Dr Gupta’s letter suggests that the reduction in lung cancer in both
Sweden and Connecticut is highly likely to be due to a reduction in
smoking in both places. This is entirely unsurprising, and as far as
Sweden is concerned is precisely what we suggested in the original paper
he referred to:
“There has been a larger drop in male daily smoking (from 40% in 1976
to 15% in 2002) than female daily smoking (34% in...
Dr Gupta’s letter suggests that the reduction in lung cancer in both
Sweden and Connecticut is highly likely to be due to a reduction in
smoking in both places. This is entirely unsurprising, and as far as
Sweden is concerned is precisely what we suggested in the original paper
he referred to:
“There has been a larger drop in male daily smoking (from 40% in 1976
to 15% in 2002) than female daily smoking (34% in 1976 to 20% in 2002) in
Sweden, with a substantial proportion (around 30%) of male ex-smokers
using snus when quitting smoking. Over the same time period, rates of lung
cancer and myocardial infarction have dropped significantly faster among
Swedish men than women and remain at low levels as compared with other
developed countries with a long history of tobacco use.” (p349,
abstract)1.
The idea that smoking and lung cancer rates may fall to a similar or
greater degree in other places is entirely irrelevant to whether or not
snus played a role in smoking reduction in Swedish men. Indeed, in the
original paper we stated clearly 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)1
It is therefore entirely unsurprising that these types of factors
will have influenced smoking and lung cancer rates in the United States
and every other country, regardless of whether or not snus is available. A
key point in our original paper that distinguished Sweden from other
countries was that smoking rates WITHIN that country have fallen
significantly faster in men than women, and that this appeared to be
related to the fact that men in Sweden use snus much more than women. So
although these comparisons between one country in Europe and a state in
the US are almost entirely irrelevant to the question of the effect of
snus use on lung cancer rates in Sweden, the more appropriate comparison
(if one wanted to make one) would be of the difference in decline of lung
cancer rates between men and women in Sweden as compared to changes in
that difference in the US. It is not clear whether the data presented in
Dr Gupta’s letter was for men, women or both.
Since the publication of our original paper there have been
subsequent publications that have confirmed that in Sweden, men who start
using snus are less likely to become daily smokers, that men who smoke and
then start using snus are more likely to stop smoking, and that a higher
proportion of men than women in Sweden have quit smoking, with the
difference largely attributable to snus use2,3. It had previously been
suggested that the men who quit smoking in Sweden are not the same ones
who start using snus (and that snus use is therefore not involved in men
quitting smoking)4. However, studies have now verified that in fact a
sizeable proportion (26-29%) of Swedish men who quit smoking use snus as a
smoking cessation aid2,5.
It is now crystal clear that their transfer of nicotine dependence
onto snus has accelerated the rate of decline of smoking among Swedish men
in substantial numbers. That transfer from an extremely harmful form of
tobacco use (cigarette smoking) to a much less harmful form (snus) has
contributed to a reduction in the rate of smoking-caused diseases in
Swedish men.
1. Foulds J, Ramstrom L, Burke M, Fagerstrom K. The effect of
smokeless tobacco (snus) on public health in Sweden. Tobacco Control 2003;
12:349-59.
2. Ramström LM, Foulds J. The role of snus (smokeless tobacco) in
initiation and cessation of tobacco smoking in Sweden. Tobacco Control
2006 Jun;15(3):210-4.Pdf available at:
http://www.tobaccoprogram.org/staffarticles.htm
3. Furberg Furberg H, Bulik C, Lerman C, et al. Is Swedish snus associated
with smoking initiation or smoking cessation? Tob Control.2005; 14:422-
424.
4. Tomar SL, Connolly GN, Wilkenfeld J, Henningfield JE. Declining smoking
in Sweden: Is Swedish Match getting the credit for Swedish tobacco
control’s efforts? Tobacco Control2003; 12:368-59
5. Gilljam H, Galanti MR. Role of snus (oral moist snuff) in smoking
cessation and smoking reduction in Sweden. Addiction 2003;98:1183-9.
Dr Gupta’s comparison of trends in lung cancer mortality and smoking
prevalence in Sweden and Connecticut purports to undermine the claim that
increasing snus use in Sweden has contributed to declining lung cancer
rates there.
Dr Gupta argues that some factor other than snus must have been at
work because the ratio of lung cancers between Sweden and Connecticut has
remained constant despite the large differenc...
Dr Gupta’s comparison of trends in lung cancer mortality and smoking
prevalence in Sweden and Connecticut purports to undermine the claim that
increasing snus use in Sweden has contributed to declining lung cancer
rates there.
Dr Gupta argues that some factor other than snus must have been at
work because the ratio of lung cancers between Sweden and Connecticut has
remained constant despite the large difference in snus use between the two
places. He identifies this “other factor” as a declining cigarette smoking
prevalence that he attributes to tobacco control policies.
We agree that a decline in cigarette smoking in both countries
explains the lung cancer trends but we don’t see how this rules out a role
for snus. This is exactly the mechanism by which proponents of snus would
claim that snus use reduces smoking prevalence, namely, that population
smoking prevalence declines because existing smokers switch to snus and
new tobacco users use snus rather than cigarettes (Ramström and Foulds
2006).
The fact that smoking prevalence declined in Connecticut as a result
of more traditional tobacco control policies simply shows that there is
more than one way to reduce smoking prevalence. The fact that the decline
in cigarette smoking over the time period examined was greater in Sweden (
-13%) than in Connecticut (-8%) supports the hypothesis that the addition
of snus to more conventional tobacco control policies has increased the
decline in smoking prevalence.
We concede that the comparison does not prove that snus was
responsible for the decline in lung cancer rates in Sweden, but it is much
more supportive of the claims for snus than Dr Gupta allows.
Yours sincerely
Coral Gartner and Wayne Hall
References
Ramström, L. M. and J. Foulds (2006). "Role of snus in initiation and
cessation of tobacco smoking in Sweden." Tobacco Control 15(3): 210-214.
Some tobacco control community members believe that advocating the
use of snus, a form of Swedish smokeless tobacco said to be less harmful
than cigarettes, would prove an effective harm reduction strategy against
tobacco related diseases. One important basis for such a claim is the
fact that snus is widely used in Sweden (23% men used snus daily in 2002),
where the incidence of cancer caused by tob...
Some tobacco control community members believe that advocating the
use of snus, a form of Swedish smokeless tobacco said to be less harmful
than cigarettes, would prove an effective harm reduction strategy against
tobacco related diseases. One important basis for such a claim is the
fact that snus is widely used in Sweden (23% men used snus daily in 2002),
where the incidence of cancer caused by tobacco is relatively low, and the
observation that the Swedish are switching from smoked tobacco to snus.
One way of looking at this claim of harm reduction through the use of snus
is to compare tobacco related cancer rates in Sweden to those in the state
of Connecticut, where use of any kind of smokeless tobacco including snus
has been consistently rare.
The table below provides a comparison of age adjusted incidence rates
for Sweden and Connecticut. As the data show, the incidence of tobacco
related cancer is much lower in Sweden, about one half that of
Connecticut. Trend data for Sweden seemingly provide further supportive
evidence to the harm reduction hypothesis, as a dramatic increase in snus
use in Sweden (0.4 kg/person in 1970 to 0.9kg/person in 2000) coincides
with a decreasing cigarette consumption (1.1kg/person in 1970 to
0.6kg/person in 2000) resulting in a decrease of tobacco related cancer
from 97.8 per 100,000 in 1966-1970 to 56.7 per 100,000 in 1993-1997.1,
However, if snus has a harm reduction effect, the incidence of
tobacco related cancers should not only decline in Sweden as snus use
increases, but it should decrease more in Sweden than in Connecticut,
where the consumption of smokeless tobacco has remained <1% over 1990s.
However, the data below demonstrate that the ratio of the incidence of
tobacco related cancer in Sweden and Connecticut has remained constant at
about 0.5 since 1973, and the same ratio for lung cancer has been stable
at about 0.4 since1960. Rather than snus causing the decrease in tobacco
related cancer in Sweden, these data suggest that another factor was
responsible in reducing cancer incidence in both Sweden and Connecticut.
That factor is likely to be the decline in cigarette use, which fell in
men from about 28% to 15% (Sweden) and 26.7% to 18.7% (Connecticut) from
1985-2003.1,3 During the period of 1970s to 1990s, both populations were
exposed to smoking reduction strategies such as increased awareness of
health risks, increased prices, a change in social norms regarding tobacco
use, etc but both places did not have an increase in snus use. Thus, the
data do not seem to support the hypothesis that the decrease in tobacco
related cancers in Sweden is due to increasing use of snus.
References
1. Foulds, J., Ramstrom, L., Burke, M., Fogerstrom K. Effect of
Smokeless tobacco (snus) on smoking and public health in Sweden. Tobacco
Control, 2003; 12:349–359.
2. Cancer Incidence in Five Continents. Vol. I-VIII. Lyon:
International Agency for Research on Cancer.
3. CDC. State System: State Tobacco Activities tracking and
evaluation system. Tobacco Use Supplement to the Current Population
Survey. 2006. Available at http://apps.nccd.cdc.gov/statesystem/. Accessed
January 17, 2007.
Reduction as a permanent solution may give people false expectations
Thanks to Dr. John R Hughes for his interesting remarks of 20 January 2007
to our article (TC 15:472-480). We have the following comments:
1. Dr. Hughes states that our main finding (no health benefit from
reducing cigarettes) has not been found in the few prior prospective
studies of this topic. This is not correct. Based on a large study
population in C...
Reduction as a permanent solution may give people false expectations
Thanks to Dr. John R Hughes for his interesting remarks of 20 January 2007
to our article (TC 15:472-480). We have the following comments:
1. Dr. Hughes states that our main finding (no health benefit from
reducing cigarettes) has not been found in the few prior prospective
studies of this topic. This is not correct. Based on a large study
population in Copenhagen, Dr. Nina S Godtfredsen and co-workers have
reported the same results in a series of publications, references given in
our article. Dr Hughes’ remarks imply that there may be other prospective
studies that give other results. We have not been able to find other
prospective studies that take up this problem.
2. Our article reports on results from three examinations; for the
majority of participants the interval between the examinations was five
years. A subgroup of the study population was nominated ‘sustained
reducers’. They were heavy cigarette smokers at the first examination, had
reduced their daily cigarette consumption by at least 50 % at the second
examination, and had remained as ‘reducers’ at the third examination.
Their mean consumption at the three examinations was 23.6 – 10.0 – 10.4
cigarettes per day (table 6 in our article).
Dr Hughes states that “the question at each follow-up did not ask about
smoking since the last follow-up”. This is correct, and we agree with Dr
Hughes that it is unknown what the rate of smoking really was between
follow-ups in sustained reducers. The sustained reducers had, however, a
mean daily consumption that was almost the same at the second and third
examination, and in our opinion, the most reasonable explanation is that
their daily cigarette consumption had stabilised at a consumption level
which actually was at least 50% lower than at the first examination. We
also underline that at the second examination, reducers had a serum
thiocyanate level that was lower than in heavy smokers, and close to the
serum thiocyanate level in moderate smokers (table 3 in our article).
3. Dr Hughes states that reduction actually increases motivation to quit.
In our paper, we state explicitly:”Undoubtedly, reduction in consumption
may have a place as a temporary measure in systematic smoking cessation”.
Our conclusion that advising reduction may give people false expectations,
refer to reduction as a permanent solution. We think that the results of
our study and of those of the Copenhagen Study, with study populations of
more than 70 000 persons together, give a sound basis for this conclusion.
Age Tverdal,
Professor
Norwegian Institute of Public Health,
Oslo
Kjell Bjartveit
Director Emeritus
National Health Screening Service
Oslo
The recent study by Tverdal and Bjartveit (TC 15:472-480, 2006) that
found no health benefit from reducing cigarettes had several assets not
found in the few prior prospective studies of this topic; e.g. the
reducers had reduced by over 50% and several outcomes were measured.
I would, however, like to make two comments. First, one asset of the
study was the examination of "sustained reducers;" i.e., those who...
The recent study by Tverdal and Bjartveit (TC 15:472-480, 2006) that
found no health benefit from reducing cigarettes had several assets not
found in the few prior prospective studies of this topic; e.g. the
reducers had reduced by over 50% and several outcomes were measured.
I would, however, like to make two comments. First, one asset of the
study was the examination of "sustained reducers;" i.e., those who
reported reduction at two consecutive examination. Although this
estimation of sustained reduction is superior to that in prior studies,
the question at each follow-up did not appear to ask about smoking since
the last follow-up but rather asked about smoking at the current time;
thus, in actuality, it is unknown what the rate of smoking really was
between follow-ups in "sustained reducers." As a result, there is still
the possibility that these results are false positives. Having said that,
I do believe the burden of proof is on those who believe reduction is
helpful to provide more rigorous tests.
Second, the concluding sentence of the abstract states advising
reduction may "give people false expectations." While this may be true to
some extent, advising reduction does not appear to undermine motivation to
quit but actually increases motivation to quit. Dr Carpenter and I
published a review paper of 19 studies (that did not come out until after
this current study was submitted). None of these studies suggested
reduction undermined motivation to stop smoking. Instead, 16 of the 19
found smoking reduction increased the probability of future cessation.
(NTR 8:739-749, 2006). Thus, I believe smoking reduction can be beneficial
to smokers if they see reduction not as an end itself but as way to
quitting. In fact, surveys suggest this is exactly how the large majority
of smokers see reduction (Hughes et al, NTR, in press)
My attention has been drawn to an error in our paper. At reference #3
we state that Addisson Yeaman was legal counsel to Philip Morris. He was
in fact legal counsel to Brown & Williamson. The mistake arose because
the document was in the Philip Morris collection and was misinterpreted as
being a Philip Morris document. Also, it dates from 1963, not 1964 as
stated.
After nearly two-fold efficacy over placebo in most clinical studies, NRT has proven no more effective than quitting without it in all real-world quitting surveys conducted since adoption of the June 2000 Clinical Practice Guideline (CPG): Minnesota 2002, California 2003, London 2003, Quebec 2004, Maryland 2005, UK NHS 2006, and Australia 2006.[...
