Kawaldip Sehmi's letter seems to advocate ignorance and a kind of
book-burning attitude to understanding this area. But in fact, better
knowledge of the science might help his cause.
The paper by Enstrom and Kabat caused problems not because its
findings conflicted with the established evidence base, but because it was
flawed and the BMJ failed to put its contribution in context with the rest
of the large evidenc...
Kawaldip Sehmi's letter seems to advocate ignorance and a kind of
book-burning attitude to understanding this area. But in fact, better
knowledge of the science might help his cause.
The paper by Enstrom and Kabat caused problems not because its
findings conflicted with the established evidence base, but because it was
flawed and the BMJ failed to put its contribution in context with the rest
of the large evidence base. In contrast, Jonathan Foulds and his
colleagues have done a good job at dispassionately examining and
presenting the evidence on snus in Sweden, and the comparison with Enstrom
and Kabat is unjustified.
Here are two examples where the developments that flow from this
analysis may work to the advantage of the community Kawaldip Sehmi is
concerned about (and where his ideas might cause more harm)...
If a regulatory framework was introduced in Europe for smokeless
tobacco as part of unbanning snus (and this is what the harm reduction
supporters are pressing for), it is likely many of the South Asian
imported products would not meet the standard and have to come off the
market. There may be a market response that reduced the hazardousness of
the range of products available to the S. Asian community - either becase
the S. Asian manufacturers would comply, or because other compliant
products would enter the market to meet the gap. This would be an
improvement on the status quo.
Science might also help re-think the evidence-free campaign to get
these other smokeless tobacco products banned - in the UK or in S. Asia.
How do the campaigners know that the former smokeless tobacco users would
turn to the much higher risk smoking products? How do they know that those
that would have started to use smokeless products would not just start to
smoke instead? (and this would be a great opportunity for predatory
cigarette companies). If they do, then they will be at much higher risk.
In taking that gamble, what are the campaigners hoping to achieve through
a prohibition and do they mind if some people are at greatly increased
risk as a result of their idea? When Sweden joined the EU it was granted
an exemption from the ban on oral tobacco - and it is a good thing too,
because there would be more Swedish smokers now if the ban had been
imposed. From reading Foulds et al's paper even the most extreme flat
earth "quit or die" advocates cannot think that the EU's ban should be
extended to Sweden - surely! But if not, why not? And if not in Sweden,
should that give prohibitionist campaigners pause for thought about their
campaigns to achieve this elsewhere? Sweden's experience issn't
necessarily applicable everywhere - but it is a reason for caution about
banning smokeless tobacco anywhere.
Please let's have less talk of editorial orifices and recognise that
Tobacco Control journal and its editor are doing public health a service
by shining light on this murky former no-go area and challenging some ill-
considered orthodoxies.
Last week in the BMJ 2003; 327 (6 December), after seeing his
comments on the Enstrom and Kabat paper on second-hand smoke being used by
Forest to advance the tobacco industry’s position, the BMJ Editor says in
a fair and frank admission:
"Reading the quote on a Forest advertisement tightens my anus, but I
wrote it and can't deny it."
Health Professionals who have been working hard towards getting
che...
Last week in the BMJ 2003; 327 (6 December), after seeing his
comments on the Enstrom and Kabat paper on second-hand smoke being used by
Forest to advance the tobacco industry’s position, the BMJ Editor says in
a fair and frank admission:
"Reading the quote on a Forest advertisement tightens my anus, but I
wrote it and can't deny it."
Health Professionals who have been working hard towards getting
chewing tobaccos banned in the many South Asian Communities in the UK had
been using the Snus ban to advance their argument. Many now feel that the
Tobacco Industry will use this paper, as was the Enstrom/Kabat paper in
the reversal of Second Hand Smoke Ban Policies, to undermine the whole
smokeless tobacco ban strategy.
In our experience, chewing tobaccos (many are packaged in shining
packets to entice kids) are the gateway to up taking of smoking later. The
child starts by using a "mouth freshener" pack of Gutkha tobacco and then
after getting addicted to nicotine in the smokeless tobacco, advances to
taking up smoking.
At the 12th World Conference on Tobacco and Health in Helsinki (3-8
August 03), the last smokeless tobacco session was heated and electric.
Bengali, Indian and Pakistani health professionals were concerned about
the impact the lifting of the flood gates of an EU ban would have on their
public health efforts to get gutka, zarda and other smokeless tobacco
banned.
UK South Asian Communities and their use of smokeless tobacco were
seen as the crack/ loophole in EU/UK Tobacco Control Legislation. The Snus
vehicle/bandwagon could be driven through this. This study has just given
the tobacco industry the starter key.
We brace ourselves now. What orifice will the BMJ Editor tighten next
time when this study is used in the undermining of smokeless tobacco use
in the future?
Watching this first salvo in the battle over whose nicotine is safer
and which side eventually makes the big nicotine maintenance bucks, Big
Pharm or Big Oral Tobacco, is sad yet understandable? Even for those few
without any financial stake in the debate, imagine the natural
frustrations born from having turned the wrong research or policy corner
and dedicated two decades of your life to having chosen to fight nicotine...
Watching this first salvo in the battle over whose nicotine is safer
and which side eventually makes the big nicotine maintenance bucks, Big
Pharm or Big Oral Tobacco, is sad yet understandable? Even for those few
without any financial stake in the debate, imagine the natural
frustrations born from having turned the wrong research or policy corner
and dedicated two decades of your life to having chosen to fight nicotine
addiction by feeding nicotine addicts more nicotine.
We've already watched as half-baked pharmaceutical financed science
undertook the intentional destruction of the credibility of earth's most
productive means of nicotine dependency recovery. We watched as Big Pharm
bought the policy door keys and embarked upon a massive campaign to erase
earth's most productive tool from cessation literature around the
globe.[1] In exchange for what, the Swedish experience or NRT?
Before throwing in the towel wouldn't a bit of reflection upon where
your last campaign took us be in order? You threw out the baby with the
bathwater in declaring the life's work, and the daily dependency recovery
programs of thousands, to be unscientific. Why grab hold of a shark when
drowning, when the water is just five feet deep?
The March 2003 OTC NRT meta-analysis published here in TC found that
only 7% succeeded in remaining smoke-free at six months.[2]
A November 2003 persistent NRT use study, also published here in TC,
suggests that as many as 7% of gum users may still be chewing nicotine at
six months.[3] If true, who actually broke free from nicotine while using
it? Unlike the one puff lesson that can eventually flow from repeated
attempts at abrupt cessation, we've known since 1993 that the only lesson
flowing from repeated NRT use is that the odds of relapse increase to
nearly 100%,[4] but that too has been kept a secret from those who needed
to know.
Overzealous public health officials must be held accountable for the
demise of highly effective community-based abrupt nicotine cessation
programs, many of which were achieving 40% midyear nicotine cessation.[5]
Imagine a mind so convinced its right that its willing to pervert the term
"science based" and use it as a weapon in order to destroy the credibility
of superior performance, so that it can claim market share and carry out
its own grand insane nicotine weaning experiment.
Now it's almost as if many of those same so called "experts" who so
badly damaged worldwide cessation (some of whom have never personally
conducted a single cessation clinic program themselves)have given-up on
dependency recovery and embarked upon a massive new social experiment to
try and transfer their failure to "safer" forms of delivery.
Worldwide cessation is in shambles and now we must watch as those
who've made the mess argue whether sloshing nicotine-rich tobacco juices
around in the mouth or allowing NRT to at last live up to its name -
"replacement" not "cessation" - is the answer to all our problems.
