While a recent editorial in Tobacco Control wonders “Falling prevalence of smoking: how low can we go?”1, in Italy something worrying is happening in tobacco control. After a constant decline in the past 3 years, in 2006 an excess of a 1000 tonnes of tobacco was sold in Italy2. This means “only” an increase of 1.1% of the total market, but represents also an excess of 50 million of cigarette packs, one for each Italian. This happened despite the important impact due to the 2005 smoking ban in workplaces, bar and restaurants, which caused a 6.2% reduction in tobacco consumption. After Ireland and Norway, this was the third important European protection law relating to environmental tobacco smoke. We don’t know if the arrival of BAT in Italy was the cause of the inversion of the trend of tobacco consumption in Italy, but we are worried: “The multinational cigarette companies act as a vector that spreads disease and death throughout the world”3. In 2003 our government sold our old and inefficient state cigarette producer ”Ente Tabacchi Italiano” to BAT for €2.325 million4. The company chose for Italy a low public profile. No advertisement (it is forbidden), no sponsorship of popular events. P. Gobbo, now undersecretary to the president, is a former member of the board of directors of BAT. They also sponsored important workshops like the ASPEN workshop (Cernobbio 2004)4 where politicians, bankers and businessmen debated the economic and political future of the country , and cultural events like the opening of the renewed Scala Opera Theatre in Milan and the concert in Rome directed by Riccardo Muti for FAI, an association for the Italian cultural heritage 4. New links with Universities were also established: BAT built up a new laboratory at Federico II University (Naples) with 35 researchers and asked some other important scientists to collaborate. In Italy we have no restrictions aimed to control tobacco funding to Universities and research centres as in the UK5. In Milan, BAT is working on “corporate responsibility” with the Catholic University and published a report6 on this issue linking the BAT logo with this important institution, a good passport to the Vatican. Political and religious power, University, and the world of culture seem to be the preferred BAT political targets in Italy. We are truly concerned about what is happening and what could happen in the next years in the tobacco market in Italy. On May 31st, we celebrated World No Tobacco Day with 300 students of secondary schools in the auditorium of National Cancer Institute in Milan. We made a petition in which we asked that the profits of tobacco market before being distributed to the BAT shareholders should be used to pay the large costs of new anti-cancer drugs that risk to make our national health system to collapse. This is the corporate responsibility that we envisage BAT should show in its intervention in Italy.

REFERENCES 1 Chapman S. Falling prevalence of smoking: how low can we go? Tobacco Control 2007;16;145-147 2 Newsletter REF Tobacco Observatory, 4 n°9, January 2007. 3 Sebriè E, Glantz S. The multinational cigarette companies act as a vector that spreads disease and death throughout the world. BMJ 2006;332:313-4. 4 Mazza R, Boffi R, De Marco C, Ruprecht A, Rossetti E, Invernizzi G. The arrival of BAT in Italy. Epidemiol Prev 2005;29:7-10. 5 Tobacco Industry Research Funding to Universities. A Joint Protocol of Cancer Universities UK, February 2004. Available online, http://info.cancerresearchuk.org/images/pdfs/jointprotocol.pdf, accessed 26 June 2007. 6 Lorien Consulting.Osservatorio permanente sulla responsabilità d’impresa. Consumatori e ambiente. I quaderni dell’osservatorio Operandi (BAT Italy‘s NGO), January 2006. Available online, www.operandi.it/export/sites/default/documenti/Quaderno_2_vol.def.PDF, accessed July 24th 2007.

A controversy has been raging regarding the relative safety of waterpipe smoking . To investigate the claims of few university students who smoked waterpipe that waterpipe smoke (WPS) does not cause dental stains, we compared cigarette and waterpipe smokers.

Two groups each of 10 subjects were selected .One group comprising of only water pipe smokers (including 9 waterpipe cafe caretakers), the other made of only cigarette smokers who smoked 20-30 cigarettes daily. All the subjects brushed once daily, using tooth paste. Thorough oral prophylaxis was done, subjects were asked not to indulge in any means of smoking other than what specified. Dental stains were evaluated every 10th day for 100 days.