After nearly two-fold efficacy over placebo in most clinical studies, NRT has proven no more effective than quitting without it in all real-world quitting surveys conducted since adoption of the June 2000 Clinical Practice Guideline (CPG): Minnesota 2002, California 2003, London 2003, Quebec 2004, Maryland 2005, UK NHS 2006, and Australia 2006.[1]
In the most recent survey, among smoking patients of Australian family practice physicians, patients quitting cold turkey doubled the rates of nicotine patch, gum, inhaler and bupropion quitters and accounted for a whopping 88% of all success stories (1,942 of 2,207).[1]
In fact, after more than two decades of use, NRT still cannot point to a single real-world performance victory in which those engaging in nicotine replacement prevailed over those engaging in nicotine cessation. The question we should all be asking ourselves is why?
On 10/27/06 the CDC reported that for the first time since 1997 the U.S. smoking rate failed to decline. I submit that intimidating physicians into betraying two decades of practice observations may increase profits for those marketing replacement nicotine, bupropion and varenicline but not without substantial needless loss of life.
Primary fault for our stalled U.S. rate is not with physicians. Whether nicotine or pain meds, it rests upon pharmacology dependent medical school curriculum developers who continue to ignore the core basics of chemical dependency recovery counseling. It also rests upon the very June 2000 Clinical Practice Guideline (CPG) here employed to coerce compliance by suggesting that physicians "might be hard pressed to defend" against civil malpractice liability if they fail to see CPG recommendations as imposing legal duties.
The authors' objective is clearly admirable. Far too many physicians ignore ever advancing circulatory, pulmonary and mental health carnage fostered by years of chemical dependency upon smoking the highly addictive super-toxin nicotine. Imagine 81 IARC identified cigarette carcinogens (including polonium) slowly building time-bombs throughout the body, when the only action taken by the average physician is to tell the patient what, to them, is already obvious - "you need to quit."
But in pounding the proverbial square peg into roundness the authors misstate the CPG's key objective, grossly overstate the document's credibility and, as already noted, confuse clinical efficacy with real-world effectiveness. As Professor Branzhaf notes, standards of care are born of consensus among impartial experts, rather than statements from hired guns. The CPG is anything but impartial. Although physicans have a duty to assist those dependent upon smoking nicotine they have no legal obligation to follow a pharmacology use directive that two decades of practical experience has convinced them is totally ineffective, a finding supported by all real-world evidence to date.
The authors fail to note that CPG recommendation seven (R7) totally consumes the remaining recommendations. It reads, "Numerous effective pharmacotherapies for smoking cessation now exist. Except in the presence of contraindications, these should be used with all patients attempting tobacco cessation." Not with "some" patients but "all."
PHS adoption of CPG R7 instantly discredited all non-pharmacotherapy counseling, support and behavioral cessation programs as being no longer in accord with U.S. cessation policy. Nicotine cessation programs that refused to integrate nicotine replacement found themselves in a state of policy illegitimacy with obvious financial and accreditation implications. Their choices were to stick with a true nicotine cessation format that within 3 days creates a nicotine free work space with the onset of full dopamine pathway neuronal re-sensitization (down-regulation), or amend the program to advocate use of chemicals which delay dopamine pathway re-sensitization for weeks or months.
Since 2000 the CDC's primary quit smoking web page has evidenced total government abandonment of support for the cessation efforts of the 80 to 90% of U.S. smokers whose natural instincts are nicotine cessation, not replacement. PHS policy does not treat CPG R7 as optional. Smokers visiting the CDC website are told that key to quitting is to "get medication and use it correctly."[2] The page lists seven pharmacotherapies that include five different NRT delivery vehicles. It then clearly suggests that clinical study efficacy findings are being mirrored in real-world effectiveness in asserting that "all of these medications will double your chances of quitting and quitting for good." The CDC knows or should know that this assertion is false.
Our government knows: (1) that nicotine is a psychoactive chemical producing an alert dopamine/adrenaline high with vasoconstriction, an increase in heart rate and blood pressure, heightened senses and an underlying "aaah" sensation; (2) that those with a quitting history are likely to have trained themselves to recognize their withdrawal syndrome; (3) that those seeking participation in pharmacology studies were not cold turkey quitters expecting to endure their withdrawal syndrome but instead those seeking "medications" that promised some degree of withdrawal syndrome reduction; (4) that a June 2004 review of NRT study blinding assessments concluded that NRT studies were generally not blind as claimed in that "subjects accurately judged treatment assignment at a rate significantly above chance";[3] and (5) that never once in any real-world quitting method survey to date has NRT use proven more effective than quitting without it.
How many nicotine cessation programs survived R7? Very few. But if your patients type "quit smoking" into any major search engine they should encounter one or more such programs as government abandonment of abrupt nicotine cessation education, skills development, counseling and support has fostered demand.
Ironically, a November 2003 persistent use study in this journal found that nearly 40% of nicotine gum users are chronic long-term users of greater than six months. Imagine R7 effectively banishing the very programs that could have aided those getting hooked on the cure. Under current policy where are they to turn to reclaim neurochemical control?
The authors paint a picture of the CPG having been created by an independent panel of experts. The authoring panel had 17 members of which 11 openly acknowledge financial ties to the pharmaceutical industry in CPG Appendix C.[4] The panel chairman, who was also the director of the Center for Tobacco Research and Intervention (CTRI), discloses that he "has served as a consultant for, given lectures sponsored by, or
has conducted research sponsored by Ciba-Geigy, SmithKline Beecham, Lederle
Laboratories, McNeil, Elan Pharmaceutical, and Glaxo Wellcome." In 1996 he was openly labeling himself "a consultant to Glaxo Wellcome."[5] In 2005 he testified that the Robert Wood Johnson Foundation (RWJF) provided CTRI with more than $8 million in funding since 1998, that he had served as director of the RWJF National Program Office Addressing Tobacco in Managed Care since 1996, and that since 1998 he had sat in a $50,000 a year university chair funded by GlaxoSmithKline.[6]
GlaxoSmithKline markets nicotine gum, a nicotine lozenge and nicotine patch. The RWJF clearly knows it could gain philanthropy credibility by severing financial and board member ties to Johnson & Johnson (J&J) and its product line, which includes a nicotine patch, nicotine inhaler and nicotine spray, but it hasn't. Instead it remains J&J's largest shareholder with a quarter of board members having been former J&J executives.
RWJF claims that in August 1998 it contributed $102,016 to CTRI as its share toward updating the CPG. It notes that on September 14-15, 1999, panel members met in Madison, WI, where they evaluated findings and prepared a draft of the new Guideline. It also asserts that "the final version was submitted to RWJF and the USPHS for approval."[7] Also of note, RWJF paid at least $235,654 toward CPG dissemination.[8]
The only fair conclusion is that pharmacology influence had major impact on the CPG. Stakeholders have no business managing the writing of U.S. cessation policy and the practice must stop. Imagine if the panel had included educators and counselors who had devoted their life to highly effective programs involving nicotine cessation, programs that RWJF and pharmaceutical companies would have zero interest in studying and promoting. Allowing more than one lone voice would likely have prevented R7 from consuming all other recommendations, and cost the pharmaceutical industry billions.
I seriously doubt that many reviewing the CPG in 2000 grasped that the document was effectively outlawing pharmacology's only serious competitor, cold turkey. How many today grasp why pharmacology seems so wonderful inside clinical trials yet so dismal once outside clinic doors?
How many smokers wanting to quit cold turkey would you expect to join a clinical trial offering a 50/50 chance of free medicine? For those seeking withdrawal syndrome diminishment, how many with a prior quitting history would be able to recognize full-blown withdrawal or, some degree of relief of withdrawal symptoms if assigned to the active group? How meaningful would clinical results be if frustrated or fulfilled expectations determined who survived and who relapsed? Real-world performace evaluations compel pharmacology quitters to at last go head-to-head with real cold turkey quitters. It's strange how the CDC relies upon surveys to establish every tobacco truth except the most effective quitting method.
Is it fair to blame the CPG and specifically R7 for bringing a decline in the U.S. smoking rate to a halt? I believe it is. Let me briefly explain why. First, think about two decades and hundreds of millions spent bashing and trashing quitter confidence in the most productive method the world has ever known, cold turkey. Still, this year it will generate more than 80% of all long-term successful quitters.
Those supporting R7 like to tell smokers that, "on average, it takes between three to five serious quit attempts before breaking free of tobacco dependence. Some may be successful on the first try, others may take three or more tries. I like to tell people to visit our clinic, that every time you make an effort, you're smarter and stronger, and you can use that information to increase the likelihood that your subsequent quit attempt is successful."[9]. What they fail to reveal is the precise lesson eventually learned or that the statistics they quote belong to nicotine cessation not nicotine replacement.
Reflect on the amazing influence upon the mind of a quitter who smokes nicotine just once after quitting, in generating a new salient dopamine "aaah" prefrontal cortex "pay attention" memory. It's an "aaah" that their missing dopamine killjoy enzyme (suppressed by nicotine) allows them to savor far longer than normal. It isn't just that their mind tasted another stolen dopamine "aaah" sensation but that it will not allow them to forget. Just one powerful puff is the single greatest predictor of full and complete relapse back to their old level of nicotine intake or higher.
We call it the "Law of Addiction."[10] This critical relapse lesson does not always come easy but eventually the failed quitter begins to see a bright line in the sand that says, "just one powerful puff of nicotine and I will again throw all this hard work out the window."
It should be obvious that toying with the very chemical that the school of hard-quitting-knocks was eventually supposed to teach them to leave alone muddies the learning waters. Renaming nicotine "medicine," labeling its use "therapy" and two decades of telling quitters that they need to replace missing nicotine has clearly interfered with a natural learning process.
Lastly, we know that unlike cold turkey quitting, where each new attempt actually increases the odds of success (unless the lesson becomes clouded by toying with pharmacology), with each subsequent NRT attempt the odds of success appears to decline. Shiffman's OTC NRT patch and gum meta analysis published here in TC in March 2003 found a 93% six-month relapse rate. But in the only two nicotine patch studies that have examined second time patch use rates, an average of 99% relapsed within six months. (100% Tonneson 1993, 98.4% Gourlay 1995). With second time NRT use rates climbing, this important yet little known finding should disturb all.
I submit that physicians have a legal duty to believe their ears and eyes above clinical study assertions that will never ever be duplicated in real-world use. I too encourage physicians to read and rely upon all aspects of the CPG except for pharmacology performance efficacy claims and use recommendations.
John R. Polito
Nicotine Cessation Educator
Editor WhyQuit.com
As the public interest attorney and law professor who first developed
the concept of using legal action as a weapon against the problem of
smoking (e.g., getting antismoking messages on TV and radio, driving
cigarette commercials off the air, starting the nonsmokers’ rights
movement, etc.), I was delighted to read a paper suggesting the
feasibility of using legal action to more effectively prod physicians to
warn patient...
As the public interest attorney and law professor who first developed
the concept of using legal action as a weapon against the problem of
smoking (e.g., getting antismoking messages on TV and radio, driving
cigarette commercials off the air, starting the nonsmokers’ rights
movement, etc.), I was delighted to read a paper suggesting the
feasibility of using legal action to more effectively prod physicians to
warn patients about smoking, and to assist them in quitting.
Actually, by way of full disclosure, my organization [Action on
Smoking and Health (ASH), http://ash.org] had made a similar suggestion in
2003, [http://ash.org/recommendations] and the New York City Health
Department warned even earlier that, "because physician intervention can
be so effective, failure to provide optimal counseling and treatment is
failure to meet the standard of care – and could be considered
malpractice." [City Warns Docs -- Help Patients Stop Smoking -- or Else,
New York Post (12/13/02)].
The Clinical Practice Guidelines referred to in the article greatly
strengthen such law suits because courts and juries are often confused by
– and therefore tend to throw up their hands regarding – testimony by
competing physicians as to the standard of what other physicians do.
Therefore they are increasingly likely to adopt, as a appropriate standard
of care, some official document which represents a consensus among
impartial experts, rather than statements from “hired gun” medical
witnesses. This is even more true where, as in the case of the tobacco
guidelines, they have been adopted and put into practice by prestigious
medical organizations.
Dr. Siegel makes some interesting observations but, as a physician
rather than an attorney, he appears to be out of his field, and – with
all due respect – perhaps out of his depth (despite his participation in
some tobacco litigation), in bluntly stating that the “legal reasoning in
[the] malpractice article is not sound.” As someone with almost 40 years
of experience with anti-tobacco litigation – and who has been called the
"Ralph Nader of the Tobacco Industry," an "Entrepreneur of Litigation,
[and] a Trial Lawyer's Trial Lawyer,” "a Driving Force Behind the Lawsuits
That Have Cost Tobacco Companies Billions of Dollars," and "The Law
Professor Who Masterminded Litigation Against the Tobacco Industry," let
me speak frankly in suggesting from a lawyer’s perspective why the legal
reasoning is sound and why the legal threat is very real.
While it is technically true that the plaintiff must prove – and then
only by a “preponderance of evidence” and not “to a medical certainty” –
that he would have quit if only the physician has warned him and assisting
him in doing so, in practice this is not a major burden for several
reasons.
1. To survive the initial motion to dismiss – where the defendant
asks the court to throw out the law suit so that defendant (and his
insurance company) will not be put to the burden of defending it – the
judge must assumes all allegations in the legal complaint are true unless
they are clearly impossible on their face. Thus a judge would refuse to
dismiss any law suit which alleged that the plaintiff would have quit if
the physician had warned him to do so, even if such a proposition were
clearly against the great weight of evidence. This refusal to grant the
motion opens the door to pre-trial discovery – including depositions,
demands for the physician’s time, documents, and records, etc. – places
a blot on his record, and perhaps interferes with his ability to obtain
malpractice coverage at favorable rates. That threat alone may motivate
many physicians (and their medical organizations and insurance companies)
to settle or – better yet – to follow the guidelines next time.