No one here argues with the logic of cleaner delivery but we should
all be deeply troubled by the knee-jerk cattle herding tactics and
priorities already employed by those now pushing transfer to "safer"
delivery. Many teach at institutions whose graduates mold society yet
somehow they seem unable to comprehend that, to one degree or another,
every graduate of effective community-based recovery programs became
recovery teachers themselves. High quality short-term abrupt cessation
education, skills development and support programs have now all but
vanished, having lost funding and favor after having been declared non
science-based, and overrun by those toying with months of weaning.
I submit that all nicotine dependent humans are entirely capable of
quitting. I submit that any attempt by science to put a positive spin on
any form of nicotine dependency should cast science in the same mold as
any other drug pusher, as more humans, not less, will become dependent.
I'm not talking about true harm reduction efforts but marketing spin and
easy access that will inevitably snare the curiosity and lives of untold
thousands of youth.
We need only look to Nicorette's current nicotine gum marketing spin
to begin to imagine just how out-of-hand a license to push daily
maintenance will quickly become.
Its website asserts that "Once in your brain, nicotine begins
working. It stimulates the secretion of neurotransmitters (chemicals in
the brain), which appear to enhance awareness and judgment. Nicotine also
increases dopamine levels, improving your mood. The substance has also
been known to even enhance memory and reduce aggression." ... "Heightened
awareness. Enhanced judgment. Better moods. Adrenaline boosts. No wonder
cigarette smoking is hard to quit."[5]
Imagine the tactics that will be employed by the tobacco industry
once Pandora's box is fully opened. Just one question, why would you again
demand the entire world as your stage when any damage could have been
limited to small test communities? It's probably a good thing that TC
does not require disclosure of financial interests. Profits or science?
[1] Polito, Is cold turkey quitting more productive and effective
than NRT? WhyQuit, July 2003 -
http://whyquit.com/whyquit/A_Cold_Turkey.html
[2] Hughes, JR, Shiffman, S, et al., A meta-analysis of the efficacy
of over-the-counter nicotine replacement . Tobacco Control, March
2003;12:21-27 - http://tc.bmjjournals.com/cgi/content/full/12/1/21
[3] Shiffman S, Hughes JR, et al, Persistent use of nicotine
replacement therapy: an analysis of actual purchase patterns in a
population based sample, Tobacco Control 2003 November; 12: 310-316 -
http://tc.bmjjournals.com/cgi/content/abstract/12/3/310
[4] Tonnesen P, et al., Recycling with nicotine patches in smoking
cessation. Addiction. 1993 Apr;88(4):533 -
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8485431&dopt=Abstract
[5] CDC Sept. 4, 1992 MMWR, Public Health Focus: Effectiveness of
Smoking-Control Strategies, United States -
http://www.cdc.gov/mmwr/preview/mmwrhtml/00017511.htm
[6] Nicorette website, How smoking affects your body.
http://nicorette.quit.com/nicr_internal/nrt1.asp
Foulds et al‘s e-response [1] provides an excellent and scathing critique of the commentary contributed by Tomar et al [2]. Though Foulds et al are far too modest to point this out,
it is important that readers understand that their original review [3] is a substantial and careful piece of work, properly edited and peer-reviewed. In contra...
Foulds et al‘s e-response [1] provides an excellent and scathing critique of the commentary contributed by Tomar et al [2]. Though Foulds et al are far too modest to point this out,
it is important that readers understand that their original review [3] is a substantial and careful piece of work, properly edited and peer-reviewed. In contrast, while Tomar et al response [2] has the appearance of an evidence review, it is a commentary that has not
been peer-reviewed. As Foulds et al [1] very ably demonstrate, their commentary is little more than a catalogue of misinterpretation, misunderstandings and non sequiturs that would not withstand even the most cursory peer review. It is troubling that it stands published in
the paper edition of Tobacco Control, appearing to the untrained eye to have equal status to and, worse still, the last word on the excellent work by Foulds et al [3].
The paper by me and colleagues, Bates et al [4], is not an attempt to review the literature, as this has been done elsewhere and anyone wishing to have an objective appraisal of the evidence can do so. Our attempt was to develop a conceptual and ethical framework for
discussing and managing harm reduction, and to suggest what implications the science has for policy in Europe. Kozlowski et al [5] provide a welcome continuation of that effort by discussing what sort of evidence is required to justify action (or a move from the evidence-free support of the status quo) and remind us that real people are involved by invoking the ‘what-to-tell-your-brother’ thought experiment – which they address with a sane and humane argument.
A disturbing aspect of Tomar et al’s contribution is the way that convoluted argument and a blizzard of mostly meaningless statistics have been deployed to make some sort of case against harm reduction. The style is reminiscent of the ‘keep the controversy alive’ strategies of the tobacco industry – the sort of thing we have seen for years purporting to demonstrate that there is no link between smoking and lung cancer or that passive smoking is harmless. Indeed if distraction was the aim, they will probably be successful. Such
obfuscation is a gift to timid law-makers and regulators seeking an excuse for continuing inaction.. The question is, what are they trying to achieve? And who’s interests do they think they are protecting? At least with the tobacco industry, that bit is obvious.
Equally disturbing is the profound bias against the use of common sense and “reality checking” that Tomar et al display. Many of the findings in Foulds et al [3], and drawn upon in Bates et al [4], are not at all surprising. In case anyone is
disorientated by the arguments here are a few pointers back to the real world:
It is hardly surprising that use of snus is much less hazardous than smoking tobacco. The latter involves drawing a toxic mixture of volatile organics, oxidants and super-heated reactive particulates into the delicate tissues of the lungs. The former doesn’t – there are no
products of combustion or inhalation.
It is hardly surprising that snus would be useful in smoking cessation. NRT is agreed to be effective but in several respects snus has superior characteristic as a substitute for smoking. It offers a stronger bolus of nicotine and some of the other sensory aspects of
tobacco found in cigarettes but not in NRT. Why wouldn’t it be a better cessation aid for smoking than NRT?
It is hardly surprising that Swedish smokers might instinctively know snus is a safer option for continuing nicotine use because of the physical processes involved and therefore switch to it or use it from the outset to control their health risks.
It is hardly surprising that the desperate efforts to find a gateway effect have failed. Sweden has the lowest male smoking prevalence in the world but with high levels of snus use. If snus is a gateway then where are all the smokers emerging the other side of the snus gateway? Snus is a gateway out of smoking and an alternative to it for some that would otherwise smoke – that’s why male smoking
prevalence is so low.
It is hardly surprising that male smoking in Sweden is the lowest in the developed world, and I think the only place where male prevalence is below female. The obvious unique factor is that many men in Sweden use their tobacco and get their nicotine in a different way – through snus. The effort that has gone into denying this simple truth
is astonishing. But the corollary of claiming that snus doesn’t contribute to the low male prevalence is that some other reason must be found, and that the use of snus is in effect additional to smoking. It means male smoking is held at a record low level by some other factor that no-one can convincingly identify. In fact it would be very
surprising if the widespread use of tobacco in another form didn’t reduce smoking, as these are substitute products.
