.” This statement is misleading for at least two reasons. First,
although 33% of smokers had a current mental disorder, 21% of nonsmokers
also had a current mental disorder; thus, the actual excess that mental
disorders could “contribute” is +12%, not 33%. Second, and more
importantly, neither this study nor the prior literature has consistently
shown that mental disorders per se cause the initiation of smoking, cause
smokers to smoke more or interfere with cessation 2. For example, recent
reviews have concluded that prior alcohol dependence and depression do not
appear to impair smoking cessation 3,4.
Since we cannot randomize smokers to mental illness, we must rely on
associative data. Among the criteria for judging whether an association
is causal 5, the plausibility, replicability, strength of the association,
dose-responsivity of the association, and the consistency with other
knowledge argue for causality. However, data on whether smoking remits
if mental disorders remit, whether the association persists when all
reasonable confounds are considered, evidence of specificity, and temporal
relationship do not strongly argue causality. For example, a) most
mental disorders temporally follow, not precede, smoking, b) those in
remission from a psychiatric disorder have not been shown to stop smoking
and c) smoking is associated with over 20 different mental disorders
suggesting nonspecificity 2. Finally, even if the association was causal,
it is unlikely that mental illness accounts for 100% of the reason these
smokers smoke. If it accounted for only half, then the excess due to
mental disorders would be only +6% (half of +12%). In summary, the
“contribution” of psychiatric co-morbidity to the current prevalence of
smoking is likely much less than the stated 33%.
References
1. Tobias M, Templeton R, Collings S. How much do mental disorders
contribute to New Zealand's tobacco epidemic? Tobacco Control 2008;17:347-
350.
2. Hughes JR. Comorbidity and smoking. Nicotine and Tobacco Research
1999;1:S149-152.
3. Hughes JR, Kalman D. Do smokers with alcohol problems have more
difficulty quitting? Drug Alcohol Depend 2005;82:91-102.
4. Hitsman B, Borrelli B, McChargue DE, Spring B, Niaura R. History
of depression and smoking cessation outcome: A meta-analysis. J Consult
Clin Psychol 2003;71:657-663.
5. Hill AB. The environment and disease: Association or causation?
295-300. 1965.
It is known that smoking increases DHEAS, the precursor of DHEA. The
same should happen because of exposure to secondhand smoke.
DHEA is the active molecule, so increases in DHEAS may indicate that
smoking is reducing DHEA. DHEA is known to be important to normal
pregnancy-associated outcomes.
I suggest the findings of Peppone, et al., may be explained by
reduced DHEA in these women.
In their article, “Existing technologies to reduce specific toxicant
emissions in cigarette smoke,” RJ O’Connor & PJ Hurley list
technologies that, they propose, manufacturers could use to comply with
ceilings on nine smoke constituents proposed by the WHO Study Group on
Tobacco Product Regulation (TobReg).
Initially, it is important to address any conjecture that these
ceilings will reduce the harm cause...
In their article, “Existing technologies to reduce specific toxicant
emissions in cigarette smoke,” RJ O’Connor & PJ Hurley list
technologies that, they propose, manufacturers could use to comply with
ceilings on nine smoke constituents proposed by the WHO Study Group on
Tobacco Product Regulation (TobReg).
Initially, it is important to address any conjecture that these
ceilings will reduce the harm caused by cigarette smoking. Even TobReg
concedes that there is no evidence – only “hope” – that its proposal will
reduce the risks of smoking. Public health officials and scientists have
long stated, however, that selectively reducing cigarette smoke
constituents is unlikely to benefit public health.
Like TobReg, O’Connor & Hurley seem to take for granted that
manufacturers can easily comply with the proposed ceilings. But their
article proves the opposite. It highlights the difficulty, if not
impossibility, of complying with ceilings on nine individual constituents
(among thousands) in tobacco smoke, especially on a commercial scale.
Although an exhaustive treatment of each listed technology is beyond
the scope of this letter, the following points illustrate pragmatic
difficulties with applying these technologies in the real world.
• Using less Burley tobacco and more Bright (Virginia Flue-cured)
tobacco to reduce TSNA. This would increase emissions of formaldehyde,
another carcinogen in cigarette smoke.
• Using DNA from salmon sperm to reduce PAH or adding haemoglobin to
reduce carbon monoxide emissions. It is difficult to envision how such
options, which even the authors question, would be acceptable from a
regulatory viewpoint or could be commercialized on a large scale.
• Adding ammonia compounds, including urea, to cigarettes to reduce
formaldehyde. Public health authorities have alleged (although we
disagree) that ammonia compounds are added to cigarettes to increase the
addictive effects of nicotine.