2. In most jurisdictions, a judge will charge the jury that there is
a legal presumption that the plaintiff would have heeded a warning, and
this jury charge is usually given even regarding small-print routine
warnings on tools, drugs, etc. which were merely inadequate rather than
nonexistent. This presumption – which in effect shifts the burden on this
issue onto the defendant – is likely to be far stronger where the specific
face-to-face warning from a physician mandated by the guidelines was not
even given, since judges as well as jurors know that warnings from
authority figures in white coats are likely to be far more effective that
tiny-print warnings on jars or packages. The presumption and jury charge,
by the way, is generally given even if the defendant introduces strong
empirical evidence that the plaintiff would not have heeded the warning.
3. The question of whether the plaintiff would have heeded the advice
and assistance of the physician if he or she had given it is a factual
issue for the jury to decide, and the issue must be left to them if
reasonably people could possibly differ – as they obviously can on this
question. Experience clearly suggests that, faced with a sympathetic and
very ill plaintiff who swears that he would have heeded a warning if it
had been given, and a physician who (as his lawyer will argue) “thumbed
his nose at his professional obligation, ignored the simple guidelines of
a governmental commission and the unanimous advice of his peers,” the
jury’s sympathy for the plaintiff will incline them to award him some
damages, even if empirical evidence as well as common experience suggests
how hard it often is to quit.
4. The same is true with regard to the burden on the plaintiff to
prove that, had he quit, he would not have had the medical problem of
which he now complains. Sympathy may well be more important in a jury’s
consideration of this issue than dry empirical and statistical evidence
and related arguments put forth by “rich doctors and their greedy
insurance company lawyers.” Moreover, since juries are so firmly
convinced that smoking causes lung cancer, arguments about latency periods
– and just when the first cell turned from healthy to pre-cancerous and
then to cancerous – are not likely to be very persuasive. Plaintiff
attorneys may also try to sue in situations based upon other diseases and
medical problems triggered and/or exacerbated by smoking – e.g., heart
attacks – where arguments based upon early damage and long latency periods
will have less traction.
5. Antismoking lawyers do not have to win every case, most cases, or
even one out of every ten cases to put strong pressure on hospitals,
medical organizations, insurance companies, and ultimately on individual
physicians to begin complying with the guidelines to avoid the risk of
being sued and the possibility – however large or small it may appear –
of losing such a law suit. In this regard, many older physicians may
remember an interesting parallel.
6. Prior to 1975, it appeared that it was not the custom and
practice of psychiatrists to issue warnings when their patients made
threats in the presence of their doctor to do serious harm to spouses,
friends, and other third parties. When the Supreme Court of California
ruled in the Tarasoff case that such a failure to warn could give rise to
legal liability if the patient carried out the threat, most psychiatrists
reportedly changed their own policies quickly, without even waiting for
the subsequent jury verdict which found the physician liable. There are,
of course, many other instances where changes were quickly made in medical
practice and procedure in response to law suits, and sometimes even to the
threat of law suits. Indeed, it would be far better for those in the
profession who do not currently follow these guidelines to begin doing so
now, rather that waiting for one or more tests of this legal reasoning.
7. Attorneys are likely to be eager to bring such cases since the
damages are likely to be high, and they will involve far less research and
preparation than traditional medical malpractice cases which often require
a very careful review of the patient’s entire medical record to find
examples of alleged errors, detailed medical research to be sure what the
standard of care is, and the need to find qualified medical witnesses
willing to testify that the named defendant violated the general standard
of care required in this specific situation. It’s obviously much easier
to find a plaintiff who had not been adequately advised and assisted to
quit, and to find a witness who will testify that the guidelines do in
fact represent an expert consensus as to the appropriate standard of care
which are followed by prestigious institutions. Also, remember the old
adage: “never underestimate the tenacity and creativity of an attorney on
a contingency fee.”
One final comment goes far beyond the narrow issue of liability for
failing to assist patients to quit smoking. Dr. Siegel seems to suggest
that any malpractice action based upon a physician’s failure to warn a
patient of a potential risk, or to suggest a treatment (medication,
operation, or other course of action), is doomed to failure if the
proposed treatment is less than 50% effective: “Until such time as there
is a truly effective treatment for smoking cessation (one that works most
of the time), there really can be no basis for establishing a causal
relationship between the breach of duty and the incurred injury.” In
other words, by this reasoning, it would appear that the medical community
would have no legally enforceable duty to do anything at all (including
refraining from negligence) where the chance of success – much less the
patient’s ultimate chance of survival – is less than 50%. But several
courts have ruled directly to the contrary, finding that even plaintiffs
whose conditions were so grave that their chance of survival was less than
50% still have a valid cause of action against a physician whose
negligence decreases those already poor odds. Good physicians should never
act negligently toward a patient, gambling that the dismal chance that a
proposed treatment will be effective will shield them from liability.
I find the argument provided in the paper to be non-compelling
because it fails to provide any reasonable argument for how the 3rd
showing in a medical malpractice case - that there is a causal
relationship between the breach of duty and the incurred injury - could
possibly be met in a smoking malpractice case. This would require proving
to the jury that the physician's failure to warn the patient to quit
smoking was th...
I find the argument provided in the paper to be non-compelling
because it fails to provide any reasonable argument for how the 3rd
showing in a medical malpractice case - that there is a causal
relationship between the breach of duty and the incurred injury - could
possibly be met in a smoking malpractice case. This would require proving
to the jury that the physician's failure to warn the patient to quit
smoking was the cause of the injury sustained by the patient.
This would imply that 3 things would have to be shown: (1) that the
patient would have quit smoking if only the physician had advised them to
quit and followed the PHS guidelines; and (2) that the reason the patient
did not quit smoking was that the physician failed to advise them to quit
and failed to follow the PHS guidelines; and (3) that if the patient had
quit smoking, he would not have developed the injury.
These seem to be unreasonable, if not impossible, points to prove.
How can we possibly know that a patient would have successfully quit
smoking if only the physician had followed the guidelines? Unfortunately,
the overwhelming scientific evidence cited in the paper supports a
conclusion that the patient would most likely not have quit smoking, even
if the physician had followed the guidelines. The data demonstrate that
the cessation success rate, even with physician treatment, is dismal. The
success rate does not even come close to approaching 50%; thus, it is more
likely than not that even with physician advice to quit smoking, the
patient would not have been successful in quitting smoking.
The success rates reported in the PHS guideline itself are generally
below 20%. This means that it is much more likely than not (in fact 4
times out of 5) that a patient who goes through the suggested intervention
will fail to quit smoking.
I view this as an intractable problem in the use of the PHS CPG in
medical malpractice lawsuits for failure to properly treat tobacco
dependence. Until such time as there is a truly effective treatment for
smoking cessation (one that works most of the time), there really can be
no basis for establishing a causal relationship between the breach of duty
and the incurred injury.
Finally, it is important to note that one would not only have to show
that the plaintiff would have quit smoking had only the physician advised
them to quit; one would also have to show that had the person quit
smoking, they would not have developed the injury. However, we know that
many former smokers still develop smoking-related injuries. It is not
clear that one could show that the plaintiff wouldn't have developed the
disease even if they had successfully quit smoking, especially for a
disease such as lung cancer where risk decreases slowly following smoking
cessation.
The paper by Henningfield, Rose and Zeller is an important
contribution to understanding the all-too-clever manipulation of language
by tobacco industry in defending its manufacture and marketing of an
addictive product. It is useful to note, as on the authors' Table 1, that
while the industry now publicly acknowldeges that cigarette smoking is
addictive, it never mentions nicotine as the principal addictive agent.
The...
The paper by Henningfield, Rose and Zeller is an important
contribution to understanding the all-too-clever manipulation of language
by tobacco industry in defending its manufacture and marketing of an
addictive product. It is useful to note, as on the authors' Table 1, that
while the industry now publicly acknowldeges that cigarette smoking is
addictive, it never mentions nicotine as the principal addictive agent.
The former attribution puts the onus on the smoker who can choose to be
addicted or not; the latter would require the industry to be responsible.
Table 1 contains two errors. The observed death rate from all
cancers combined among women in 1991 was 175.3 per 100,000 in 1991 (not
173.3). The percentage decrease in the death rate from 1991 to 2003 was
8.4%. We noted and corrected both errors in the galleys but the
corrections were not picked up by the copy editor.
The recent article by Gilpin, et al.,[1] reported the major initial
impact of California’s tobacco control efforts was to initially reduce
cigs/day among continuing smokers and this was followed by an increase in
quitting.[1] We would like to make three comments on this paper.
First, this study was one of the first to decompose the effects of
tobacco control into effects on initiation, cessation and reducti...
The recent article by Gilpin, et al.,[1] reported the major initial
impact of California’s tobacco control efforts was to initially reduce
cigs/day among continuing smokers and this was followed by an increase in
quitting.[1] We would like to make three comments on this paper.
First, this study was one of the first to decompose the effects of
tobacco control into effects on initiation, cessation and reduction. Such
analyses are crucial to understanding how tobacco control works. Second,
decreased tobacco sales data appeared to be an early indicator of later
declines in prevalence; thus, when tobacco control programs are pressed to
show changes in the first few years, sales data may be the most sensitive
measure to document progress or the lack thereof.
Third, although the authors did not state that reduction in cigs/day
caused later changes in quitting, some readers could interpret their data
to indicate this. An alternate explanation is that reduction in cigs/day
was simply an indicator of other processes such as denormalization of
smoking. However, other data suggest reduction may, in fact, cause
increased cessation. Our recent review found that among the 19 studies of
reducing cigs/day in smokers not trying to quit, 16 found reduction was
followed by increased cessation.[2] Importantly, among the 10 randomized
controlled trials of using medications or behavioral treatments to induce
reduction, 9 found reduction led to increased quitting. Although these
studies focused on interventions at the individual level, it may be that
reduction in cigs/day achieved by tobacco policies, taxes, community
interventions, etc. also lead to later cessation.
Gilpin, et al., [1] hypothesized a mechanism by which reduction might lead
to cessation; i.e., reduced cigs/day may lead to decreased dependence.
Although this is highly feasible, surprisingly, our review could not find
any studies that have tested this. Other possible mechanisms include
reduction increases self-efficacy or disrupts the association of smoking
with specific environmental cues.
If reduction leads to cessation, then when treatment programs observe
that some relapsed smokers return to lower cigs/day than prior to
attempting to quit, they should implement treatments to maintain this
reduction. In fact, the Lung Health Study undertook such a strategy (via
continued use of medication) in many relapsed smokers[3] and reported one
of the highest rates of long-term cessation in the literature.[4]
Reference List
1. Gilpin EA, Messer K, White MW et al. What contributed to the
major decline in per capita cigarette consumption during California's
comprehensive tobacco control programme? Tob Control, 2006;15:308-316.
2. Hughes JR, Carpenter MJ Does smoking reduction increase future
cessation and decrease disease risk? A qualitative review. Nicotine Tob
Res, in press
3. Hughes JR, Lindgren PG, Connett JE et al. Reduction of smoking in
the Lung Health Study. Nicotine Tob Res, 2004;6:275-280.
4. Anthonisen NR, Connett JE, Kiley JP et al. Effects of smoking
intervention and the use of an inhaled anticholinergic bronchodilator on
the rate of decline of FEV. JAMA, 1994;272:1497-1505.
Care is needed when using aggregate smokeless tobacco (SLT)
consumption data to examine the potential for SLT being used as a
potential reduced exposure product. As far as I am aware very few people,
if any, are suggesting that traditional chewing tobacco be used as an aid
to smoking cessation; any hopes in this area have been focused on moist
smokeless tobacco (MST).
Care is needed when using aggregate smokeless tobacco (SLT)
consumption data to examine the potential for SLT being used as a
potential reduced exposure product. As far as I am aware very few people,
if any, are suggesting that traditional chewing tobacco be used as an aid
to smoking cessation; any hopes in this area have been focused on moist
smokeless tobacco (MST).
Data from the US Alcohol and Tobacco Tax and Trade Bureau (TTB),
available at www.ttb.gov, show that MST and chewing tobacco have had very
different consumption patterns over the last decade. Using taxable
removals (in pounds) in the US, plus imports, as a proxy for consumption,
consumption of chewing tobacco seems to have declined at a rate of 5.2% a
year between 1997 and 2005, while consumption of MST grew at a rate of
3.6% a year over the same period. Aggregate SLT consumption over the
period declined at 0.1% a year.
The picture of steady growth in annual MST volumes – contrasting with
declines for cigarette consumption – is also corroborated by industry
data. Data from Swedish Match, based on AC Nielsen figures, suggest that
consumption of MST grew at 3.7% a year between 1997 and 2005, as measured
per can (available in investor presentations section of
www.swedishmatch.com).
Both the TTB and the industry data suggest that MST consumption may
have accelerated in recent years. Measured by weight, MST consumption grew
at an annual rate of 3.3% from 1997 to 2002, and by 4.0% a year from 2002
to 2005 according to TTB data. Measured in cans, MST consumption grew at
2.3% a year from 1997 to 2002, and by 6.2% annually from 2002 to 2005,
according to Swedish Match. The latest Nielsen figures also seem to be
indicating that the MST category is growing by volume at 6-7% in the first
half of 2006.
I have not seen a definitive study of why this apparent acceleration
of consumption is happening. Part of the explanation is down to the fairly
rapid growth of discount snuff brands, which may be encouraging existing
MST users to consume more product. But industry leader UST also believes
that the number of adult consumers has increased recently.
According to UST survey data (see its December 2005 Annual Investor
Meeting presentation at www.ustinc.com) the number of adult consumers of
MST grew from 4.7mn in 2001 to 5.4mn in 2004. If we take US Census Bureau
(www.census.gov) estimates for the population size in July of each of
those years (285.1mn in 2001 and 293.7 in 2004), that would mean MST
prevalence grew from 1.65% to 1.83% over the period. The same UST survey
from 2004 also suggests that 63% of those MST users who had been using MST
for less than a year had used cigarettes or roll-your-own tobacco as their
first regular tobacco product.
Disclosures:
Deutsche Bank and/or affiliates own one percent of more of the common
equity of Swedish Match, expects to receive, or intends to seek,
compensation for investment banking services in the next three months, and
received non-investment banking related compensation from this company
within the past year.