It is hardly surprising that female smoking is also low, even though there is little snus use among women. Admittedly, some of this may be due to Sweden’s tobacco control efforts – but there are no plane-loads of experts from California, Atlanta or Massachusetts trying to discover the secrets of Sweden’s amazing results on per capita programme spend of about one tenth of the top US programmes. There is a less surprising explanation. Doesn’t the tobacco control community see ‘de-normalisation’ as one of the most important approaches. This justifies tireless campaigning for smoke-free environments in the hope that it will de-normalise smoking, remove sensory cues to smoke and provide a temptation-free environment that supports quitting. But
this is exactly what snus use does. And furthermore, it takes the denormalisation of smoke into the home. It would be very surprising if snus use among men in Sweden didn’t drag down female smoking through de-normalisation.
It is hardly surprising that sane public health advocates should call for snus to be un-banned in Europe and no longer lied about in the US. There are no precedents we can think of for banning a many-times
less hazardous variant of the market leader (in this case cigarettes). In fact, if it was attempted in any other area of public life, we would think the perpetrators were acting immorally, and probably illegally. Banning a much less hazardous version of a product that causes a great
deal of harm is just plain dumb.
It is not surprising that the widespread use of a much less hazardous alternative to the market leader tobacco product reduces harm and has a net public health benefit both through reducing active smoking and passive smoking exposure. What is surprising is that legislators in Europe have decided to deny smokers outside Sweden the
option to use products like this to take control of their risks, and have thereby stopped a market in harm reduction products developing. The equivalent American approach appears to be to do this by misleading smokers about smokeless tobacco. Sadly, this credibility-busting
tactic seems to have spread to the once-authoritative US Surgeon General in his recent testimony to Congress, thus supporting those that wish to devalue the science base underpinning tobacco control.
Of course, the fact that something isn’t surprising doesn’t make it so – but common sense is a good starting point for reality-checking very convoluted, tenuous or unconvincing arguments [2] and gives extra confidence when careful assessment of the evidence converges with our understanding of how the real world and real people work [3].
Finally, I would like to say that I think this is actually quite a simple issue, not the great complex challenge that some suggest. It is beyond doubt that smokeless tobacco products are much less hazardous and can substitute for the market leader, cigarettes. No-one has the right to stop nicotine users taking responsibility for their health by switching to such products if they choose to or cannot or will not give up tobacco or nicotine. Where did Tomar et al, the US Surgeon General, the European Union and others acquire the authority and astonishing high-handedness to sit in their smoke-free citadels and deny smokers these potentially life-saving choices?
I think a strong regulatory framework is a good idea and that there is an opportunity to achieve it in Europe, if the tobacco control community is clear that its goal is to reduce death and disease, not just have fights with the tobacco industry. But should a new regulatory framework be a pre-requisite for moving from the status quo in which this option is banned outright in the EU? Well, I
also think that the status quo is unacceptable - banning a product that is so much less hazardous than the market leader is such an egregious violation of the right of smokers (and potential smokers) to contain the severe risks they face, that it should be reversed even under the
current regulatory environment.
Should American campaigners be honest with the public about relative risks of smokeless and smoking? In my view there is not even an overwheening paternalist case for misleading people about this, let alone a respectful, honest, citizen-focussed public health justification.
Clive Bates [Former director of Action on Smoking and Health UK, writing in a personal capacity]
[1] Foulds J, Ramstrom L, Fagerstrom K. Effects of smokeless tobacco in Sweden: a reply to Tomar et al. Tobacco Control Online, 5 Dec 2003
[2] Tomar SL, Connolly GN, Wilkenfeld J, et al. Declining smoking in Sweden: is Swedish Match getting the credit for Swedish tobacco control’s efforts? Tobacco Control 2003;12: 368-371
[3] Foulds J, Ramstrom L, Burke M, et al. Effect of smokeless tobacco (snus) on smoking and public health in Sweden. Tobacco Control 2003;12: 349-359
[4] Bates C, Fagerstrom K, Jarvis MJ, et al. European Union policy on smokeless tobacco: a statement in favour of evidence based regulation for public health. Tobacco Control2003;12 360-367
[5] Kozlowski LT, O’Connor RJ, Quinio Edwards B. Some practical points on harm reduction: what to tell your lawmaker and what to tell your brother about Swedish snus. Tobacco Control 2003;12:372-373
The earth is flat, ABBA couldn’t sing a song, Scotland is going to
win the soccer World Cup sometime soon, and snus has played no part in the
reduction in smoking prevalence among Swedish men – or so Tomar et al.
[1]would have us believe. Of all of these issues not remotely supported by
the evidence, the last one is a little more serious in that it may influence
tobacco control...
The earth is flat, ABBA couldn’t sing a song, Scotland is going to
win the soccer World Cup sometime soon, and snus has played no part in the
reduction in smoking prevalence among Swedish men – or so Tomar et al.
[1]would have us believe. Of all of these issues not remotely supported by
the evidence, the last one is a little more serious in that it may influence
tobacco control policies that will affect the lives (and premature deaths) of
millions of people. We therefore feel the need to respond to the plethora of
inaccuracies contained in Tomar et al’s commentary on our review of
the effects of snus in Sweden.[2]
1. Misrepresentation of our review
Tomar et al’s commentary misrepresents our paper throughout. For example,
it states in the second paragraph that a section of Bates et al’s [3]article
cites only three reports and that our review adds "little additional
evidence". We can only assume that Tomar et al. were missing some of
the 11 journal pages, 8 figures, 2 tables and 66 references of evidence. Our
concern that Tomar and colleagues may have been missing some pages was
strengthened when they accused us of ignoring a recently published critical
review by Critchley et al. [4] on the health effects of smokeless
tobacco. On the contrary, our review not only cited the Critchley article, but
quoted its main conclusion verbatim:
"Chewing betel quid and tobacco is associated with a substantial
risk of oral cancers in India. Most recent studies from the US and Scandanavia
are not statistically significant, but moderate positive associations cannot
be ruled out due to lack of statistical power."[4] (quoted on p351)
Similarly, the accusation that "Foulds et al. pay little attention to
those other plausible determinants of patterns of tobacco use in Sweden"
seems rather strange as we stated plainly that:
"Both within and outside Sweden, smoking is primarily influenced by
factors other than availability of smokeless tobacco (for example, real price
of cigarettes, health education, smoke-free air policies, industry marketing
etc)." (p357)
Tomar et al asked, "Could any health professional seriously advocate
taking up oral tobacco as a means of preventing cigarette smoking? This seems
dangerously close to advocating oral opiod narcotics such as codeine as a
means of avoiding heroin use." However, as neither our nor Bates et al’s
articles mentioned a word about health professionals advising their patients
to use oral tobacco or codeine, (nor do we think that they should for those
purposes) we find this to be yet another example of the "straw man"
style of argument on which Tomar’s commentary was largely based.
2. Selective reporting of findings
Tomar et al accused us of selective reporting of findings. Any reviewer
given a word-limit by a journal has to make selective judgements. This is
problematic if methodologically strong studies, particularly those with
results that conflict with the conclusions of the review, are omitted. We
stand by the selection of both studies and results included in the review. For
example, Tomar et al cite two reports by Lindstrom et al. [5,6]
that we
did not mention. These reports were from a single study based in a single city
(Malmo) in the far south of Sweden. We did not include these reports because
they were located in a small part of Sweden where snus use is markedly less
prevalent than the country as a whole, as acknowledged by Lindstrom et al
(e.g. the daily snus prevalence of 7% in men reported in the study is about
one third of that for the country as a whole). Basing conclusions about snus
use in Sweden on a study based exclusively in Malmo is like basing conclusions
on smoking and smokeless use in the USA on studies in Utah. Given that
Lindstrom et al. [5] concluded that:
"Snuff consumption may explain a part of the increase in smoking
cessation among men as opposed to women in Sweden,"
we were also confident that this is not an example of omitting studies that
don’t agree with the review’s conclusions.