These examples underscore the need for a science-based, rational
approach to tobacco policy that applies science consistently and
coherently when examining regulatory and public health proposals.
O’Connor & Hurley concede that TobReg’s proposal would force the
majority of existing cigarette brands off the market. We fully agree.
Viewed through this lens, the proposal is not “a conservative first step”
as TobReg contends. It is a strategy to remove as many tobacco products
from the market as possible.
Resources would be better spent on developing a regulatory framework
that includes evidence-based standards for reduced risk assessment, rather
than on promoting poorly-reasoned, speculative performance standards that
are not likely to reduce the risk of tobacco-related diseases.
Jim Sargent says I support business as usual for Hollywood. What I
emphatically and unapologetically do support is business as usual for
consistency. R-rating of any scene of smoking invites unavoidable
questions about parallel controls on a wide range of activity that an
equally wide range of interest groups would wish to see implemented in the
name of health, religion or morality. Jonathan Klein implies that because
ni...
Jim Sargent says I support business as usual for Hollywood. What I
emphatically and unapologetically do support is business as usual for
consistency. R-rating of any scene of smoking invites unavoidable
questions about parallel controls on a wide range of activity that an
equally wide range of interest groups would wish to see implemented in the
name of health, religion or morality. Jonathan Klein implies that because
nicotine is addictive, this confers exceptionalist status on the
importance of keeping smoking scenes away from children. Smoking is
extraordinarily dangerous, but is it any worse than violence, crime, or
racism to name but three which are often seen in movies to which children
are admitted?
The reductio ad absurdum of arguments to prevent children seeing any
smoking in movies would be to stop children seeing any smoking anywhere.
By what magic process could the sight of smoking in film be influential
while being benign in reality? Doubtless the time is not far away when
someone wielding research will call for public smoking to classified
alongside indecent exposure as a felony. I would not wish to be associated
with such nonsense and believe many others share my concerns that momentum
to selectively prune unacceptable health related behaviours from film
holds open the door for a conga line of other supplicants using the same
reasoning. This should be resisted by all who value freedom of expression.
I do not doubt that a majority of Americans agree with the
proposition that any smoking scene should cause a movie to be R-rated. But
I’d be confident that many of the same people who support that proposition
would also support proposals to do the same with scenes showing liquor or
many other health concerns, blasphemy and various moral panics. And let’s
remember also that many Americans also believe in miracles (89%), hell
(69%), ghosts (51%), astrology (31%) and reincarnation (27%) [1] and 40%-
50% accept a creationist account of the origins of life [2]. The
popularity of beliefs is not always a reliable guide to their wisdom. Not
long ago, the “wardrobe malfunction” that exposed Janet Jackson’s breast
on national TV for a nano-second caused national outrage. Such reactions
perplex many outside the US who have long been used to far more relaxed
regulation of film and television.
R-rating advocates are fond of arguing that scenes of smoking should
be treated identically to use of the word “fuck”, which many in the USA
apparently believe holds special powers to corrupt and deprave children.
Perhaps some of these advocates need to get out more and broaden their
horizons. Non R-rated movies in many other nations (eg: Europe, Australia,
Canada) frequently contain swearing, moderate violence and sex scenes
where panels appointed to judge the rating for the entire film have
decided that these scenes do not overwhelm the overall suitability of the
film to be screened to those legally defined as children. These panels are
typically not constrained by prescribed formulae as would appear to be
the case with swearing in the USA, but asked to make a holistic judgement
with reference to unspecified community standards. Part of the problem in
this debate may lie in US advocates believing that the rest of the world
shares (or ought to share) its standards, which have historical roots in
Puritanism.
Finally, if my critics are correct that smoking scenes in movies have
increased in the last 15 years, that these scenes “predict one-third to
half of smoking uptake”, and that there is a dose-response relationship
between exposure and smoking uptake, how do they reconcile this with the
major declines in youth smoking that have happened in the USA[3], Canada
[4] and Australia (to name three) over the same period? The answer can
only be that whatever effect smoking in movies has is small in relation to
other influences which are acting to reduce uptake. Such a conclusion
needs to be taken into consideration when we discuss moves to direct
artistic expression in the name of health.
I do support R ratings (actually M15, as this is roughly the
Australian equivalent to an American R) for films that decidedly
glamourise or blatantly promote smoking. I do however believe that smoking
can be shown in films in ways that do not promote the product - without
having to be a hit-you-over-the-head health message.
While I agree the current system of ratings for films has to be
considered in any realist...