The eletter entitled "A Personal Experience with Goza and Shisha
Smoking is authored by only FOUAD A. Al-BELASY. The names of other co-
workers were mistakenly entered during submission from below the bar
displaying how to enter other colleagues.
Shisha, Goza, Hashish and Street Children: What the
Egyptian Scene Teaches Us
For historical,
sociocultural and health reasons, Egypt is certainly the most important country
in the world regarding shisha smoking (*). So, many thanks to Pr Fouad
Al-Belasy and his colleagues for the very rich comments about the Egyptian Goza
and Shisha. This showed, once more, the complexity of the issue and how different
from the cigarette world it is. It is not everyday that we have a scientist with such hands-on experience and whose studies, particularly the last one in the Journal
of Oral and Maxillofacial Surgery, definitely reflects such qualities.
MOLLASSES. In his contribution, the
tobacco-mollasses mixture (mu‘assel; and “maassel” in Egyptian Arabic…) is said
to be unflavoured. I would like to inform him that in other countries,
particularly Arab countries, the same word is employed for the flavoured
product as well. And when the unflavoured product is used, it is sometimes
called jurâk.
BOURY. “Boury” can be used synonymously for
Shisha, he says. I would like to note that in a country like Yemen, such a
word represents the clay bowl of the madâ‘a (the national narghile) filled with
tumbak (raw tobacco)(*). I assume that this is a metonymic description
as it often happens in this field. For instance, “hookah” is literally an
Arabic word (for “urn”, e.g. of water) and similarly “shisha”, which means, in
Persian, something like a “bottle” (sise in Turkish). In Asia,
the same linguistic transfer seems to occur where “chillum” may mean the bowl
but sometimes, also, the hookah itself (*).
GOZA. What Pr Al-Belasy states about the
Goza (take care with the different spellings – perhaps we should keep “Goza”
and forget about “gooza” and “gûza”), and the description he gives of its
material details (from the valve to the reed and from the lighter to the
“bilya”…), and how they are used (body techniques), are indeed very important
because of their deep consequences on the related biomedical studies. I would
like to add that, my own work also contains similar descriptions of the Goza
and its users. For instance, I quote a popular song by M. Sêlem (‘El-Kîf) where the whole atmosphere of a Goza party is depicted as in Pr
Al-Belasy’s input (*). I have also carried
on an analysis of a book by Egyptian Nobel Prize Naguib Mahfûz (Tharthara fawqä n-nîl) in which the Goza is used as a mere pretext (a
relevant key sociological notion), being described in almost every page of the
novel (*). To close this chapter, thank you for recalling Salem, a pioneer in
research on Goza smoking, author of so many valuable studies on it (see our
Tetralogy)(*).
HASHISH.As for the use of hashish
in the goza, Pr Al-Belasy’s anthropological description (in the true sense of
the word) of its smokers is also very interesting. In my chief work, I also
provide extensive narrative depictions of situations where such odd
characters as the Me‘ellem (Sultan), his wife the Me‘ellema, and other
colourful actors of the “gurez” (secret smoking rooms) “sign” their goza
by placing the substance inside the bowl (*).
CHILDREN SMOKING. What Pr Al-Belasy tells us about
children and smoking in his country is very useful because there has been a lot
of confusion in this respect. He is a personal witness of how poverty may
transform the “commonly accepted traditions” that maintain children away from
smoking. In the poor countries, not only shoe-shine boys at work are
commonplace scenes but also children selling cigarettes in the streets. For
them, the cafés are a natural and important place because there are many
potential clients. They are also a place where they can rest a little. Now, if
you were such a street child, probably in charge of several brothers and
sisters, you would feel that you have quickly become an adult simply because
you spend a great part of the day working in adult environments such as the
above cafés.
Consequently, from
time to time, you may try to reward yourself because the child is still in you.
Why not ask for a delicious “apple, peach, banana, or cherry shisha” since
nobody in society cares for you and your brothers and sisters anymore ? Neither
the walkers nor the employees of the coffee-shops would try to exert any kind
of moral or social control over you. You see, if these children were normal,
i.e. if they were not poor, of course their parents would never let them ask
for such a product and would let them clearly understand that this is
forbidden. Alternatively, they could find out that it is a kind of “rite of
passage” to the world of men and grown-ups. In these conditions, they would
learn, instead, to ask for an ice-cream flavoured with the same above fruits...
Shisha vs. “Water-pipe” : The Question of a
Unifying Term
Hookah, Narghile
and Shisha are definitely not “local words” (Maziak). “Hookah” is used
(with slight spelling variations) in India, Pakistan, the USA, Canada and many
English speaking countries. “Narghile”, with the same reservations, is
prevalent in many countries of the Middle East, including Turkey, where it is
the official name (“nargile” with no “h”), and Iran where it is one of both
national forms with the Qalyân. “Narghile” is also used in many European and
African languages. As for “Shisha”, it has been a word widely employed in Asia
and Africa for centuries. Today, its related service (within the so-called
“shisha bars”, “shisha lounges”, etc.) is offered in almost all countries of
the world.
By contrast, I am
afraid the word “water-pipe” lacks the necessary essence in a field where the
socio-cultural context is known to be complex and highly important in relation
to biology and psychopharmacology. So, I would encourage my colleagues to
keep it exclusively for experiments on smoking machines in a laboratory and never
use it for real human smoking. Another problem with “water-pipe” is its strong
connotations with the drug culture, particularly in the USA in the context of
the Drug Paraphernalia Laws(*). Indeed, peoples of the Middle
East are always shocked when they hear or see that the shisha they have been
using for centuries in convivial settings, is portrayed in the West as a mere
drug taking device.
If only one among
the 3 major universal words (Hookah, Narghile, Shisha) had to be kept, I would
personally recommend Shisha. On one hand, this word is used everywhere in the world. It can be
easily pronounced and memorised by almost any individual in the world (remember
why the commercial word “Kodak” was chosen). On the other, like “Hookah”
(Arabic for urn), “Narghile” (Sanskrit then Persian for coco nut) and “Goza”
(Egyptian Arabic for coco nut), Shisha is consistent with the wide diversity
covered by an anthropological genus that perfectly reflects the phylogenetic
link between the common element (water recipient) and its remote –and
considered so important- origin when a coco nut, half filled with water, was
used as a smoke filter. From this perspective, Shisha is highly generic,
understood as descriptive of all members of a genus.
I also think the
question of sharing knowledge among researchers has no relation with the words
by themselves, be they narghile, hookah, shisha or “water-pipe”, but rather
with the will to cooperate and take stock of the existing work carried in this
field (*) and in any language. Unfortunately, this has not been done
when a report for a supranational organisation (WHO), supposed to be based on a
“world review”, was recently prepared on this subject. Besides, I may wonder
where the real linguistic standardisation problem lies when recurring studies
(Natto 2005 and Tamim 2006, just to mention recent ones) mistake one product
for the other. Finally, the selection of one word should have been discussed
among researchers. Unfortunately, this did not happen so the related choices
are obviously arbitrary and hence, questionable.
This is to comment on the following recently published eletter:
The issue of nomenclature: Wasim Maziak (17 June 2006)
In a dictionary search for Hookah, Hubble-bubble, Narghile, Arghile,
Water-pipe and Shisha, the Oxford Paperback Dictionary [1] defines Hookah
as an oriental tobacco pipe with a long tube passing through a glass
container that cools the smoke as it is drawn thr...
This is to comment on the following recently published eletter:
The issue of nomenclature: Wasim Maziak (17 June 2006)
In a dictionary search for Hookah, Hubble-bubble, Narghile, Arghile,
Water-pipe and Shisha, the Oxford Paperback Dictionary [1] defines Hookah
as an oriental tobacco pipe with a long tube passing through a glass
container that cools the smoke as it is drawn through and defines Hubble-
bubble as (i) a simple Hookah, (ii) a bubbling sound and (iii) a confused
talk. No definition was given in this Oxford dictionary to Narghile,
Arghile, Shisha or Water-pipe. Al-Mawrid [2] defines Hookah into its
literal meaning as well as Narghile and Shisha (the Arabic word). It
defines Water-pipe as (i) a water tube and (ii) Narghile and gives the
term Narghile its literal meaning. Al-Mawrid also gives no definition to
Arghile or Shisha. In this context, the term Hookah dominates. Therefore,
the conclusion that the term Water-pipe has the strength of highlighting a
unique and unifying feature of all other local types [3] has to be
reconsidered.
It is the scientific literature as well as Media which paves the way
for the publicity of scientific terms. In this respect, one can review the
deep effect of Media on the widespread use of scientific terms (acronyms)
such as AIDS and SARS to the extent of publicity despite the specificity
of both terms and the deficient knowledge of the public. Therefore, with
the international use of Shisha as well as benefiting the deep effect of
Media, the term Shisha, in my opinion, will be more appropriate for the
scientific literature increasing the potential of sharing and
communicating research results [3].
It is interesting to say that in the search for the definition of
Shisha, the term Shish-kebab was found in both dictionaries and I believe
that the habit of Shisha smoking is of no less significance than the habit
of eating Shish-kebab.
References:
1- Liebeck H, Pollard E: The Oxford Paperback Dictionary. Oxford
University Press 1994.
2- Ba'albaki M: Al-Mawrid: A Basic Modern English-Arabic Dictionary.
Beirut- Lebanon 2002.
3- Maziak W: Eletter: The issue of nomenclature. TC online 17 June 2006.
I thank the authors of letters regarding our published work (Ward et
al, 2006) on their useful remarks. It is self-understandable that no one
uses the world waterpipe when asking the public about this tobacco use
method, but use the local word for it. The same way that we never ask the
public about ischemic heart disease but use this term extensively in
research papers about this problem. It is also understandable that t...
I thank the authors of letters regarding our published work (Ward et
al, 2006) on their useful remarks. It is self-understandable that no one
uses the world waterpipe when asking the public about this tobacco use
method, but use the local word for it. The same way that we never ask the
public about ischemic heart disease but use this term extensively in
research papers about this problem. It is also understandable that there
is a need to use some unified term related to this tobacco use method in
order to facilitate the indexing, search, and communication of research
results related to this tobacco use method. While the waterpipe may not be
a perfect term, local words describing this method (hookah, shisha,
narghile, etc) can not be used as a unified term because of their local
nature. The term waterpipe has the strength of highlighting a unique and
unifying feature of all these local types; that is the passage of smoke
through the water before inhalation by the smokers. In the end, people are
free to use whatever term they see optimal in their research papers, but
having a unified term at least in their key words will increase the
potential of sharing their research results with all interested in this
issue.
This is to comment on the following recently published eletter:
Chaouachi K: Syria, Lebanon, Tobacco Research in General and Narghile
(Hookah, Shisha) Smoking in Particular. TC Online 8 June 2006.
I completely agree with the statement that Shisha is now used
internationally because of the global hookah craze whereas “waterpipe” is
no hypostasis and adhere to the notice that this wo...
This is to comment on the following recently published eletter:
Chaouachi K: Syria, Lebanon, Tobacco Research in General and Narghile
(Hookah, Shisha) Smoking in Particular. TC Online 8 June 2006.
I completely agree with the statement that Shisha is now used
internationally because of the global hookah craze whereas “waterpipe” is
no hypostasis and adhere to the notice that this word creates
bibliographic noise in databases since it also refers to household
infrastructure plumbing equipments [1]. Goza and Boury, however, are two
other common names in Egypt. While Shisha and Boury may be synonymously
asked for in a café shop by tobacco smokers in Egypt, Goza- not available
now in all café shops- is the favorite for some smokers; especially
Hashish smokers.
The use of Shisha as a substitute for cigarettes after quitting, and
the fact that Shisha triggers relapse for some cigarette quitters is
indeed a unique and worrisome observation [1, 2]. In addition, the
initiation of Shisha smoking by a significant number of cigarette smokers
is truly a significant unintended consequence of cigarette smoking
cessation. While tobacco smokers who are only Shisha smokers never
initiate cigarette smoking upon quitting, cigarette quitters may initiate
Shisha smoking. However, cigarette quitters who initiate Shisha smoking
are highly expected to resume cigarette smoking because they soon realize,
under the effect of nicotine dependency, the ease of smoking a cigarette
while reading, driving or talking in the telephone, for example.
References:
1- Chaouachi K: Syria, Lebanon, Tobacco Research in General and Narghile
(Hookah, Shisha) Smoking in Particular. TC Online eletter 8 June 2006.
2- Ward KD, Eissenberg T, Rastam S, Asfar T,Mzayek F, Fouad MF, Hammal
F,Mock J, Maziak W: The tobacco epidemic in Syria. Tobacco Control 2006;
15; 24-29.
Being a son of a famous well-qualified owner of a café shop, I have
been, since the early days of my perception, in direct contact with Goza
and Shisha smokers.
Goza is a modified form of Shisha. It has its head, body, water-container,
and hose [1]. However, Goza has no mouth-piece separated from the hose and
no disposable plastic mouth-piece is served or commonly used. Yet, the
water-container of Goza was and still is ma...
Being a son of a famous well-qualified owner of a café shop, I have
been, since the early days of my perception, in direct contact with Goza
and Shisha smokers.
Goza is a modified form of Shisha. It has its head, body, water-container,
and hose [1]. However, Goza has no mouth-piece separated from the hose and
no disposable plastic mouth-piece is served or commonly used. Yet, the
water-container of Goza was and still is made from metal and the hose is 1
-1.5 meter long semi-dry sloping reed in which the partitions are hollowed
through the use of a thin heated auger (not anyone can do this). Moreover,
the water container of Goza has a small opening covered by a small piece
of soft leather fastened by rolling several loops of thread or elastic to
the lower end of the body, which acts as a valve allowing smoke entrapped
in the vacuum space to be expelled between inhalations or before use by a
sharing smoker. However, this valve ("Raffas") was devoid in earlier Goza.