The other cohort study cited by Tomar et al [7] was flawed because
it ignored the effect of the change in wording of the questions on snus in the
Living Conditions surveys after 1980-81. The 1980-81 survey simply asked,
"Do you use snus?" (thus including both daily and occasional users)
whereas the subsequent surveys asked specifically about daily and occasional
use.[8] This study therefore mistakenly compared all snus use in
1980-81 with only daily use in 1988-9.
As a test of who has "selectively reported findings", lets
compare our reporting on the prevalence of smoking in young people, and that
of Tomar et al. We summarized the data as follows:
"Looking only at daily smoking prevalence among 16 year olds in
Sweden, this has remained remarkably stable at around 11% for boys and 16% for
girls for the past 20 years." (p357)
Tomar et al, on the other hand, state that:
"Between 1981 and 2001 daily smoking declined more rapidly for
15-16 year old girls (23% to 16%) than boys (13% to 10%), snus use remained
rare among girls, and the sex difference in smoking prevalence decreased."
The full data for daily smoking prevalence by sex for 1981 to 2001 are
shown in the figure below.[8] We’ll let the readers decide whether
this shows a more rapid decline for girls or a stable pattern (other than
normal fluctuations due to sampling differences and factors affecting both
sexes equally such as price changes). We’d suggest that the 1981 figure for
girls smoking prevalence was an outlier (possibly associated with changes in
the wording of the survey questions and definitions of "daily
smoking" that took place 1981-3), and that choosing to emphasize it is an
example of Tomar et al’s own "selective reporting"
Prevelance of daily smoking in Sweden by
boys and girls ages 15 and 16 with linear regression lines.
From annual surveys by CAN, Swedish Council for Information on Alcohol and other
Drugs
3. Tomar et al’s errors in critical appraisal of health effects of snus
Tomar et al. accuse us of "misinterpreting the findings from the Lewin
et al. study", claiming that we cited only the univariate analyses of
results. On the contrary, in addition to their confusion over whether they
were quoting relative risks or odds ratios, Tomar et al chose to cite the
results of the univariate analyses based on only 9 cases and 10 referents (not
controlling for factors such as alcohol use). We concurred with the authors of
the original article [9] in choosing to emphasize the results based on
a larger number of cases after adjusting for factors such as smoking and
alcohol consumption.
Tomar et al also chastized us for "ignoring" the Institute of
Medicine Report.[10] We did in fact cite that report and its findings
many times, but perhaps we should have gone further and quoted that report’s
conclusion on snus and oral cancer:
" In Sweden, there is a very high rate of Swedish snuff (snus) use.
But, the use of snus in Sweden has generally not been associated with oral
cavity cancer (Idris et al, 1998; Kresty et al, 1996; Lewin et al, 1998;
Nilsson, 1998; Schildt et al, 1998). Snus is not fermented and so has a much
lower level of N-nitrosamines (Nilsson, 1998) and has a lower genotoxic
potential (Jansson et al, 1991), which might be related to the lack of
increased risk." Institute of Medicine, [10] 2000, p428, para
2.
Again, it is apparent that our choice not to draw from that report more
heavily was not because it contradicted our overall conclusions. In
fact the IOM report’s assessment of the snus-cancer relationship is at odds
with that of Tomar et al. Perhaps Tomar et al feel that the IOM report was
also, "uncritical, misinterpreted the findings", or is "illustrative
of the type of simplistic conclusions that might be reached when the nuances
of epidemiologic research are not fully appreciated, findings are not fully
evaluated." Or perhaps it is Tomar et al. who are out on a limb in
their interpretation of the evidence?
Among the litany of inaccurate criticisms and repetitions of points that we
and others have already made (e.g. the need for proper regulation of tobacco
and medicinal nicotine products,[2,11] the possible
cultural-specificity of Sweden’s experience,[2] etc), Tomar et al
made two potentially substantive points: those relating to the pattern of
cohort effects in Sweden, and their suggested alternative explanation for the
sex-difference in Sweden’s smoking prevalence.
4. Birth-cohort patterns relating smoking and snus use.
Tomar et al suggested that the people who initiated snus use in Sweden are
not the same people who have quit smoking, and present an analysis of birth
cohort effects claiming to demonstrate this. They compared the snus use
prevalence among males in different age groups (16-24, 25-34 etc) in 1988/89
with the prevalence of snus use with a different sample (but born in the same
years) collected in a survey in 1996/97. They then compared this with the
relatively small reduction in cigarette smoking prevalence between 1989 and
2000 among different samples from the same birth cohort (offering no
explanation for the change in survey year, to 2000, for the smoking analysis).
They imply that the relatively large increase in snus use and the relatively
small reduction in prevalence of daily cigarette use within the same age
cohort (if not the same sample) shows that the snus use increase and smoking
cessation are independent phenomena.
There are major problems with this analysis, some of which stem from the
fact that the changes in tobacco use are not based on the same people over
time. It is no big surprise that people tend to take up tobacco use when they
are young and try to stop it when they are older (as they do for just about
every other kind of substance use). It is perfectly plausible that despite
this being the over-riding pattern of snus and cigarette use, a meaningful
proportion of smokers in the older age cohorts take up snus (sometimes
temporarily) as a way of stopping smoking and are more successful in their
quit attempt as a consequence. So long as this number is smaller than the
number ceasing snus use (without having smoked), one wouldn’t necessarily
observe an increase in snus prevalence in these older age groups. This is
particularly likely when a sizable proportion of those taking up snus to
replace smoking do so only on a short-term basis, ending up tobacco free by
the next survey. The cohort analysis presented by Tomar et al. is therefore
irrelevant to the issue of whether men who quit smoking were helped to do so
by snus.
A recently published study [12] followed the same cohort of
3244 (75% of the original 4349) participants in the 1980-81 National Survey of
Living Conditions through the 1988-9 and 1996-7 surveys. A strength of this
data-set is that it follows the same participants over a long time period (16
years), and the weaknesses are that those participating tended to be have
slightly lower smoking prevalence than non-participants, some participants
were lost to follow-up (201 men and 129 women due to death) and snus use was
not reported in the published paper. As shown in the table below, smoking
prevalence fell uniformly across the birth cohorts for men (around –14%
prevalence) but the reduction in smoking in women was greater in the younger
age group (-16% in those aged 18-25 in 1980-1, compared with –3% in those
aged 66-73 in 1980-81), and lower overall in women than men (-9 vs –14).
This study did not report snus use data in this cohort and we do not believe
it is appropriate to guess it based on prevalence in a different sample.
However, it is noteworthy that male snus use (occasional plus regular)
increased in Sweden from 16.6% to 25.4% from 1980-81 to 1996-7. Thus a higher
proportion of male than female smokers have succeeded in quitting smoking in
every age group except for 18-40 (most likely due to the extra boost to
cessation surrounding pregnancy in women), and a much higher proportion of men
than women use snus in every age group. The question of how many men quit
smoking by using snus is best addressed by other surveys (discussed below).