Dental Stain Grading: Only lingual aspects of lower anterior teeth were evaluated.

Grade 1- Stain present on the cervical (lower) 1/3rd

Grade 2- Stain present on the cervical and middle 1/3rds.

Grade 3- Stain present on the cervical, middle and incisal 1/3rds.

It was observed that waterpipe smokers did not develop any dental stains while cigarette smokers had Grade 3 dental stains at the end of 100 days.

Staining of teeth results primarily from coal tar combustion products.[1] One may assume that coal tar combustion does not happen in waterpipe smoking , since no stains formed in 100 days. In fact, the smoke from a single waterpipe use contains approximately the same amount of tar as 20 cigarettes.[2] However, the tar produced by a waterpipe may differ from that produced by a cigarette, because tobacco in a waterpipe is not burnt, but heated.[3] Also, the smoke after passing through the water bowl loses heat almost completely before reaching the oral cavity.

High incidence of pre cancerous oral lesions has been reported due to reverse smoking, possibly due to increased intra oral temperature and different combustion products.[4] In reverse smoking the chemical action of tobacco is supplemented by the irritant effect of heat. Where as in WPS, the heat factor is negated. Temperature may be positively related to tar related tumorigenicity and mutagenicity.[2,3]

This should not let us underestimate the potential ill effects of WPS. WPS contains charcoal-combustion products as well. The water does absorb some of the nicotine.[5] Reduced concentration of nicotine in the WPS may result in smokers inhaling higher amounts of smoke until they get enough nicotine to satisfy their need and addiction;[6] and thus exposing themselves to higher levels of cancer-causing chemicals and hazardous gases such as carbon monoxide than if none of the nicotine was absorbed by the water.[7]

References

1. Carranza FA, Newman MG. Clinical Periodontology, 8th ed. W.B. Saunders Company: 1996:158.

2. Shihadeh A. Investigation of mainstream smoke aerosol of the argileh water pipe. Food Chem Toxicol. 2003;41:143-152.

3. Maziak W, Ward KD, Afifi Soweid RA, et al. Tobacco smoking using a waterpipe: a re-emerging strain in a global epidemic. Tob Control. 2004;13:327-333.

4. Lynch MA, Brightman VJ, Greenberg MS. Burket’s Oral Medicine, Diagnosis and Treatment,9th ed.J.B.Lippincott.1994:93.

5. Shafagoj YA, Mohammed FI, Hadidi KA. Hubble-bubble (water pipe) smoking: levels of nicotine and cotinine in plasma, saliva and urine. Int J Clin Pharmacol Ther. 2002; 40:249-255.

6. National Cancer Institute. Risks associated with smoking cigarettes with low machine-measured yields of tar and nicotine. Smoking and Tobacco Control Monograph No.13.Bethesda MD, United States Department of Health and Human Services ,Public Health Service ,National Institutes of Health ,National Cancer Institute.2001.

7. Knishkowy B, Amitai Y. Water-pipe (narghile) smoking: An emerging health risk behavior. Pediatrics. 2005;116:113-119.

On March 15 2007, my attention was drawn to a patent for a tobacco smoking device, filed with the U.S. Patent and Trademark Office (USPTO) for a "Hookah with simplified lighting" on June 9 2005. One of the authors of the device being patented was Kamal Chaouachi, who on December 2 2004, had a rapid response published in Tobacco Control [1] which was critical of a paper by Masiak et al [2]. The submission process for rapid responses asks authors to “Please declare any competing interests”. I noted that Dr Chaouachi’s letter contained no competing interest statement and so wrote to him requesting that he submit a further rapid response which would clarify his competing interest.

He duly submitted two rapid responses. The first, which I have not published but retained, simply said “no competing interests”. I replied that this brief response was unacceptable and that in the circumstances of the revelation about his ostensible interest in the smoking device, he should elaborate in a further rapid response.