Serving both Goza and Shisha necessitates changing water from time to
time, frequent cleaning of the body internals using a thick heated auger
followed by several washings using hot water, and flaming of the lighter
before being placed over the head. Unlike Shisha, however, the water-
container of Goza can be placed in a small basin filled with cold water
while not in use. But, Goza necessitates holding it while smoking; usually
by the smoker himself. In this respect, it is interesting to say that some
Goza smokers were seen to fantastically design a metallic short stand with
a movable ball bearing socket in order to avoid keeping hold of Goza and
to freely pass the hose from one smoker to another. This altogether with
decorations of Goza or Shisha implies the deep effect of the habit on some
smokers.
Up to the nineties of the passed century, only adults and elderly men were
seen smoking Goza or Shisha. It was extremely rare to see a child (17-19
years old) who smokes Goza or Shisha. To my experience, having a seat and
table in a café shop was only an act of adults. Children were not allowed
to enter any café shop except for watching the T.V. No child could dare to
ask for Goza or Shisha otherwise he will be forced out or remembered to
his parents or guardian. Moreover, a cigarette smoking child was
considered violating the commonly accepted traditions of society. However,
cigarette smoking by homeless children was only accepted and pitied at the
same time by society during these days. Therefore, with the dramatic
changes in the accepted norms by new societies, it has become usual to see
a café shop partly occupied by children smoking tobacco.
From another perspective, maassel was and still is the most commonly used
tobacco in Goza or Shisha smoking. Maassel is of three common degrees:
hot, moderate and cold. Flavored tobacco, on the other hand, has become
widely available in most café shops. Both can be provided in the café shop
by the server but maassel; in addition, can be purchased by the smoker
himself. Unlike maassel, flavored tobacco can be easily smoked by a child
without feeling lightheadedness, headache or an altered state of
consciousness. Therefore, it has become usual to see children in café
shops asking for an apple, peach, banana, or cherry Shisha. They usually
ask for it cheerfully as if they were asking for a drink. However, in
underdeveloped or developing countries a question may be raised about home
circumstances, financial support and character of the child who can pay
for multiple drinks as well as Shisha smoking in a café shop.
In the past, smoking Goza or Shisha by elderly females was accepted by
society and considered as equal or parallel to snuff dipping or snuff
inhalation; a habit that was widely prevalent among old females at that
time. While the habit of smoking tobacco by adult females was considered
pornographic, only adult female with the nickname "Mealemma" {(Master) or
a female in charge of a café shop or agency for example} was accepted as a
Shisha smoker. At the present time, with the wide prevalence of
Satellites, and Media over-flow [2] as well as sexual effects, it has
become familiar to see adult females sitting freely in café shops and
smoking flavored Shishas.
Maassel can be considered the most commonly used tobacco by dependent Goza
or Shisha smokers. Some of those dependent Goza or Shisha smokers may be
Hashish smokers. In the past, most café shops had an isolated corner for
Hashish smokers who were given a due consideration by the server. However,
because of a governmental pursue the habit of Hashish smoking has been
almost eradicated in café shops. Nevertheless, "Bango" (an intoxicating
plant leaves) has become the alternative despite the war against both.
Serving a Hashish or Bango smoker differs from serving a maassel or
flavored tobacco smoker. Maassel or flavored tobacco smoking is served by
asking for alternative heads on an individual basis where the server is
entirely responsible to provide a highly working Shisha or Goza with the
head fully filled with tobacco and covered with a burning lighter. in
Hashish smoking, however, a set of heads usually five or ten made from
crockery are first filled with maassel and placed before the smoker over a
wooden stand where the smoker covers maassel with Hashish cut into small
discs (approximately .5-1mm thick and .3-.5 cm in diameter) or Bango
spread over in a coarse powdered form. This entails that the head in
Hashish smoking is only 1/4 filled with maassel ("Tasheirah"). Moreover,
and unlike maassel or flavored tobacco smoking, the server in Hashish
smoking will join the smoker where he is required to change the heads,
flame the lighter before every time another head is used and even share in
smoking.
While cigarettes can be filled with Hashish or Bango to have a "Saroukh"
(rocket) by some smokers, Goza or Shisha is essentially instrumental in
Hashish or Bango smoking habit. This simply may be a corollary to the well
known fact that Goza or Shisha smoking is a social habit practiced and
shared in groups. In addition to health hazards relevant to the used
tobacco, type of lighter as well as the risk of disease transmission
through sharing the hose of Goza [3-5], Hashish or Bango smoking becomes
more hazardous. Therefore, endeavors and strategies aimed at
understanding, analyzing and preventing this habit should be developed and
implemented by all concerned authorities.
References
1. Maziak W, Ward KD, Afifi Soweid RA, Eissenberg T: Tobacco smoking
using a waterpipe: a re-emerging strain in a global epidemic. Tobacco
Control 2004; 13: 327-333.
2. Chaouachi K: Eletters: About the so-called epidemic and the poor
smoking people - Ward KD, Eissenberg T, Rastam S, Asfar T,Mzayek F, Fouad
MF, Hammal F,Mock J, Maziak W: The tobacco epidemic in Syria. Tobacco
Control 2006; 15; 24-29.
3. Salem ES, Sami A: Studies on pulmonary manifestations of goza smokers.
Chest 1974; 65:599.
4. Shihadeh A: Investigation of mainstream smoke aerosol of the argileh
water pipe. Food Chem Toxicol 2003; 41:143–52.
5. Al-Belasy FA: The relationship of "shisha" (water pipe) smoking to
postextraction dry socket. J Oral Maxillofac Surg 2004; 62:10-14.
This is to comment on
the following recently published study:
Ward KD,
Eissenberg T, Rastam S, Asfar T,Mzayek F, Fouad MF, Hammal F,Mock J, Maziak W. The
tobacco epidemic in Syria. Tobacco Control 2006;15;24-29.
About
the So-Called Epidemic and the Poor Smoking People
The paper is globally unbalanced in
favour of a certain focus on narghile (hookah, shisha) smoking. After reading
the three following quotations, the reader may wonder whether we can call
hookah smoking an “epidemic” in Syria:
1-"The
prevalence of cigarette smoking was 56.9% for men and 17.0% for women, while
the prevalence of waterpipe smoking was 20.2% for men and 4.8% for women (fig 1)"
2-"The
opposite pattern was observed for waterpipe, with 1.0% smoking daily (1.4% for
men and 0.6% for women), and 10.6% smoking occasionally (18.8% of men and 4.2%
of women). The prevalence of combined daily use of cigarette and waterpipe was
reported rarely—0.1% (0.1% men, 0.1% women)."
3-"Daily
cigarette smokers averaged 20.8 (SD 14) cig/day (23.6 (13.9) for men and 12.8
(11) for women), while weekly waterpipe smokers smoked on average 1.7 (1.1)
waterpipe/week (1.6 (1) for men and 1.7 (1.4) for women)."
We encourage our
colleagues to inform the Syrian Ministry of Health of these statistics and urge
it to take steps to curb the cigarette epidemic in this country. Of course the
task is huge because of the nature of the market and the diverse interests at
stake. Syrians smoke national, international, smuggled and counterfeited
cigarettes. Certainly the solution is regional integration and cooperation.
Syria and Lebanon, where more than a half of the population smokes cigarettes
in both countries, can work hand in hand towards a Middle East free from
tobacco all the more that they are one same people.
So, we are afraid
“epidemic” might not be the best word to describe the revival of narghile use
in the Middle East. Besides, a corresponding scenario was proposed two years
ago by the same team (1). According to it, the Arab information satellite
television channels would have been greatly responsible for the development of
the hookah craze. Unfortunately, such a conclusion is not in agreement with
our socio-anthropological
research findings in the Middle East which point to at least 15 factors set out
and analysed in an early document (2).
Now, if "quitting
is also more prevalent among waterpipe smokers especially in the poorer
sections of the society", then this is good news because one reason
behind the failures of many tobacco prevention programmes in the world is not
dealing with the health consequences of poverty in this field. By good fortune,
great original researchers showed how marginalized groups adopt unexpected
strategies to adapt to any new situation stemming from rises in tobacco prices.
Just to mention some of them, they may leave shorter butts which is
unfortunately an extremely hazardous behaviour (3). They may also hand-roll
cigarettes that pose higher oral cancer risks (4). More, they can stuff hand
rolled cigarettes with the remaining tobacco from the butts of other, used
filters and dry leaves, or share the same cigarette (5).
About Carbon
Monoxide Levels
“Results suggest that waterpipe users are exposed to
more CO than previously reported (we observed a mean increase from 5.6 ppm
before use to 36.3 ppm after use (p , 0.01), compared to the mean of 14.2 ppm
after waterpipe use reported by Shafagoj and Mohammed)”.
This fact may be surprising for the
authors. However, this is in agreement with our own findings so we will be
happy to comment on it but only when the corresponding study is out since it is
only an announcement. Indeed, we regret that the authors too often refer to
forthcoming publications.
About
the Adaptation of Questionnaires
Kozlowski actually
warned against the misuse, in English, of the words “craving” and “urge” (6,
7). So, we really wonder how, in a sophisticated language like Arabic, these
concepts, and the subtleties they convey, will be rendered in a corresponding
translated questionnaire. Many studies in this field refer to “adapted”
versions of internationally known and validated questionnaires (like
Fagerstrom’s, Tiffany–Drobes’, Prokorov’s, Hughes-Hatsukami’s, etc.) and,
sometimes, to an Arabic “version” of them. However, they are never made public.
Since science is based on the possibility offered for any researcher to
reproduce, in the same conditions, any experience previously carried on, we
think the so-called documents should be annexed to the studies publishing the
corresponding results. Indeed, it is all the more easy that in most cases the
adapted questionnaires are very short in length. From there, we hope to see the
Arabic version of the Tiffany-Drobes questionnaire published soon so our team,
presently working on dependence patterns, can test, in its turn, its claimed
applicability.
Also note that the
same Kozlowski warned against the use of smoking machines in the field of
cigarettes, where, however, the smoking session (c. 5 minutes) is extremely
short in comparison with the hookah (30-60 minutes)(8). So, this kind of cogent
reflection may render questionable a certain number of findings (9).
About
Initiation Age
Strangely enough, statistics reveal
that there is no so-called children use in Syria:
"Age of initiation differed according to method
of smoking and gender. On average, men initiated use of cigarettes at age 17.9
(5.3) years and waterpipe at 25.5 (9.1) years, while women initiated use of
cigarettes at 22.5 (8.4) years and waterpipe at 28.9 (9.9) years (p , 0.05 for
all gender and smoking method comparisons by t test)."
Consequently, and
since Syria is an Arab country, this result is apparently not in agreement with
the first Advisory Note on “Waterpipe” smoking ever published by WHO (World
Health Organisation). This last document states, among other errors that could
have been avoided, that in the Arab world (described as “South-West
Asia and North Africa”):
“it is not uncommon for children to smoke with their parents” (10). In fact, our
socio-anthropological work showed that in Syria as in many other countries of
the region, narghile (hookah, shisha) initiation is more akin to a kind of
“rite of passage” (2).
About
Dependence
"Less
interest in quitting and a higher quit rate among waterpipe users compared to
cigarettes possibly indicate lower level of nicotine dependence among waterpipe
users."
In a former study (11), on
which we already commented (12), one assumption was that"nicotine dependence may also result from repeated inhalation of
tobacco smoke from a waterpipe [...] Until recently, no studies have
characterised a waterpipe withdrawal study of seven waterpipe using men, daily
use was associated syndrome, though some of the hallmarks of dependence are
apparent: continued use despite potential health risks, financial cost, and
reported inability/difficulty quitting."
In order to spare
time and from our original transdisciplinary experience, we would be happy if
our colleagues would accept to contemplate other possible research orientations
in this important field. Indeed, on one hand, original research on narghile
will help, not only understand the dependence phenomenon related to the use of
narghile, but also the dependence process as a whole and, most importantly,
regarding cigarette smoking. People do not necessarily smoke the hookah for
nicotine and another evidence for this is that the fashionable “hookah lounges”
already offer herbal fruit-flavoured tobacco-free smoking mixtures to their
patrons.
On the other hand,
there is a serious debate over the central role of nicotine in the dependence
process (13). Indeed, the importance of flavours (only in the case of tobamel,
the popular tobacco-molasses based smoking mixture) would make the dependence very
similar to that induced by coffee (14). Thus, not only nicotine but MonoAmine
Oxidase Inhibitors (MAOI), other not so « important » low-dose
potentially dependence-inducing alkaloids, ligands of opioid receptors, and
other substances, might play a not so minor role in the dependence process
(15).
About
Anthropological Work
The paper refers to a
“new” orientation of the team activities within the framework of the so-called
“grounded theory approach”. Here, we would like to emphasise that the
anthropological work implies very long observation periods. In our case, we
actually carried on early socio-anthropological work in the Middle East for a
period of four years. We have interviewed hookah users and drawn, only in the
last stage, relevant and originalconclusions,
particularly regarding dependence (2). We regret that the authors openly
present “preliminary” results or analysis of an ongoing work of this nature.
This is not possible. From the very methodological point of view of
anthropology, we are afraid this cannot be done and this is one of the
peculiarities of some social sciences.
Poland et al. have
clearly shown in the columns of this journal where the last frontiers of
tobacco control are (16). Their rare and deep analysis is valid for any country.
In the light of the debate over orientalism opened by Edward Saïd (17) to an
unexpected horizon, we scientists (particularly from the Middle East or of
Middle East origin), either from the biomedical or social science field, will
be answerable for the way we have been doing science (18). Do we make it with
the people and for the people and their health or for academic research only -
sort of Art for art’ sake ? From this perspective, we commented on Poland’
study and showed the actual similarities and dissimilarities between both the
cigarette and hookah worlds (19). So, why not take advantage of the recent
archives of this journal ?
A statement we fully
agree is : "What is unique and worrisome about the
waterpipe is its use as a substitute for cigarettes after quitting, and the
fact that the waterpipe was the trigger of relapse for some cigarette quitters.
Thus, initiation of waterpipe use can be a significant unintended consequence
of cigarette smoking cessation." Indeed, we are glad to see how our colleagues
now share the conclusions we drew more than five years ago (2, 20, 21).