Men (n=1834)
Women (n=1610)
Agein
1980-1
% Smoking
1980-1
% Smoking
1988-9
% Smoking
1996-7
% Smoking
1980-1
% Smoking
1988-9
%
Smoking
1996-7
Change in
Smoking 1980-97 (Men)
Change in
Smoking 1980-97 (Women)
18-25
32
27
18
41
34
25
-14
-16
26-33
36
29
21
41
38
31
-15
-10
34-41
40
32
26
36
33
29
-14
-7
42-49
28
22
15
33
27
23
-13
-10
50-57
30
23
15
23
21
16
-15
-7
58-65
27
17
11
17
13
10
-16
-7
66-73
32
24
18
12
12
9
-14
-3
Total Population
33
26
19
32
28
23
-14
-9
Table 1. Prevalence of daily smoking in Sweden in a cohort recruited in
1980-1 and followed up in 1988-9 and 1996-7, by sex and age in 1980-1.[12]
5. Is the sex difference in smoking prevalence due to fewer women in the
smoke-free workplace?
Tomar et al. proposed a speculative and entirely evidence-free explanation
for the differences in smoking prevalence trends for men and women in Sweden:
Smokefree workplace regulations have prompted more men than women to quit
because a lower proportion of women than men are in full time employment (i.e.men
are more likely to be impacted by smokefree workplace regulations).
One thing that doesn’t seem to fit with that is the data on the older age
groups presented in the table above. Those aged 50+ in 1980-1 in that data
would mostly have retired from the workforce by 1996-7 and so might be less
affected by workplace smoking bans. However, despite that, the sex-difference
in cessation is actually stronger in that age group than any other.
Similarly, at the opposite end of the age spectrum, the sex differences in
smoking among school children (shown above) cannot be explained by policies on
smoke-free environments as boys and girls in Sweden are subject to the same
school environment. Examination of the 2002 Swedish Survey of Living
Conditions smoking data [8] by profession also casts doubt on Tomar et
al’s proposal. For examples, among adult students (presumably both sexes
sharing the same campus environment), 11.6% of men smoke compared with 18.6%
of women (no sign of a "gateway effect" here either). Among lower
level office staff, smoking prevalence in men fell from 32.6% in 1989 to 18.0%
in 2002, whereas the change was only from 29.0% to 26.4% for women. In short,
while smoke-free workplace legislation almost certainly triggers smokers to
try to quit, any (non snus-related) sex difference in the effects is extremely
unlikely to be of sufficient magnitude to account for the relatively large sex
differences in smoking patterns that occur even within occupational groups in
Sweden. More persuasive is the data from surveys on the use of snus as a
smoking cessation aid by Swedish men.
6. Use of snus as a smoking cessation aid.
Tomar et al failed to address the evidence [13-16] that a
substantial minority (around 30%) of Swedish men who had quit smoking, state
that they used snus to help them quit smoking. Rather strangely, Tomar et al
tried to brush this important piece of evidence under the carpet by stating
that "the majority" of men quit smoking without snus. If this
statistic had referred to the proportion of ex-smokers who quit by using some
other method (e.g. doctor’s/dentist’s advice, or use of nicotine
replacement therapy) we suspect that Tomar et al would have more honestly
acknowledged that anything that helps 30% of successful quitters to do so is
having a meaningful and important role in smoking cessation.
7. This is about Sweden, not the USA.
Tomar et al belatedly suggest that the rhetoric be toned down and that
their differing focus relates to differences between national regulations,
companies and products (presumably referring to differences between the USA
and Sweden). However, these national differences are not directly relevant
here because (for once) these papers were NOT about the U.S. These papers were
published in an international journal and focused very specifically on the
evidence to date in Sweden,[2] and the potential implications for
European policy.[3]
8. Both snus and Swedish tobacco control deserve some of the credit
Finally, we’d like to address another point made by Tomar et al – namely
that Sweden quite rightly deserves credit for its tobacco control efforts. In
addition to inventing nicotine replacement therapy, the Swedes have implemented
a number of positive tobacco control interventions and the reduction in smoking
prevalence among women (which has very little to do with snus use) has been
impressive. Sweden’s tobacco control movement has had a particularly strong
component designed to reduce tobacco use among women, thanks in no small part to
the efforts of Margaretha Haglund, who has also been the President of the
International Network of Women Against Tobacco (INWAT) for many years. However,
it is in that context of strong tobacco control measures, often targeting women,
that the larger reduction in smoking prevalence in Swedish men is all the more
remarkable. To deny that snus has played some part in that success (which is the
issue we were asked to review) is to deny the weight of the evidence.
Acknowledgements
Jonathan Foulds and Michael Burke are primarily funded by New Jersey
Department of Health and Senior Services. Jonathan Foulds, Karl Fagerstrom ,
and Lars Ramstrom have worked as consultants and received honoraria from
pharmaceutical companies involved in production of tobacco dependence
treatment medications. Lars Ramstrom has also received project support from
the Swedish National Institute of Public Health and salary from short term
employment with WHO. None of the authors has accepted any funding from the
tobacco industry.
Jonathan Foulds University of Medicine and Dentistry of New Jersey- School of Public health,
Tobacco Dependence Program, New Brunswick, USA
Lars Ramstrom Institute for Tobacco Studies, Stockholm, Sweden
Michael Burke
University of Medicine and Dentistry of New Jersey- School of Public health,
Tobacco Dependence Program, New Brunswick, USA
Karl Fagerstrom Fagerstrom Consulting and The Smokers Information Center, Helsingborg, Sweden
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cessation and smoking reduction among Swedish men. Addiction 2003; 98:1183-9.
I'd like to challenge the suggestion in this paper that mobile phone
use does not reduce smoking, simply because smoking teenagers are more
likely to own mobile phones.
The hypothesis advanced by Ann Charlton and I is that mobile phones
share some of the same charatcteristics that attract young people to
smoking (initiation to adult life, peer bonding, individualistic
expression, brand identification etc). I...
I'd like to challenge the suggestion in this paper that mobile phone
use does not reduce smoking, simply because smoking teenagers are more
likely to own mobile phones.
The hypothesis advanced by Ann Charlton and I is that mobile phones
share some of the same charatcteristics that attract young people to
smoking (initiation to adult life, peer bonding, individualistic
expression, brand identification etc). If this is the case, then they are
competing with smoking, and with other expenditures, for teenagers'
spending money. If this is the case, it wouldn't be entirely surprising
to see more mobile phone use among smokers that can afford both. We
implied that needs may be met by mobiles rather than smoking, but it is
possible that teenagers seek these attractive attributes from both mobiles
and smoking.
Whether mobile phone ownership reduces smoking is another matter...
and it depends on how teenagers that don't have a lot to spend or have
other things to spend their money on decide their priorities. It is quite
possible to reconcile higher use of mobile phones among smoking teenagers
with lower overall teenage smoking as a result of mobile phone use. The
difference would be in those non-smokers that would otherwise have become
smokers had they not chosen to spend their discretionary cash on mobile
phones instead of smoking. Those that would have been uninterested in the
shared attributes of smoking and mobile phones would tend neither to smoke
nor to make much use of mobile phones - hence a lower rate on average
among non-smokers even though. In other words, what matters is the
behaviour of the those wavering between smoking and not smoking, not the
overall averages.
Whether the fall in UK teenage smoking can be attrributed in any part
to the rise of mobile phone use is impossible to determine. It could have
reflected a period of adjustment in the spending patterns of young people
that eventually settled with the mobile phone being a 'must-have'
accessory rather than a choice. Smoking rates among teenagers have
remained lower than the high water mark of 1996, but are creeping up. As
teenagers have more spending money, more would be able to afford both.
PS. it remains a hypothesis and I don't claim it to be established as
true. I just don't think that it is convincingly falsified by this paper.