In the second response Dr Chaouachi stated that he had signed away his rights “in the presence of a State Attorney” to his tobacco smoking invention patent on June 15 2005, some six days after the US patent was filed. Dr Chaouachi reiterated that “I had no competing interest at the time my Letter to the Editor entitled 'Serious Effors in this Study" was sent to the Tobacco Control Journal.”

This last statement, in fact, is false. I am in possession of a report from the French patent office (Bulletin Officiel De La Propriete Industrielle Brevets D'Invention). At page 18 a patent in the names of Billard, Chaouachi (Kamal), and De La Giraudiere is described. The patent number is 04 06287, the company filing the patent is "Shishamania International", the title of the patent is "NARGUILLE A ALLUMAGE SIMPLIFIE". The date of filing is June 10 2004.

Thus, the US patent, filed at the US PTO on June 9, 2005, was first filed in France on June 10, 2004. Dr Chaouachi’s e-letter was submitted on December 2 2004. Therefore, the e-letter was submitted after the French patent was filed, and before the date on which he reports that he relinquished his rights to the patent.

In further correspondence during March 17, I confronted Dr Chaouachi with the fact that his device had been registered with the French patent authorities in June 2004 and that therefore he had made a false statement in his declaration of no competing interests. He replied “This is not "false statement" (!). … The French patent was filed at the date you said. You are probably right as I cannot say myself so far when it was. I have been informed of procedure. This is all.”

In summary, at the date Dr Chaouachi submitted his rapid response, he had a commercial interest in the subject of that submission. He did not declare this interest. When later given the opportunity to do so, he maintained that he had no competing interest at the time of writing his rapid response. He did not voluntarily declare that the patent had in fact been filed in France in June 2004.

In such circumstances, it is Tobacco Control’s policy to inform offending authors’ institutions of such conduct. Dr Chaouachi would appear to not be currently working for any institution. Tobacco Control is unwilling to accept any further submissions from Dr Chaouachi.

Simon Chapman Editor

1. Chaouachi K. Serious Errors in this Study. http://tc.bmj.com/cgi/eletters/13/4/327 rapid response

2. Maziak W, Ward KD, Afifi Soweid RA, Eissenberg T. Tobacco smoking using a waterpipe: a re-emerging strain in a global epidemic Tob Control 2004; 13: 327-333

Henley et al’s paper (1) showing worse health outcomes in men switching from cigarettes to smokeless tobacco, compared with men ceasing tobacco use completely, adds to our understanding of the potential risks from smokeless tobacco use. However, it also raises some additional questions:

1. Like the authors’ earlier paper comparing health outcomes in exclusive smokers with those of exclusive smokeless users in CPS-II (2), this paper did not report a comparison with those people who continued to smoke. Papers by other groups examining the health outcomes from potential harm-reducing behavior changes (3,4) have presented the whole picture, comparing the outcomes for continuing smokers, never smokers and those making the potentially less harmful change (e.g. reducing cigarette consumption). Occasionally clinicians are asked by smokers who don’t want to quit tobacco, whether their health risks would be reduced by switching to smokeless tobacco. This question may come up more frequently with some of the major cigarette manufacturers now test-marketing smokeless products. The CPS studies have the data to help answer that question. The public should be informed just how much their chances of premature death from lung cancer, COPD etc are likely to be reduced by using smokeless tobacco rather than smoking. The authors should be encouraged to analyze and publish those data as well. A survival curve comparing never tobacco users, smokers and smokeless tobacco users would be helpful, as would the adjusted risks of each tobacco-related disease for each group.