About
the word “water-pipe”
We are afraid this
word is misleading and deepens the gap between scientists and the true world of
hookah users. Please refer to our critique of a paper in the columns of this
same journal (22). Indeed, we are quite sure that our colleagues will never
use, in a related study or questionnaire into Arabic, “galyûn bi-l-mâ‘
(or galyûn mâ‘î), which are, as they may know, laughable literal
translations of “water-pipe”.We are
sure they would use the words “narghile” or “shisha” (“hookah” if they were in
India or Pakistan). Indeed, they will understand that it would be funny to
imagine a naïve anthropologist asking smokers in a Syrian coffee-house: What
about your “galyûn bi-l-mâ‘” practice ?
Indeed, in this field
where tradition and the sociocultural context meet so closely with
pharmacology, it is of utmost importance to use the language the people use
then reflect this in our publications. Further to a comprehensive analysis of
the world linguistic variations and the higher observed prevalence for some of
them, we concluded that three terms are highly relevant: narghile , hookah and
shisha (2). These words can be found in any good English academic dictionary.
Shisha is now used internationally because of the global hookah craze whereas
“waterpipe”, we are afraid,is no
hypostasis. More, we have noted how this word creates bibliographic noise in
databases since it also refers to household infrastructure plumbing equipments…
Certainly the artefact is a “water-pipe” in a chemistry laboratory (9).
However, once you are in the street or in a domestic setting, it is a hookah, a
narghile, a shisha and even much more. This stresses, once more, the importance
of a scientific discipline like anthropology whose object is not the study of
folklore.
About Capacity
Building
The so-called RAM
(Research Assistance Matching) action was already advertised in the Science
journal and we had the opportunity to comment on it by emphasising the fact
that the best studies in the field of hookah smoking have been carried on in
the South with no external aid (23). For instance, who could say that Shafagog
(24), who worked with a small team in a poor country like Jordan, was lacking know-how,
ignoring international best practices or expertise ? He has actually produced
the best reference studies on cotinine/nicotine levels and an excellent other
one on CO intake in true narghile smokers.
The same applies for
Sajid (25) and his team in Pakistan, whose findings, obtained with modest
means, contributed in pushing forward research. He had this fantastic idea of
measuring CO levels according to the size of the device, the nature of the
tobacco-based mixture and even the charcoal varieties. He and his colleagues
are simply brilliants. They remained relatively unknown for a very long time
until we described their work six years ago then advertised it here and there
(2). We could follow with many other examples from the so-called South.
So, what we defend is
a capacity building project that takes into account other dimensions than the
RAM one. The objective of ours, hopefully soon carried on with the
collaboration of the prestigious University of La Sapienza, is to train
Western researchers on the specificities of the socio-cultural context of the
countries where hookah smoking seems to cause a problem for certain
authorities. Perhaps the RAM project may be of some use for cigarette smoking.
However, for narghile, our own opinion is that we definitely need not new or
modern methodologies or approaches. What we need are ideas that originate from
the local context. We have already helped dozens of researchers in this new way
of thinking and we hope to train more and more people in the future on these trailblazing
conceptual frameworks.
Kamal Chaouachi,
Researcher in Socio-Anthropology and Tobaccology
Consultant in Tobacco Control (Paris)
REFERENCES
(1) RASTAM S, WARD KD, EISSENBERG T,
MAZIAK W. Estimating the beginning of the waterpipe epidemic in Syria. BMC
Public Health 2004; 4:32.
(2) CHAOUACHI Kamal. Le
narguilé : analyse socio-anthropologique. Culture, convivialité, histoire
et tabacologie d’un mode d’usage populaire du tabac. Transdisciplinary
doctoral thesis, Université Paris X (France), 420 pages. [Engl.: "Narghile (hookah): a
Socio-Anthropological Analysis. Culture, Conviviality, History and
Tobaccologyof a Popular Tobacco Use
Mode”].
(3)
MOLIMARD R, AMRIOUI F, MARTIN C, CARLES P. Poids des mégots et contraintes
économiques [Eng. Weight
of Cigarette Butts and Economic Constraints]. La Presse Médicale 1994 ; 23 :
824-6.
(4) DE STEFANI E, OREGGIA F, RIVERO
S, FIERRO. Hand-rolled cigarette smoking and risk of cancer of the mouth,
pharynx, and larynx. Cancer
1992 (Aug 1);70(3):679-82
(5) ALOOT CB, VREDEVOE DL, BRECHT ML. Evalutation of high-risk smoking
practices used by the homeless. Cancer Nursing 1993; 16 : 1202-3
(6) KOZLOWSKI LT, MANN RE, WILKINSON DA,
POULOS CX. "Cravings"
are ambiguous: ask about urges or desires. Addict Behav. 1989;14(4):443-5.
(7) KOZLOWSKI LT, WILKINSON DA. Use and misuse of the concept of
craving by alcohol, tobacco, and drug researchers. Br J Addict. 1987 Jan;82(1):31-45.
(8) ZIELINSKI S. Smoking Machine
Test Inadequate and Confusing, But No Replacement a Decade Later. Journal
of the National Cancer Institute 2005 (Jan 5); 97 (1): 10-1.
(9)
SHIHADEH A,SALEH R. Food and
Chemical Toxicology : Polycyclic aromatic hydrocarbons, carbon monoxide, “tar”,
and nicotine in the mainstream smoke aerosol of the narghile water pipe. Food
and Chemical Toxicology 2005; 43(5): 655-661.
(10) WORLD HEALTH ORGANISATION.
Advisory Note: Waterpipe Tobacco Smoking: Health Effects, Research Needs and
Recommended Actions by Regulators. Tobacco Free Initiative 2005. Retrieved
15 Dec. 2005 from: www.who.int/tobacco/global_interaction/tobreg/en/
(11) MAZIAK W, WARD KD, AFIFI SOWEID
RA, EISSENBERG T. Tobacco smoking using a waterpipe: a re-emerging strain in
a global epidemic. Tobacco Control 2004; 13: 327-333.
(12) CHAOUACHI K. eLetter to the
Editor: Serious Errors in this Study. Tobacco Control 2004 (2 Dec.). A
critical analysis of the above study http://tc.bmjjournals.com/cgi/eletters/13/4/327
(13) FRENK HANAN, DAR REUVEN (book). A
Critique of Nicotine Addiction. Kluwer Academic Publishers (Boston) 2000.
(14) CHAOUACHI K. Tabacologie
du narguilé [Eng.: Tobaccology of Narghile]. Alcoologie. 1999; 21
(1/83):88-9.
(15) MOLIMARD R.. Dépendance,
la nicotine est-elle la seule responsable ?[Eng.: Dependence. Is nicotine solely
responsible ?]Soins Psychiatr 2001 (May-Jun);(214):33-5.
(16) POLAND B, FROHLICH K, HAINES
RJ, MYKHALOVSKIY E, ROCK M. SPARKS R. The social context of smoking: the
next frontier in tobacco control?. Tobacco Control 2006;15:59-63.
(17) SAID Edward (book). Orientalism. Routledge & Kegan Paul 1978 (London).
(18)
CHAOUACHI K. Culture matérielle et orientalisme. L’exemple d’une recherche
socio-anthropologique sur le narguilé. Arabica, tome LIII,2, 177-209. Koninklijke Brill NV (Leiden) 2006. [Engl.: Material Culture and Orientalism.
The Example of a Socio-Anthropological Research on Narghile](www.brill.nl )(available here
or contact author)
(19) CHAOUACHI K. Letter to the
Editor: The Social Context of Individual and Collective Smoking: Similarities
and Differences. Tobacco Control 2006 (1 April). A critical analysis of Poland’ study. http://tc.bmjjournals.com/cgi/eletters/15/1/59
(20) CHAOUACHI K. Shisha, hookah. Le narguilé
au XXIe siècle. Bref état des connaissances scientifiques. [Eng.: Narghile, Hookah in the 21st
Century: An Overview of the Scientific Knowledge]. Le Courrier des
Addictions 2004 (Oct) ; 6 (4) : 150-2. Full
English version available.
(21) CHAOUACHI Kamal. A 60 page tetralogy on narghile (hookah)
smoking and health published in Tabaccologia, the official Journal of
the Italian Society of Tobaccology: Introduction (Tabaccologia 2005; 1:
39-47); Pharmacology (2005; 3: 27-33); Health Aspects (2006;1:27-34); Prevention (forthcoming).
Includes English abstracts. www.tabaccologia.org/archivio.htm
(22)
CHAOUACHI K. Letter to the Editor: Some Misconceptions in a Good Alert Paper.
Tobacco Control2006 (18 Jan.). A critical analysis of the following
study: AFIFI-SOWEID
Rima. Lebanon: water pipe line to youth. Tobacco Control 2005;14:363-4.
(23) CHAOUACHI K. Letter
to the Editor: Arabs
Neither Need a Scientific Revolution Nor Are They a Cultural Exception. Science (eLetter, 07 March 2006). A critical analysis of the following
study: MAZIAK W. Global
voices of science. Science in the Arab world: vision of glories beyond. Science.
2005 Jun 3;308(5727):1416-8.
(24) 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(6):249-55.
(25)
SAJID KM, AKTHER M, MALIK GQ (1993 Sep). Carbon monoxide fractions
in cigarette and hookah. J Pak Med Assoc.; 43(9):179-82.
When I was 16-years, I lived a very rough life and found myself in
the foster-care pool. I came to live with Gloria and Bill Tuttle, and
stayed for a few months. I was a very disturbed and distraught child, and
I did not get along well with Gloria at all. (In hindsight it wasn't
because she was mean, it was because she was in charge!!!) Bill was
another story all together. He was quiet. Almost serene. He was tired a
lot...
When I was 16-years, I lived a very rough life and found myself in
the foster-care pool. I came to live with Gloria and Bill Tuttle, and
stayed for a few months. I was a very disturbed and distraught child, and
I did not get along well with Gloria at all. (In hindsight it wasn't
because she was mean, it was because she was in charge!!!) Bill was
another story all together. He was quiet. Almost serene. He was tired a
lot, and he always was in pain. He tried to hide it, but we could tell...
I remember looking forward to walks with Bill and the other girls. I was
always into medicine, and I am the type that when I don't understand
something, I make it my mission. Bill answered my questions. ALL of them!
He never tired of telling me anything I wanted to know about his illness.
He told me once he wasn't afraid to die, only of dying too soon. When I
asked him what he meant, he said that he wanted to tell everyone about his
illness and what caused it, so no one else would have to live the way he
did. He was such a good person for me at that time. Like a Grandpa. He
would walk with me and hold my hand and tell me anything I wanted to know.
I am sad that he died, but I am so proud of him for all his bravery. He
was truly an extraordinary person. I am so blessed to have spent time with
him and I hope lots of people learned from him and continue to even after
his death...
Studying the social context of cigarette smoking was acknowledged as
a pressing need in tobacco control. However, with new emerging health
concerns like the growing use of the hookah (narghile) in the world, the
social context, which bear similarities in both individual and collective
smoking, also shows great differences that need to be reviewed. This
letter introduces the reader to the specificit...
Studying the social context of cigarette smoking was acknowledged as
a pressing need in tobacco control. However, with new emerging health
concerns like the growing use of the hookah (narghile) in the world, the
social context, which bear similarities in both individual and collective
smoking, also shows great differences that need to be reviewed. This
letter introduces the reader to the specificities of collective smoking.
It is based on a comprehensive and updated review of the related
literature that includes several scientific books.
Recent efforts are geared towards the necessity of exploring further
the complexity of the social context of smoking and its consequences on
policy making. However, even if the background social theory is sometimes
the same, the analysis in the case of individual smoking (cigarette) and
collective smoking (hookah, narghile) is necessarily different in both
cases and social scientists, as well as biomedical researchers, working in
the field of tobacco control must be aware of similarities and
differences.
For instance, a team of social scientists has recently published a
study on the importance of the social context in tobacco control (1). An
emphasis, placed so far on the disease or addiction model, would have
resulted in negative consequences for the understanding of the human
smoking behaviour. In this respect, this is particularly true in the case
of fashionable hookah (narghile, shisha) smoking, our very field of
research, where the social context is completely different from the one
based on six dimensions: power relations, physicality (body in smoking),
consumption patterns, social identity, desire and pleasure, place (1).
Apart from the peculiar traditional, historical and “exotic” aspects,
we also have to deal with a collective (vs. individual) tobacco use mode
with a particular staging of the “situation” with the meaning given to
this last word by sociologist Ervin Goffman (2). In the USA, the
interviewed hookah smokers themselves strongly insist in describing their
practice as “social smoking” and, by coincidence, their peers in French-
speaking countries use most of the time and spontaneously the word
“conviviality”.
With all social scientists, we insist on the necessity of studying in
depth the social representations related to smoking. In the case of
narghile, we had to face a central one related to drug use so we decided
to proceed as follows. We very early treated this question as a priority
by publishing a core document on this aspect (3). This way, we avoided
negative interferences with our further comprehensive approach of the
other dimensions of hookah use in the world which are mainly related to
tobacco use only (4).
Then, there is another set of social representations not to be found
in the case of cigarette use: orientalism. On the one hand, this last
concept is familiar for social scientists because the corresponding issue
is considered as very serious in their field of work where a researcher
like Edward Said (5) actually touched off an epistemological revolution.
Unfortunately, on the other hand, biomedical researchers had no concrete
clue for an evaluation of the relevance of such a concept in the field of
tobacco control. So, we will limit here ourselves to cite a cogent
publication on the subject (6) that develops further an earlier analysis
(4).
As mentioned earlier, the central role of power relations, out of the
six dimensions set out for any social context regarding cigarette smoking,
was underscored (1). Notwithstanding, we wish to suggest an excellent
relatively unknown study carried on in this respect where researchers
actually showed how marginalized groups adopt unexpected strategies to
adapt to a new situation posed by rises in tobacco prices. Just to mention
one of them, they leave shorter butts which is unfortunately an extremely
hazardous behaviour (7).
Then, once again, hookah smoking, as a collective practice, is
different from cigarette use known to be individual. Both in traditional
historical or modern social settings, the practice indistinctly covers the
whole social spectrum. European travellers of the past centuries, to Asian
and African traditional societies, were often startled by this
sociological aspect and this was highlighted in their narrations (4).