The abstract's conclusion that persistent use of nicotine gum is
"very rare" casts serious doubt upon the authors' objectivity. How can
they here describe a 6.7% chronic nicotine gum use rate at six months as
reflecting a 'very rare' condition while their March 2003 OTC NRT meta-
analysis - published in this same journal - embraced a 7% six-month
smoking abstinence rate finding as "effective?" [1]
The abstract's conclusion that persistent use of nicotine gum is
"very rare" casts serious doubt upon the authors' objectivity. How can
they here describe a 6.7% chronic nicotine gum use rate at six months as
reflecting a 'very rare' condition while their March 2003 OTC NRT meta-
analysis - published in this same journal - embraced a 7% six-month
smoking abstinence rate finding as "effective?" [1]
I do hope the FDA will lay the authors' March 2003 meta-analysis
beside this study's findings as the shocking news is that almost 100% of
nicotine gum users who were declared to have quit smoking for six months
(7%) appear to have still been hooked on the nicotine gum at six months
(6.7%).
The big news is that one-quarter (24%) of nicotine patch users (1.7%
of the 7%) who were previously reported to have successfully quit at six
months were likely still using the nicotine patch.
If almost 100% of gum and 95% of patch users are still hooked on
nicotine at six months and success is "very rare" then doesn't some rather
serious life threatening NRT marketing deception need to be immediately
addressed and corrected? The authors apparently want us to believe that
those spending hundreds of dollars violating FDA use guidelines were not
chemically dependent.
Yes, I'm clearly using Table 1 "one month gap"findings. But if this
study is to be taken seriously, after the authors discarded all purchase
data reflecting multiple same day scans on the assumption that they were
scanning errors, some of which obviously evidenced purchases of multiple
month supplies, I think we must. It also brings the authors selective
data "estimates" closer to historical study findings.
What I find interesting is that there was zero analysis of any
nicotine purchases except for NRT when every nicotine product sold has UPC
codes and participants were required to scan all purchases. Why would
their NRT scans be anymore reliable than other nicotine product scans?
Wouldn't that have provided data on the number of smokers in each
household, their brands, and whether or not they attempted cessation? In
single smoker households the nicotine use picture should be amazingly
clear.
It would be interesting to see this data analyzed by researchers who
are not acknowledged NRT industry consultants and who do not feel
compelled to disclose within the study that they have a personal financial
stake in the development and marketing of new NRT products. The patterns
of NRT use interlaced with cigarette and other nicotine purchases should
produce some rather fascinating info on just how well "therapy" was
actually going. I just don't know if it would be in the pharmaceutical
industry's financial interests to share such details.
If the real agenda of this study - and reflecting back there seems to
have been an overabundance of marketing objectives - is to get the FDA to
double the OTC NRT use recommendation period from three to six months,
thus substantially enhancing profits, the FDA would be well advised to
attack the pharmaceutical industry's hiding of nicotine’s addictive
properties with the same vigor it would if allowed to regulate tobacco
product warnings and a failure to have any U.S. dependency disclosures.
The authors assert that "the literature has seldom examined
dependence upon NRT." Is there any wonder why? Imagine having to put
nicotine addiction warning labels on all nicotine weaning products. They
are badly needed too. The 2003 Memphis youth NRT use survey finding that
teens who have never taken a single puff off of any cigarette are now
daily NRT users should have set off major alarms at the FDA.[2]
Is one of the objectives of this study to diminish growing concern
that NRT products are the new gateway to a lifetime of nicotine dependency
for tens of thousands of youth? If so, is it just possible that a bit of
"real" dependency science may at some point be in order?
In reading this study it's almost as if the authors want us to
believe that the brain's dopamine, adrenaline and serotonin neurons are
somehow able to discriminate between nicotine from a cigarette and
nicotine from NRT products. How are such shell games and nonsense any
different from the tobacco industry's nonsense?
This study's intro and discussion read like decades of tobacco
industry spin on the issues of addiction and safer cigarettes while again
totally ignoring all nicotine dependency biochemistry or studies raising
legitimate nicotine health risks.
Nicotine addiction isn't about getting high but about how the mind
and body have redefined "normal." Our bodies rebelled against those
first few puffs but quickly adjusted to inhaling thousands of chemicals.
Amazingly, nicotine crossed the blood-brain barrier and was a chemical key
that snugly fit the acetylcholine locks responsible for fine tuning a host
of brain neurochemical pathways including select dopamine, adrenaline and
serotonin circuits, and through cascading indirectly controlling more than
200 neurochemicals.
The mind's adjustments to being constantly bombarded with nicotine
were gradual yet constant. But eventually the brain ran out of tricks as
it could no longer keep up with the smoker smoking more nicotine in order
to achieve remembered prior performance. It did everything possible to
protect its reward, mood and anxiety circuits from overload and burnout.
It some areas it reduced the number of receptors for nicotine, in others
the number of transporters were diminished, while in some regions of the
brain millions of additional neurons were grown.
Through disbursal and turning down the brain's receptiveness to
nicotine, normal brain chemistry was altered as a new sense of normal
emerged and an addiction was born. It was a sense of normal now
completely dependent upon nicotine's two-hour chemical half-life.
Successful dependency recovery is being willing to allow the brain
the time needed to readjust to again functioning without nicotine, and the
quitter time to adjust to the brain's adjustments. It is impossible for
the brain, body and consciousness to adjust to functioning and living
without nicotine until its arrival stops.
If true, how can NRT claim responsibility for a 7% midyear nicotine
cessation rate? It can't. As shown by superimposing this study upon the
authors' March 2003 finding, within six months zero gum users and only
five in one hundred patch users are nicotine free.
But what about the 5% who transdermal nicotine seemed able to help
escape? I submit that they did not quit nicotine while engaged in using
it but only after pulling off that last patch. There is a substantial
body of non-NRT study evidence strongly suggesting that almost twice as
many patch users (10%) would have succeeded if they had not toyed with
months of nicotine weaning.[3]
An unsupported and uneducated quitter's core motivations and nicotine
cessation desires appear unaffected by cessation method unless that method
deprives them of some of their own natural recovery abilities. NRT
appears to do just that by prolonging the up to 72 hours needed for 100%
of nicotine and 90% of nicotine metabolites to be removed from the body
and the brain to begin sensing the arrival of and adjusting to nicotine-
free blood serum.
One of NRT's biggest fictions is that real world 'on-your-own'
quitting rates are the same as those being generated in OTC NRT studies
trying to cope with admitted blinding failures or even employing nicotine
as a placebo device masking agent.[4] It's why the authors continue to
take stabs at the 2002 Pierce JAMA survey conclusion that NRT is no longer
effective, and ignore London and Minnesota surveys with similar findings.
Nicotine is the natural chemical defense that keeps the roots, leaves
and seeds of the tobacco plant from being eaten by bugs. Drop for drop
it's more deadly that strychnine and three times deadlier than arsenic.
Amazingly, the FDA allowed the pharmaceutical industry to redefine and
market an insecticide as medicine and label its use therapy.
It also stood by while new tortured definitions of quitting,
cessation, and abstinence were created allowing NRT to hide nicotine and
addictiveness concerns while making billions in profits by claiming
meaningless odds ratio victories. It watched as researchers kept straight
faces while pretending that those still using nicotine had accomplished
some great feat that was then compared to those who truly had ended all
nicotine use.