I do support R ratings (actually M15, as this is roughly the
Australian equivalent to an American R) for films that decidedly
glamourise or blatantly promote smoking. I do however believe that smoking
can be shown in films in ways that do not promote the product - without
having to be a hit-you-over-the-head health message.
While I agree the current system of ratings for films has to be
considered in any realistic smoking in movies tobacco control strategy,
why doesn't the system that supports the absurdity of counting F-word
instances merit questioning? I appreciate that supporters and researchers
of smokefree movies have done the hard yards and found a solution to
eliminate tobacco promotion that best fits with the American moving making
and rating system. That doesn't mean that those of us who are relatively
newish to the debate cannot argue that the blunt instrument of an
automatic R rating that equates seeing any onscreen smoking as enticing
children to smoke is a poor tool.
Yes, movie making is a business, and as the current economic climate
attests, businesses must be regulated in order to protect the public
interests. But is this black and white form of regulation truly the ONLY
way forward?
Disclaimer: Simon Chapman is my PhD supervisor but my opinions are my own.
The responses so far to Dr. Chapman's article have missed the
fundamental point of his argument: that a policy requiring an R-rating for
any movie which depicts smoking is a narrow-minded one that treats smoking
differently than other dangerous health behaviors depicted in films and
which fails to address the overall public health problem of the media
portrayal of unhealthy behaviors.
The responses so far to Dr. Chapman's article have missed the
fundamental point of his argument: that a policy requiring an R-rating for
any movie which depicts smoking is a narrow-minded one that treats smoking
differently than other dangerous health behaviors depicted in films and
which fails to address the overall public health problem of the media
portrayal of unhealthy behaviors.
In order to defend the policy from Dr. Chapman's criticism, one would
have to justify why smoking should be treated differently than the myriad
of other unhealthy behaviors shown in films that influence adolescent
behavior: violence, unprotected sex, alcohol abuse, sexual abuse, and
physical abuse. While Smoke Free Movies and other public health groups are
calling for a single depiction of smoking - under virtually any
circumstances - to automatically trigger an "R" rating, they fail to argue
that depictions of violence, alcohol abuse, and sexual or physical abuse
should similarly trigger an automatic "R" rating.
In fact, this narrow-minded approach results in the rather perverse
result of having these organizations publicly "endorse" (with a thumbs-up
rating) a number of movies which don't depict smoking, but which show
alcohol abuse, violence, and spousal abuse.
Dr. Klein makes an attempt to differentiate smoking by arguing that
unlike these other behaviors, it is addictive. This argument not only
fails (alcohol is also an addictive drug) but seems irresponsible, since
it sanctions the depiction of violence and abuse on the grounds that these
are not addictive behaviors.
The ultimate point which Dr. Chapman makes is that we in tobacco
control must maintain a wide, public health-based view of societal
problems and avoid looking at the world with blinders so that all we see
are problems related to smoking. We should not be a single issue-oriented
movement; we should be a public health movement that is concerned about
all threats to the well-being of the public.
Simon Chapman's editorial supports business as usual for Hollywood.
By considering only the commercial element of paid product placement, he
ignores that making films in Hollywood is a business. Free artistic speech
is a fundamental right that everyone in Western societies supports, but
Hollywood uses it as a mantra to avoid changing how they do business.
Movies are a combination of art and business, just like many othe...
Simon Chapman's editorial supports business as usual for Hollywood.
By considering only the commercial element of paid product placement, he
ignores that making films in Hollywood is a business. Free artistic speech
is a fundamental right that everyone in Western societies supports, but
Hollywood uses it as a mantra to avoid changing how they do business.
Movies are a combination of art and business, just like many other
products that include artistic design elements, such as cars, furniture
and appliances. Movie production includes negotiations about what is
suitable for the audience and what sells tickets. Big movie producers
shoot several endings and focus group tests determine which one to use and
decide on the rating they want before they shoot a frame. That’s why an R
rating for smoking would simply cause them to leave smoking out of films
aimed at kids. Just as they trim violence and sex to get the rating they
want, they would also trim the smoking.
Chapman unfairly criticizes the Smoke Free Movies R-rating proposal
under the “Banning all Smoking in Movies” section of his editorial. In
the R rating proposal, smoking triggers and R rating not a ban. Movie
ratings systems are designed to warn parents of unsuitable content. We
are used to thinking of violent content as unsuitable, and few one
question that trigger. The research that links movie smoking with kid
smoking is new, but it is also very compelling, with movies being
responsible for one-third to one-half of youth smoking onset. Movie
ratings systems are designed to warn parents of unsuitable content. From
a health perspective, trying smoking is one of the biggest mistakes an
adolescent can make. Surely this warrants an R-rating as much as using
the “F” word twice, one of the current MPAA triggers.