According to a famous anthropologist, the sultan would share his hookah
with the street sweeper (8).
A second key dimension of the social context is physicality or the
use of body in smoking (1). However, since a hookah is much bigger in size
than a cigarette, the psycho-anthropological analysis differs in both
cases with deep consequences on the physicality of smoking. Indeed, it is
not only a question of how a cigarette is held by the smoker but how the
body adapts to a device that can reach the size of a smoker sitting on a
chair. The same Marcel Mauss, who actually created the “body techniques”
(techniques du corps) concept, defined the latter as the ways and manners
men, society by society, and in a traditional way, know how to use their
body (9).
Excellent examples are given by the many orientalist paintings, where
the narghile is omnipresent, but also in a recent article in the
biomedical literature that features a young narghile female smoker lying
by a swimming pool in Lebanon (10). The importance of the Maussian concept
was further investigated and applied by other social scientists within the
framework of what is now called “material culture” (6, 11).
Apart from the diverse dimensions of the social context, two main
ideas should guide research work in the field of tobacco control. The
first one is reflexivity defined as “maintaining a self critical attitude
and questioning taken-for-granted assumptions regarding the (political)
nature of our work and its (intended and unintended) effects, as well as
the social distribution of these effects” (1).
Such an attitude will certainly have positive practical implications
for policy makers and tobacco control activists. It may be seen as
“novel”; however, it is familiar and natural for social scientists because
this very interrogation is at the root of the anthropology discipline
itself. Indeed, a scientist like Bourdieu was often considered as an
anthropologist rather than a mere sociologist (4). In any case, this also
shows the importance of collaboration between social and biomedical
researchers.
The second important point is that the smokers’ voice would be
rather absent from most of the studies. Indeed, this is one the first
striking things any social scientist involved in tobacco control notice.
In our early work on hookah smoking, we gave the transcripts of several
unique face to face qualitative early interviews carried on in the Middle
East (4). Such a literature reveals the many details to which some of our
colleagues of the biomedical field did not pay the sufficient attention.
For instance, our findings were crucial in understanding the
specificity, particularly pharmacological and behavioural, of the
dependence process, completely different from that related to cigarette
(12). On the daily life level, we can see that the so-called “hookah
lounges” in the West already offer herbal fruit-flavoured tobacco-free
smoking mixtures to their patrons. To close this chapter, we point out
that our typology of the diverse tobacco-based smoking mixtures (tobamel,
jurâk, tumbâk, etc.) was more than a mere ethnographic classification
exercise (4, 13). For having ignored this point, the authors of recent and
widely advertised studies, misled by a misnomer used by local scientists,
actually mistook one type for another (14).
In conclusion, we invite our colleagues of both the social and
biomedical sciences field to consider other forms of smoking and pay
attention to the findings set out in this text. Some of them, like the
hookah are gaining increased public health interest because of their
dramatic development (15).
Kamal Chaouachi
REFERENCES
(1) POLAND B, FROHLICH K, HAINES RJ, MYKHALOVSKIY E, ROCK M. SPARKS
R. The social context of smoking: the next frontier in tobacco control?.
Tobacco Control 2006;15:59-63.
(2) GOFFMAN Erving (book). Les moments et leurs hommes. Seuil (Paris)
1988.
(3) CHAOUACHI Kamal (book). Le narguilé. Anthropologie d’un mode
d’usage de drogues douces [Engl.: An Anthropology of Narghile: its Use and
Soft Drugs], Ed. L'Harmattan, 1997, 262 pages.
(4) CHAOUACHI Kamal. Le narguilé : analyse socio-anthropologique.
Culture, convivialité, histoire et tabacologie d’un mode d’usage populaire
du tabac. Doctoral Thesis, Université Paris X (France), 420 pages. [Engl.:
"Narghile (hookah): a Socio-Anthropological Analysis. Culture,
Conviviality, History and Tobaccology of a Popular Tobacco Use Mode”].
(5) SAID Edward (book), L’orientalisme: L’Orient créé par l’Occident
(orig. Title : Orientalism, 1978), Seuil (Paris) 1980.
(6) CHAOUACHI Kamal. Culture matérielle et orientalisme. L’exemple
d’une recherche socio-anthropologique sur le narguilé, Arabica (Paris III
Sorbonne et EHESS), 2006. Published by Brill (The Netherlands) [Engl.:
Material Culture and Orientalism. The Example of a Socio-Anthropological
Research on Narghile], 32 pages. Soon available online at www.brill.nl
(7) MOLIMARD R, AMRIOUI F, MARTIN C, CARLES P. Poids des mégots et
contraintes économiques [Eng. Weight of Cigarette Butts and Economic
Constraints]. La Presse Médicale 1994 ; 23 : 824-6.
(8) LEVI-STRAUSS Claude (book). Tristes tropiques [Eng. Sad Tropics].
Plon (Paris) 1955.
(9) MAUSS Marcel (book). Sociologie et Anthropologie. Presses
Universitaires de France (Paris) 1968.
(10) CHAOUACHI Kamal. eLetter to the Editor: Some Misconceptions in a
Good Alert Paper. Tobacco Control (18 January 2006). A critical analysis
of the following study: AFIFI-SOWEID Rima. Lebanon: water pipe line to
youth. Tobacco Control 2005;14:363-4.
http://tc.bmjjournals.com/cgi/eletters/14/6/363-a#479
(11) WARNIER Jean-Pierre (book). Construire la culture matérielle :
l’homme qui pensait avec ses doigts. Presses Universitaires de France
(Paris) 1999.
(12) CHAOUACHI Kamal. Shisha, hookah. Le narguilé au XXIe siècle.
Bref état des connaissances scientifiques. [Eng.: Narghile, Hookah in the
21st Century: An Overview of the Scientific Knowledge]. Le Courrier des
Addictions 2004 (Oct) ; 6 (4) : 150-2.
(13) CHAOUACHI Kamal. Presentazione del narghilè e del suo uso. Guida
critica della letteratura scientifica sul narghilè (shisha, hookah,
waterpipe). Dalle origini ai giorni nostri : necessità di un approccio
interdisciplinare socio-antropologico, medico e farmacologico.
Tabaccologia (tabaccologia.org) 2005; 1: 39-47.
[Engl.: A critical review of scientific literature on narghile
(Shisha, Hookah, Waterpipe) from its origins to date: the need for a
comprehensive socio-anthropological, medical and pharmacological
approach]. A tetralogy on all aspects of hookah smoking (further issues on
Pharmacology, Pathologies and Public Health). All issues available at
www.tabaccologia.org and www.tabaccologia.org/archivio.htm)
(14) Among others: NATTO S, BALJOON M, BERGSTROM J. Tobacco Smoking
and Periodontal Health in a Saudi Arabian Population. Journal of
Periodontology 2005; 76 (11): 1919-26.
(15) CHAOUACHI Kamal. The Recent Development of Hookah Use in the
World : a Serious Epidemic or just a Passing Fad ? The Need for a Socio-
Anthropological and Medical Approach. IFSSH (International Forum for
Social Sciences and Health), World Congress “Health Challenges of the
Third Millenium”. Istanbul, 21-26 Aug. 2005. Published by Yeditepe
University, Dept. of Anthropology, Aug. 2005, tome I, pp. 360-1.
NOTE: A full English version or at least an official English
abstract are available for most of the above cited references.
Less Harmful cigarettes do exist, but the majority of the smoking
public is unaware that they are available. Isn't it about time that our
government establish an agency that would regulate all tobacco products? I
have recently been made aware of a new company that makes a less harmful
cigarette. The companies name is Wellstone Filters(lowertar.com), and they
have a developed a special cigarette filter that is patented and...
Less Harmful cigarettes do exist, but the majority of the smoking
public is unaware that they are available. Isn't it about time that our
government establish an agency that would regulate all tobacco products? I
have recently been made aware of a new company that makes a less harmful
cigarette. The companies name is Wellstone Filters(lowertar.com), and they
have a developed a special cigarette filter that is patented and FTC
tested that screens out up to 95% of all carcinogens in cigarette smoke.
It looks and acts just like a regular cigarette filter. Why don't all
cigarettes manufactures use these or similar filters to provide a less
harmful cigarette?
If the FDA would regulate tobacco, the public could benefit from many new
less harmful products. The citizens of our great free country have every
right to enjoy a relaxing smoke, and why not make them less harmful! The
anti smoking public would be better served if they would focus there
energy toward getting our governmental agencies to demand from the tobacco
companies less harmful tobacco products! It could all begin with the FDA
regulating tobacco products!
It would have to be seen as the most intriguing question of our era;
to understand how, with all the most educated of scholarly voices
abdicating for world wide smoking bans, how not one of those participants
has the vision to see outside the box. To understand with very little
imagination how beneficial it could be to society as a whole to simply
look at the product before punishing it’s victims. When we view
tobacco a...
It would have to be seen as the most intriguing question of our era;
to understand how, with all the most educated of scholarly voices
abdicating for world wide smoking bans, how not one of those participants
has the vision to see outside the box. To understand with very little
imagination how beneficial it could be to society as a whole to simply
look at the product before punishing it’s victims. When we view
tobacco as one of the most dangerous products on the shelf, does it make
sense to anyone it is also the only product on the shelf with no list of
ingredients. While we are well informed as to the contents of, the smoke
it could produce, it is downplayed how significantly the quantities
present, individually or as a whole, represent a substantial risk. It is
indisputable, the lack of ingredients list can be directly associated to
the potential harm. If we look at what is revealed it is also indisputable
many of the toxins and carcinogens could not be derived from the burning
of Tobacco alone. The scientific community as a whole can still err in the
description of the product as tobacco, either through lack of proper
information or as a deliberate act to substantiate political will. Either
excuse adds to the misinformation being supplied to the public with a
scientific community rubber stamp of approval, contrary to well-
established rules of informed consent. Human rights are no longer a
priority in fact are being deliberately ignored in seek of the greater
good. A major mistake, one which one-day, will greatly expand the list of
names attributed to the Darwin awards. The danger is, the words scientific
integrity could also be included on that list of casualties.
Simplistic regulation barring the use of known dangerous ingredients
would reduce the harm of the product in its use. If as advocacy would
proclaim the protection of health is the purpose for anti smoker advocacy
perhaps the mortality figures stated as preventable could be greatly
reduced by regulating the products. Of course, this would result in a
decreased risk to non-smokers and the most efficient means of solving the
problem at hand. Perhaps advocacy would be less effective if the numbers
were reduced and we could deal with a more significant problem of violence
and impunity, which is the most prominent effect of anti smoker advocacy.
The alternative is relying on case research studies investigating the
effects of a range, of millions of possible combinations in the products
being consumed. Predictably, we see a wide range of determined theoretic
results of little scientific value. Further confusion added by the
absolutes of smoking debates resulting in biases which undermine the
credibility of any research study, with the current indicator being, who
paid for the study as a judgment of integrity. No matter how much care and
integrity was incorporated by the researcher, his absolute credibility
will be determined by who pays the bill.
Is this the best we have to offer in the realm of scientific
discovery? Facts by consensus and that consensus determined by the size of
our gang, our ability to create facts or having the finances to establish
those facts in the media and through that a silencing of all opposition.
Public confidence in the process is understandably reserved to say the
least.
It was revealed to me today the president of mychoice.ca in Canada
was threatened with death on her doorstep for nothing more than a
perceived threat she represents, as a non-smoker advocating for nothing
more than respect of her neighbors in community. She has never stated
smoking is not dangerous and has consistently stated it is, in every
public discussion. She was once given an award by her peers speaking out
on the topic of violence against women. Now she is disassociated from
integrity in her opinion, in advocacy against the same topic, Hatred and
Violence. Where are the advocates rushing to her aid and praise this time
around? Have our values now changed so absolutely it is permissible to
excuse the abuse of others as long as we can create a good enough reason?
Not original in fact in 1930s Germany those same assessments were made
Praised and encouraged internationally, using the smoking issue as a wedge
to join the parties in health advocacy lobbying, we know how that turned
out, how soon we did forget. On the other hand, perhaps we are smarter now
and are assured the results will be different. Consistent with the
insanity theory of repetitive actions expecting a different result.
Lunacy? I would say so.
Are we so bent we cannot see the damage to us all here? The bullies
are campaigning confidently and without fear of reprisals, for barring a
smoker from Employment, Housing or Community Many others join in declaring
child abuse against parents in custody hearings could be justifyable. The
Ontario Government dispensing hatred to our children endorsed and
applauded, at a site they call stupid, it’s very name screams
violence, this is indefensible by a government in a civilized society yet
no one noticed. The same Government ministry has recently announced a
couple of decries of note; "Quit or be punished" and more recently "Fat is
the new tobacco" Will the term fat have a similar wide berth of definition
in science, so we can repeat the process in the coming decade? Now they
approach our homes the castle to some will be a fortress to others,
defending their fading right to escape from their insidious tormentors.
The diagnosis should be clear we could do a lot better. The
alternative again could be defense of a momentous lawsuit on our horizon
in the civil rights abuses against the victims of both the product and the
gang of bullies. Justice will have the final say in the campaign of
hatred, a deliberately created pandemic in our culture.
Does a smoking ban result in protection of non-smokers who now deal
with an increasingly meaner more violent society?
Do we reduce preventable death by ignoring the cause?
Can any deny informed consent is not well served in our current approach?
If any are determined enough to answer yes to any of these questions;
a self-examination is in order, to understand your need to express
intolerance and abdicate for crimes against others for the use of a legal
product.
Food for thought
From the British Medical Journal;
http://tc.bmjjournals.com/cgi/content/full/14/suppl_2/ii3?ijkey=51532084409cd1fe36c22cbb2fb51ee231739f0c
I read the article by Offen et al with great interest. It is an
excellent elucidation of the concepts of ‘boycott,’ ‘buycott,’ and
‘perimetric.’ One opportunity for perimetric action not mentioned is the
option each academic has to boycott and/or draw attention to universities
and medical schools that accept tobacco industry funds or hold tobacco
stock. (1) The converse is equally appropriate; ‘buycott’ centers that
hav...