What FDA officials should not sweep under the rug or allow studies
such as this to redefine, ignore or minimize is the growing awareness of
the destructive potential of this amazing pesticide. The authors'
assertion that "prolonged use of NRT is not thought to be harmful" is
simply untrue as it flies in the face of a growing list of study concerns
produced by real experts engaged in real science.
The U.S. National Cancer Institute has raised cancer concerns over
the nicotine-derived nitrosamine NKK on normal lung epithelial cells. The
Paris National Institute of Health recently found evidence that nicotine
causes a major fall in production of PSA-NCAM, a protein with a vital role
in the plasticity of the brain with apparent impairment of learning and
memorization.
A 2001 Stanford study concluded that nicotine tremendously
accelerates tumor growth rates and atherosclerosis through angiogenesis.
And an October 2000 study in Pediatrics that followed 8,000 teenagers has
depression experts rethinking why so many nicotine dependent Americans
suffer from chronic depression and other mental health concerns.
But I want to mention one more risk that harm reduction oriented NRT
experts just can't seem to grasp. I'm talking about an entire life being
chemically dependent upon nicotine's two-hour chemical half-life. I'm
referring to again sensing the full glory of our own reward pathway
releases that flow from accomplishment, a big hug, or even a nice cool
glass of water. About handling our own adrenaline releases, our own
anxieties and anger, determining when it's time to eat, dealing with real
hunger pains for the first time in decades, or even something as simple as
the circumstances under which we'll feel our fingers grow cold.
Not only does the brain adapt to the chemical world of nicotine
normal, the new addict quickly forgets who they really were and the
amazing sense of calmness that existed inside their mind prior to climbing
aboard the nicotine, dopamine/adrenaline/serotonin roller-coaster ride of
endless highs and lows. Natural regulation of mood, flight or flight, and
reward is life itself, something more nicotine cannot return.
Big brother health policy has unforgivably used nicotine cessation as
a practice arena for someday going head-to-head with big tobacco in
supplying the daily nicotine needs of a billion addicts. Smokers trusted
us "science" to help arrest their dependency and it lied to them. It not
only knew that "their" definition of quitting included nicotine, NRT
marketing knowingly played upon it by constantly undermining their natural
inclination to want to give up all nicotine by quitting cold.
The white-coat ceremony vow was to do no harm yet physician science
remains silent while knowing that the dismal 5.3% six-month nicotine patch
quitting rate (derived by subtracting persistent purchasers rate of 1.7%
from the OTC NRT finding of 7%) drops to almost zero percent during a
second or subsequent patch attempt.[5] If true, how can those calling
themselves addiction scientists sleep at night knowing that there is no
lesson to be learned from repeated NRT use but that relapse is 100%
guaranteed as dependency, destruction, decay and disease continue bringing
forth vastly increased odds of early demise.
John R. Polito
Nicotine Cessation Educator
[1] Hughes JR, Shiffman S. et al, A meta-analysis of the efficacy
of over-the-counter nicotine replacement, Tobacco Control. 2003
March;12(1):21-7. Full text link -
http://tc.bmjjournals.com/cgi/content/full/12/1/21
[2] Klesges, L. et al, Use of Nicotine Replacement Therapy in
Adolescent Smokers and Nonsmokers, Arch Pediatr Adolesc Med. 2003;157:517-
522. Abstract link - http://archpedi.ama-
assn.org/cgi/content/abstract/157/6/517
[3] Polito, JR, Does the Over-the-counter Nicotine Patch Really
Double Your Chances of Quitting? Link to online article -
http://whyquit.com/whyquit/A_OTCPatch.html
[4] Polito, JR, Are nicotine weaning products a bad joke? Link to
online press release -
http://www.emediawire.com/releases/2003/10/prweb84809.htm
[5] Tonnesen P, et al., Recycling with nicotine patches in smoking
cessation. Addiction. 1993 Apr;88(4):533. Link to abstract -
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8485431&dopt=Abstract
. Also note references to unpublished studies such as the Korberly
nicotine patch study presented at the March 1999 Society for Research on
Nicotine and Tobacco conference in New Orleans in which only 1 out of 149
OTC nicotine patch users was still not smoking at the six month mark.
In all of the arguments I see in many articles, both pro and con,
concerning smoking bans, I note arguments tend to concentrate on
"smoker's rights" and "non-smoker's rights", when neither are relevant to
the real issue. That is, whether or not a proprietor has the right to
operate a business as he sees fit, allowing those who seek and enjoy the
business he offers to freely do so or freely decline it. That speaks more
t...
In all of the arguments I see in many articles, both pro and con,
concerning smoking bans, I note arguments tend to concentrate on
"smoker's rights" and "non-smoker's rights", when neither are relevant to
the real issue. That is, whether or not a proprietor has the right to
operate a business as he sees fit, allowing those who seek and enjoy the
business he offers to freely do so or freely decline it. That speaks more
to the essence of freedom than governmental regulation.
In your article you touch on the fact that the consumer would likely
not report internet pruchases for fear of reprisal in taxation issues. The
state does in fact over look the 1 or 2 carton of cigarette purchase
issues when for instance a business man travels to Kentucky and buys a
couple ther and brings them back with him to California.
I have also detected, in the industry of Internet Toabacco sales,
where th...
In your article you touch on the fact that the consumer would likely
not report internet pruchases for fear of reprisal in taxation issues. The
state does in fact over look the 1 or 2 carton of cigarette purchase
issues when for instance a business man travels to Kentucky and buys a
couple ther and brings them back with him to California.
I have also detected, in the industry of Internet Toabacco sales,
where the new proposals for laws have only one true effect. 91% of the
Internet sales are accpomplished by Soveriegn Tribal nations that pay for
the most part no state or federal taxes and also from the international
online sales points which also pay no state or federal taxes.
There is a movement a foot to set the Jenkins act more stringant and
also prohibit the mailing of cigarettes thru the USPS via the S1177. The
issue would eliminate only and I do say "only" the American online
retailers that pay the federal and for the most part state taxes.
The retailer I web master for is a brick and mortar operatin in
florida, pays Florida and Federal taxes on all cigarettes he sells, online
and thru his store. He would be affected by the changes propsed and the
ones that have already been made in effect in New York for example. Yet
the 91 % that are exempt from following those proposed changes will not be
affected. Not in the slightest bit. To assume that changing the laws to
affect only those that actually pay some State taxes and all federal taxes
would have an impact on internet sales is at the very least a sign of
ignorance. Those who are legitimate would stop and the customers would go
to the tribal nations or to foreign entities for the savings.
Tribal Nations avaoid taxes and ship vis the USPS in New York and the
Universal Postal Union Convention ratified by the United States forbids
the Federal and state governments from prohibition of foreign sales. I see
the irony that a few politicians are seeking special interest money and
support and ignoring the truth and only affecting American tax paying
citizens.
I doubt if you as a liberal would even care but I felt the need to
get it off my chest and tell yo just how wrong you really are in your
views and reporting.
Has the end of Malawi’s tobacco-driven economy come?
Author:
Adamson S. Muula MB BS, MPH
Department of Community Health
University of Malawi College of Medicine
Private Bag 360, Blantyre 3
MALAWI
Email: amuula@medcol.mw
Letter to Editor
In his article about Malawi’s economic reliance on the “green gold”
(tobacco), Peter Davies 1 clearly presented the dilemma that an African
country in...
Has the end of Malawi’s tobacco-driven economy come?