2. Also like the previous paper (2), this study found raised risks of death from lung cancer and COPD among those who switched to smokeless tobacco. For example, among snuff users (27% of switchers), the adjusted hazard ratios for all cause mortality (1.11, 95% CI=0.94-1.3), coronary heart disease (1.12: 0.82-1.53) and stroke (0.89: 0.49-1.62) were not significantly elevated, and were lower than those for lung cancer (1.75: 1.2-2.5) and COPD (1.68: 0.9-3.3). The authors have pointed out the possibility that the increased lung cancer risk could be caused by circulating carcinogens from the tobacco. However, the authors did not speculate on the possible cause of increased risk of death from COPD among those switching to smokeless tobacco compared with those quitting completely. It is hard to think of mechanisms that do not involve increased exposure to smoke, either from secondhand smoke, or increased smoking (including smoking other substances) before or after recruitment to the study. It would be useful to hear the authors’ thoughts on what caused the smokeless users’ raised COPD risks, and also how that might affect interpretation of the other raised risks found in these studies (i.e. are these effects likely due to confounding with smoke exposure, rather than smokeless use per se?).

3. This excellent study by the American Cancer Society reported increased risks of cancer of the oral cavity and pharynx (HR=2.5, CI=1.2- 5.7), based on 7 deaths in switchers, and the previous paper comparing exclusive smokeless users with never tobacco users in CPS-II found an adjusted hazard ratio for oropharynx cancer of 0.90 (0.12-6.71). The US American Cancer Society website currently states that:

“Smokeless tobacco ("snuff" or chewing tobacco) is associated with cancers of the cheek, gums, and inner surface of the lips. Smokeless tobacco increases the risk of these cancers by about 50 times.” (5)

The authors have previously stated that, “We do believe that there has been inadequate concern about potential adverse risks of spit tobacco use”(6). In fact the available evidence suggests that the public drastically overestimates the relative risks from smokeless tobacco. For example, only 11% of smokers believe that smokeless is less harmful than cigarettes (7). Perhaps the information on the ACS website should be updated to be more consistent with the results of these two ACS studies so as not to add to the public’s biased perception?

Lastly, this paper is important to informing the harm reduction debate as it pertains to smokeless tobacco, but it only contributes to part of the story. It fails to point out that the largest difference in risk is likely to be the one between switchers and continuing smokers, while the difference between switchers and complete quitters is relatively small. It is not surprising that those that switch to another form of tobacco may have elevated health risks compared to those who quit tobacco entirely. But what is sorely needed is analysis of the risks of switching to a potentially less harmful tobacco product (smokeless) versus continuing to smoke the most deadly form of tobacco, the manufactured cigarette.

1. Henley SJ, Connell CJ, Richter P, Husten C, Pechacek T, Calle EE, Thun MJ. Tobacco-related disease mortality among men who switched from cigarette to spit tobacco. Tobacco Control 2007;16:22-28

2. Henley SJ, Thun MJ, Connell C, Calle EE. (2005) Two large prospective studies of mortality among men who use snuff or chewing tobacco (United States). Cancer Causes and Control 16:347-358

3. Godtfredsen NS, Holst C, Prescott E, Vestbo J, Osler M. Smoking reduction, smoking cessation, and mortality: a 16-year follow-up of 19,732 men and women from The Copenhagen Centre for Prospective Population Studies. Am J Epidemiol. 2002 Dec 1;156(11):994-1001.

4. Tverdal A, Bjartveit K. Health consequences of reduced daily cigarette consumption. Tob Control. 2006 Dec;15(6):472-80.

5. www.cancer.org “Detailed Guide: Oral Cavity and Oropharyngeal Cancer What Are The Risk Factors for Oral Cavity and Oropharyngeal Cancer?” (accessed Feb 14, 2007)

6. Henley SJ, Thun MJ. Response to: Foulds J and Ramstrom L letter regarding "Causal effects of smokeless tobacco on mortality in CPS-I and CPS-II". Cancer Causes Control. 2006 Aug;17(6):857-8.

7. O'Connor RJ, Hyland A, Giovino GA, Fong GT, Cummings KM. Smoker awareness of and beliefs about supposedly less-harmful tobacco products.Am J Prev Med. 2005 Aug;29(2):85-90.