Chapman argues against an R rating because it would not prevent all
children from seeing all smoking onscreen. No one has ever suggested that
the R rating would eliminate exposure to onscreen smoking for all
adolescents, just reduce it. The average R-rated movie is seen by only
14% of young adolescents, compared to about 30% for a typical PG-13 movie
(see Sargent, J. D., S. E. Tanski, et al. (2007). Exposure to Movie
Smoking Among US Adolescents Aged 10 to 14 Years: A Population Estimate.
Pediatrics 119(5): e1167-1176). Movie producers know that fewer
adolescents see R rated movies; that's why they fight an R rating for
smoking.
Because so many adolescents see smoking in PG and PG-13 movies,
rating smoking R would cut exposure to onscreen smoking in newly released
movies by about half, without violating anyone's free speech rights. This
would reduce smoking onset because, as Chapman himself notes, exposure to
onscreen smoking causes adolescents to smoke. But the trigger has to be
unambiguous, or Hollywood will just announce the incorporation of smoking
into the ratings system and then do nothing, maintaining its business as
usual stance. Fortunately, smoking is as easy to recognize in movies as
the "F" word.
Zhu et al. reported that 0.3% of men who were exclusive current smokers in 2002 became smokeless tobacco users at follow-up in 2003 (1). Similarly, they reported that 1.7% of men who were former smokers of one year or less duration and 0.3% of men who were former smokers for a longer time were smokeless tobacco users in 2003.
These percentages are quite small, prompting the first author to issue a statement in...
Nitzkin and Rodu raise several interesting points about harm reduction and how they would like to see the current FDA bill (HR1108/S625) be improved [1]. However, the purpose of Zhu et al.’s paper is not to advocate for or against harm reduction. It is simply to examine whether current US data replicate the Swedish results [2].
If large numbers of US smokers could be induced to switch to smokeless tobacco, tha...
Zhu, et al., when comparing tobacco-related behaviors in the U.S. and Sweden concluded that “promoting smokeless tobacco for harm reduction in countries with ongoing tobacco control programs may not result in any positive population effect on smoking cessation.” [1]
We believe that this conclusion is too pessimistic.
Promotion of snus in the U.S., as a low-risk alternative for smokers unable or unwillin...
A recent article in Tobacco Control 1 reported that 33% of cigarettes are consumed by smokers who had a current mental disorder. The title, abstract and discussion of that article stated that this 33% represented how much “mental disorders contribute to tobacco consumption in New Zealand.” This statement is misleading for at least two reasons. First, although 33% of smokers had a current mental disorder, 21% of nonsmok...
It is known that smoking increases DHEAS, the precursor of DHEA. The same should happen because of exposure to secondhand smoke.
DHEA is the active molecule, so increases in DHEAS may indicate that smoking is reducing DHEA. DHEA is known to be important to normal pregnancy-associated outcomes.
I suggest the findings of Peppone, et al., may be explained by reduced DHEA in these women.
In their article, “Existing technologies to reduce specific toxicant emissions in cigarette smoke,” RJ O’Connor & PJ Hurley list technologies that, they propose, manufacturers could use to comply with ceilings on nine smoke constituents proposed by the WHO Study Group on Tobacco Product Regulation (TobReg).
Initially, it is important to address any conjecture that these ceilings will reduce the harm cause...
Jim Sargent says I support business as usual for Hollywood. What I emphatically and unapologetically do support is business as usual for consistency. R-rating of any scene of smoking invites unavoidable questions about parallel controls on a wide range of activity that an equally wide range of interest groups would wish to see implemented in the name of health, religion or morality. Jonathan Klein implies that because ni...
I do support R ratings (actually M15, as this is roughly the Australian equivalent to an American R) for films that decidedly glamourise or blatantly promote smoking. I do however believe that smoking can be shown in films in ways that do not promote the product - without having to be a hit-you-over-the-head health message.
While I agree the current system of ratings for films has to be considered in any realist...
The responses so far to Dr. Chapman's article have missed the fundamental point of his argument: that a policy requiring an R-rating for any movie which depicts smoking is a narrow-minded one that treats smoking differently than other dangerous health behaviors depicted in films and which fails to address the overall public health problem of the media portrayal of unhealthy behaviors.
In order to defend the polic...
Simon Chapman's editorial supports business as usual for Hollywood. By considering only the commercial element of paid product placement, he ignores that making films in Hollywood is a business. Free artistic speech is a fundamental right that everyone in Western societies supports, but Hollywood uses it as a mantra to avoid changing how they do business. Movies are a combination of art and business, just like many othe...
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