Author:
Adamson S. Muula MB BS, MPH
Department of Community Health
University of Malawi College of Medicine
Private Bag 360, Blantyre 3
MALAWI
Email: amuula@medcol.mw
Letter to Editor
In his article about Malawi’s economic reliance on the “green gold”
(tobacco), Peter Davies 1 clearly presented the dilemma that an African
country in Malawi’s position faces. Such difficult position has been a
matter of debate in other publications 2, and it would seem that it will
basically be economic considerations and not strict public health
(although the economy cannot be wholly delineated from public health) on
the part of countries like Malawi that will eventually force them to
reduce tobacco growing. Of course, part of their reduction of tobacco
producing could be related to the anti-smoking lobby.
Malawi’s economic performance has lately been a matter of concern.
Like in many African countries, the causes and the effects of such slump
in economy is poorly documented. We can not therefore say anything much
about rising malnutrition levels, increasing unemployment and by how much,
as a result of the deteriorating state of the economy. However, we can
speak about the role that tobacco has played in the present state of
affairs.
Malawi is the largest producer of burley tobacco in the world.
According to the Tobacco Exporters’ Association of Malawi (TEAM), Malawi’s
burley tobacco production has been dwindling since 2000. TEAM comprises:
the international tobacco buying companies, the Ministry of Agriculture,
Irrigation and Food Security, Agricultural Research and Extension Trust
(ARET), Auction Holdings Limited (AHL), the National Association of Small
Holder Farmers in Malawi (NASFAM), Tobacco Association of Malawi (TAMA)
and Tobacco Control Commission (TCC). In a press release of 20th September
2003, TEAM reported that while Malawi produced 142.3 million kilograms of
burley tobacco in 2000, production was 102 million kilograms in 2003.3
This 28.3% drop in production translated in loss of US$ 43 million. The
grouping is currently campaigning to ensure that in the forthcoming
growing season, more farmers and hectarage is dedicated to burley tobacco.
What could be the reasons Malawian farmers are no longer growing much
tobacco. Economic considerations rank high. According to Team, the
problems that the Malawi tobacco farmer face include: high transport
costs, input and marketing costs, various bank charges, devaluation of the
local currency and low selling prices for the tobacco at the auction
floor. Auction Holdings Limited, which charges commission for use of its
markets also charges commission and the farmers faces the brunt.
In order to motivate farmers to grow more tobacco, the following
measures have been put in place: the commission payable to Auction
Holdings has been reduced from 3.95% to 3.5%,4 taxes on Hessian bags (for
packaging tobacco) have been removed, tobacco awareness campaign
instituted. TEAM has also embarked on an initiative that will ensure that
the tobacco that reaches the markets will be of high quality thus further
attempting to ensure higher monetary returns to the farmers. This will
probably be achieved through: sales of high quality certified tobacco
seeds, maintenance and construction of tobacco curing barns, holding on
and off-farm field days and conducting tobacco grading course for farmers.
Malawi’s reliance on tobacco has reached a crossroads. Economic
factors have forced the tobacco growing community to reduce production, at
least of burley tobacco. While this goes on, the public health fraternity
in the country is relatively quiescent, probably for lack of viable
alternative in the prevailing circumstances. The tobacco industry has
produced a strategy on gaining lost glory. Speaking on the only national
television on 22nd September 2003, the principal secretary in the Ministry
of Agriculture in Malawi said he was aware of the adverse health effects
of tobacco and that was not a matter of argument. It was the lack of
alternatives that mattered. He went on to say, if the anti-tobacco lobby
is successful, then he would ensure that “the last cigarette to be smoked
must come from Malawi”. There is need for the public health teams to take
advantages of the current problems.
Conflict of Interest
None
References
1. Davies P. Malawi: addicted to the leaf. Tobacco Control 2003, 12(1): 91
-3
2. Muula AS. The challenges facing third world countries in banning
tobacco. Bulletin of the World Health Association 2001, 79(5): 480
3. Tobacco Exporters’ Association of Malawi. An appeal to all burley
growers: grow more burley tobacco for more money. Malawi News, 20th-26th
September 2003 p16
4. Auction Holding Limited. Reduction in selling commission. Weekend
Nation. Tamvani, 22nd-23rd September 2003 p 31
Kawaldip Sehmi's letter seems to advocate ignorance and a kind of book-burning attitude to understanding this area. But in fact, better knowledge of the science might help his cause.
The paper by Enstrom and Kabat caused problems not because its findings conflicted with the established evidence base, but because it was flawed and the BMJ failed to put its contribution in context with the rest of the large evidenc...
Last week in the BMJ 2003; 327 (6 December), after seeing his comments on the Enstrom and Kabat paper on second-hand smoke being used by Forest to advance the tobacco industry’s position, the BMJ Editor says in a fair and frank admission:
"Reading the quote on a Forest advertisement tightens my anus, but I wrote it and can't deny it."
Health Professionals who have been working hard towards getting che...
Watching this first salvo in the battle over whose nicotine is safer and which side eventually makes the big nicotine maintenance bucks, Big Pharm or Big Oral Tobacco, is sad yet understandable? Even for those few without any financial stake in the debate, imagine the natural frustrations born from having turned the wrong research or policy corner and dedicated two decades of your life to having chosen to fight nicotine...
A reply to Tomar et al’s flat earth commentary
Foulds et al‘s e-response [1] provides an excellent and scathing critique of the commentary contributed by Tomar et al [2]. Though Foulds et al are far too modest to point this out, it is important that readers understand that their original review [3] is a substantial and careful piece of work, properly edited and peer-reviewed. In contra...
Dear Editor
The earth is flat, ABBA couldn’t sing a song, Scotland is going to win the soccer World Cup sometime soon, and snus has played no part in the reduction in smoking prevalence among Swedish men – or so Tomar et al. [1]would have us believe. Of all of these issues not remotely supported by the evidence, the last one is a little more serious in that it may influence tobacco control...
I'd like to challenge the suggestion in this paper that mobile phone use does not reduce smoking, simply because smoking teenagers are more likely to own mobile phones.
The hypothesis advanced by Ann Charlton and I is that mobile phones share some of the same charatcteristics that attract young people to smoking (initiation to adult life, peer bonding, individualistic expression, brand identification etc). I...
The abstract's conclusion that persistent use of nicotine gum is "very rare" casts serious doubt upon the authors' objectivity. How can they here describe a 6.7% chronic nicotine gum use rate at six months as reflecting a 'very rare' condition while their March 2003 OTC NRT meta- analysis - published in this same journal - embraced a 7% six-month smoking abstinence rate finding as "effective?" [1]
I do hope...
In all of the arguments I see in many articles, both pro and con, concerning smoking bans, I note arguments tend to concentrate on "smoker's rights" and "non-smoker's rights", when neither are relevant to the real issue. That is, whether or not a proprietor has the right to operate a business as he sees fit, allowing those who seek and enjoy the business he offers to freely do so or freely decline it. That speaks more t...
In your article you touch on the fact that the consumer would likely not report internet pruchases for fear of reprisal in taxation issues. The state does in fact over look the 1 or 2 carton of cigarette purchase issues when for instance a business man travels to Kentucky and buys a couple ther and brings them back with him to California.
I have also detected, in the industry of Internet Toabacco sales, where th...
Has the end of Malawi’s tobacco-driven economy come?
Author:
Adamson S. Muula MB BS, MPH Department of Community Health University of Malawi College of Medicine Private Bag 360, Blantyre 3 MALAWI Email: amuula@medcol.mw
Letter to Editor
In his article about Malawi’s economic reliance on the “green gold” (tobacco), Peter Davies 1 clearly presented the dilemma that an African country in...
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