I read the article by Offen et al with great interest. It is an
excellent elucidation of the concepts of ‘boycott,’ ‘buycott,’ and
‘perimetric.’ One opportunity for perimetric action not mentioned is the
option each academic has to boycott and/or draw attention to universities
and medical schools that accept tobacco industry funds or hold tobacco
stock. (1) The converse is equally appropriate; ‘buycott’ centers that
have clear policies abhorring tobacco investments or funding.
When information on such policies – or the lack of them – becomes freely
available, we can engage in “less research and more action” as has been
suggested elsewhere. (2)
1. Wander N, Malone RE. Selling Off or Selling Out? Medical Schools
and Ethical Leadership in Tobacco Stock Divestment. Acad Med
2004;79(11):1017-26.
2. Blum A, Solberg E, Wolinsky H. The Surgeon General's report on smoking
and health 40 years later: still wandering in the desert. Lancet
2004;363(9403):97-8.
The trial testimony of Sanford Barsky, offered by David Egilman in
his email letter to Tobacco Control, provides an illustrative example of
why tobacco industry sponsored research should not be published in Tobacco
Control or other responsible scientific periodicals. In the testimony
Barsky argues for non-tobacco causation of a case of squamous cancer of
the lung.
Examination of tobacco industry documents housed in the...
The trial testimony of Sanford Barsky, offered by David Egilman in
his email letter to Tobacco Control, provides an illustrative example of
why tobacco industry sponsored research should not be published in Tobacco
Control or other responsible scientific periodicals. In the testimony
Barsky argues for non-tobacco causation of a case of squamous cancer of
the lung.
Examination of tobacco industry documents housed in the Legacy Tobacco
Documents Library http://www.legacy.library.ucsf.edu
reveals that the tobacco industry organized and funded an effort, Council
for Tobacco Research (CTR) Special Projects (SP) 47 and 110, to recruit
eminent physicians to identify cases of epidermoid (squamous) carcinoma of
the lungs in non-smokers. [1], [2] This search was important to the
tobacco industry because of public testimony by prominent pathologists
like Oscar Auerbach MD that he "had never seen a case of squamous cancer
in a nonsmoker". [3] The stated purpose of SP-110 was "To demonstrate that
epidermoid lung cancers do occur in nonsmokers and thus refute assertions
that these cancers occur only in smokers." [4]
This research effort was led by pathologist Lauren Ackerman MD and
included a number of thoracic surgeons, including Society of Thoracic
Surgeons president Lyman Brewer III.MD and Thomas Burford MD Chair of
Thoracic Surgery at Washington University. Ackerman, a pathologist at
Washington University was the recipient of a $3.6 million tobacco industry
research grant. [5] Also involved in SR-110 was Yale epidemiologist Alvan
Feinstein PhD, who received more than $2 million from the industry during
his long career. Other participants in the study are listed in a footnote
below. Of these individuals, only Feinstein ever published on the topic.
He reported after a review of medical records that he had found 17 cases
of epidermoid cancer in non-smokers. This assertion prompted a review and
1970 publication by Yale pathologists Raymond Yesner and N.A. Gelfman who
determined that none of Feinstein's cases were, in fact, epidermoid
cancers. Remarkably, although he was a coauthor on this
publication, in two letters to the editors of JAMA and the Medical
Tribune, Feinstein "regretted the premature publication" and disassociated
himself from Yesner's conclusions, stating that he did not believe that
epidermoid cancer was a "tobacco cancer" based upon his interpretation of
data. [6][7]
Finally, in 1973 another reexamination of 449 Yale lung cancer cases by
the same authors confirmed that the incidence of squamous and small cell
lung cancers is very uncommon in non-smokers (approximately 1%). There
were no cases among non-smoking men. [8] In 1974, Feinstein took a new
tack, suggesting that the reason that there was an increase in lung cancer
in smokers was a "bias" on the part of clinicians who were more likely to
consider a diagnosis of lung cancer and initiate testing for the disease
in smokers. [9]
No publication on this topic by any of the other researchers involved in
SP-110 could be found in a search of the Index Medicus. The clear
implication is that none of the experts could find cases of squamous lung
cancer in non-smokers in the records of their medical centers.
This should cause no surprise to clinicians and pathologists experienced
in the care of lung cancer, who know that cases of such cancers in non-
smokers are rare. It is also reasonable to assume that, if the SP-110 and
SP-47 investigators had identified cases of squamous lung
cancer in never-smokers, the results would have been published and
trumpeted by the industry in courtroom testimony. The fact that the
results of SP-110 were not published reflects the willingness of the
tobacco industry to stifle publication of adverse results, and represents
a clear and typical example of the insidious and self-serving nature of
tobacco industry funded research. Good science
involves the publication of all results, not just those that serve the
agenda of a killer industry.
Appendix:
Physicians and scientists mentioned in documents as participating in
these CTR "Special Projects"included.
Robert E. Stowell MD
Dean Davies
Lauren Ackerman MD St.Louis MO
Avrill Liebow MD New Haven CT
Samuel G. Taylor MD Chicago IL
Russell Irwin MD San Diego CA
William H. Sheffield MD
Thomas Burford St. Louis MO
Haynes Shepherd San Diego TS
Homer Peabody MD San Diego CA
John R. Kiser MD San Diego CA
Alvan Feinstein MD New Haven CT
Doris Herman Los Angeles CA
Lyman Brewer MD Los Angeles CA
References:______________________________
[1]http://legacy.library.ucsf.edu/cgi/getdoc?tid=zxz95a00&fmt=pdf&ref=res
ults ; "Special Project # 47." Bates # 92613988
[2]http://legacy.library.ucsf.edu/cgi/getdoc?tid=aqw90c00&fmt=pdf&ref=res
ults ; "Special Projects" January 1, 1968. Bates #995007392
[3]http://legacy.library.ucsf.edu/cgi/getdoc?tid=dod3aa00&fmt=pdf&ref=res
ults Memorandum Leonard Zahn and Associates "American College of
Surgeons". Bates # unknown.
[4]. http://legacy.library.ucsf.edu/tid/ydm06a00 "Collect Cases of
Epidermoid Lung Cancer in Non-Smokers". Bates # 955008212 19660226
American Tobacco Company
[5]http://legacy.library.ucsf.edu/cgi/getdoc?tid=dzg33f00&fmt=pdf&ref=res
ults ; "Washington University March 1971". Bates # 680601980
[6] Feinstein AR. Smoking and cancer morphology. JAMA. July 6, 1970,
213:131
[7]Feinstein AR. Smoking-histology study. Medical Tribune 1 June
1970;33:11.
[8]Yesner R, Gelfman NA, Feinstein AR. Reappraisal of histopathology in
lung cancer and correlation of cell types with antecedent smoking. Am Rev
Resp Dis 973;107:790-7
[9]Feinstein AR, Wells CK. Cigarette smoking and lung cancer: the problems
of "detection bias" in epidemiologic rates of disease. Trans Assoc Am
Physicians. 1974;87:180-5
While I'm delighted that these tobacco industry trial products of
unproven merit continue to "taste like s__t" (-a reference to the RJR
president's famous quote in "Barbarians at the Gate"), I hope that we'll
not see much more of OSH's time spent on what amounts mostly to market
research valuable to the tobacco malefactors.
I certainly agree with most of the comments of Dr
Kamal Chaouachi but the need to develop one generic
name for the different types of this form of tobacco
smoking is definite and we tend to prefer the term water-
pipe smoking as it denotes the similarity that links all
these forms and shapes and local names. Certainly
these different names are associated with local
geographical languages and idenified best in the
reps...
I certainly agree with most of the comments of Dr
Kamal Chaouachi but the need to develop one generic
name for the different types of this form of tobacco
smoking is definite and we tend to prefer the term water-
pipe smoking as it denotes the similarity that links all
these forms and shapes and local names. Certainly
these different names are associated with local
geographical languages and idenified best in the
repsective languages. The need to use a common generic name is recognized
to avoid using three to five different names in every paper to make sure
that the study covers these
types. Water-pipe tobacco smoking is a good common
name and reflects the major difference from direct
tobacco smoking which is a lower temperature of
burning as well as cooler smoke temperature. This is
reflected in the composition of the smoke and
characteristics of toxic and carcinogenic componenets
as alluded to in some work from Lebanon by Alan
Shihada cited in the original paper discussed here.
Mostafa K. Moahmed
Professor of Community Medicine
AinShams University Faculty of Medicine
Abbassia , Cairo, Egypt
Principal investigator
Egyptian Smoking Prevention Research institute ESPRI
Tel /fax Office 20-2-368-2774 / 368-6275/ 368-8400
Mobile 20-12-241-7933
email: ecgc@internetegypt.com
We wish to draw your attention to some misconceptions in the
following study:
Rima AFIFI SOWEID. Lebanon: water pipe line to youth. Tobacco Control
2005;14:363-4.
>"In Lebanon, youth and women are the target of a marketing
campaign featuring a new tobacco product for use with the more traditional
water pipe."
The caption for the embedded picture is a an erroneous
interpretation. Sociological semiology showed us in the fifties that if
you want to sell a car (to men, of course), you have to depict it with a
nice looking girl leaning on it. Once again, in the present case, the
message is not directed to "youth and women" but to men in the first
instance.
Then, the word "water pipe", in the title and elsewhere, is not
appropriate. It is used only in a certain orientalist or neo-orientalist
literature,(1) just like the sometimes disparaging "hubble-bubble" (2). If
you enter a café in the Middle East or in Europe and North America
nowadays, and order a "water pipe" or a "hubble-bubble", in most cases you
will not be understood. So, let us use the words people use in the real
human world we are interested in, as scientists serving the public health.
-"(N)arghile" is widely used in the Middle East: from Turkey to Iran
via Lebanon, Syria, etc.
-"Hookah" is quite common in Asia (India, Pakistan, etc.) and the English-
speaking world.
-"Shisha" fits first the North of Africa: countries such as Tunisia,
Libya, Egypt and now Morocco but it is also common in the Arab-Persian
Gulf region and now, thanks to the world hookah craze, in every part of
the globe (3).
>"The water pipe is a traditional form of tobacco smoked in Arab
countries, including Lebanon."
It is not. It has been used for centuries in Asia and Africa and not
only in the Arab countries (4).
> "Recently, trends have shifted between tobacco types, and water
pipe smoking is becoming the preference for young people and women
specifically, ousting the once more popular cigarette."
We are afraid they have not. It is also becoming the preference for
men too. It is not ousting the cigarette; on the contrary. People, in
countries like Lebanon, smoke indistinctly hookahs and cigarettes (5).
Tobaccologists are not that much interested in the dozens of millions of
recreational hookah smokers around the word who have been smoking a hookah
once a week or a month over the past centuries. What is of utmost concern
to them is those dual smokers and those who have switched from cigarette
(or bidi, etc.) smoking to narghile use. The body memory of their past
career and their inhaling patterns are different. This is the real health
concern we have to focus on (6)(7).
> "Ironically, with an eye on an ever "health conscious consumer",
the new product comes in individually wrapped portions (hitherto in large
bales) and the promise that it has not been touched by human hands."
We are sorry to say that it is not a "new product". Indian
manufacturers, like Afzal, for instance, have been providing with these
individually wrapped portions for a very long time now. Besides, this
marketing concept, adopted and developed further by Western manufacturers,
will be very soon available in the whole world.
Generally speaking, this article is interesting and, despite the
above commented upon misconceptions, we cannot but share the author's
concern regarding the existence of this kind of advertisement. Any
advertisement for any substance should be prohibited as a rule.
Kamal Chaouachi, Paris Universities.
Researcher in Socio-Anthropology and Tobaccology
REFERENCES
(1) CHAOUACHI Kamal. Culture matérielle et orientalisme. L'exemple
d'une recherche socio-anthropologique sur le narguilé, Arabica (Paris III
Sorbonne et EHESS), 2005. [Engl.: Material Culture and Orientalism. The
Example of a Socio-Anthropological Research on Narghile]
(2) CHAOUACHI Kamal. Le narguilé. Anthropologie d'un mode d'usage de
drogues douces [Engl.: An Anthropology of Narghile: its Use and Soft
Drugs], Ed. L'Harmattan, 1997, 262 pages.
(3) CHAOUACHI Kamal. The Recent Development of Hookah Use in the
World : a Serious Epidemic or just a Passing Fad ? The Need for a Socio-
Anthropological and Medical Approach. IFSSH (International Forum for
Social Sciences and Health), World Congress "Health Challenges of the
Third Millenium". Istanbul, 21-26 Aug. 2005. Published by YEDITEPE
University, Dept. of Anthropology, Aug. 2005, tome I, pp. 360-1.
(4) CHAOUACHI Kamal. Le narguilé : analyse socio-anthropologique.
Culture, convivialité, histoire et tabacologie d'un mode d'usage populaire
du tabac. Doctoral Thesis, Université Paris X (France), 420 pages. [Engl.:
"Narghile (hookah): a Socio-Anthropological Analysis. Culture,
Conviviality, History and Tobaccology of a Popular Tobacco Use Mode"].
(5) Baddoura R., Wehbeh-Chidiac C. Prevalence of tobacco use among
the adult Lebanese population. July-Sept. 2001; 7 (4/5): 819-28. St-Joseph
University, Beirut, Lebanon. Published by WHO/EMRO.
(6) CHAOUACHI Kamal. Presentazione del narghilè e del suo uso. Guida
critica della letteratura scientifica sul narghilè (shisha, hookah,
waterpipe). Dalle origini ai giorni nostri : necessità di un approccio
interdisciplinare socio-antropologico, medico e farmacologico.
Tabaccologia 2005; 1: 39-47. [Engl.: A critical review of scientific
literature on narghile (Shisha, Hookah, Waterpipe) from its origins to
date: the need for a comprehensive socio-anthropological, medical and
pharmacological approach].
(7) CHAOUACHI Kamal. Shisha, hookah. Le narguilé au XXIe siècle. Bref
état des connaissances scientifiques. [Eng.: Narghile, Hookah in the 21st
Century: An Overview of the Scientific Knowledge]. Le Courrier des
Addictions 2004 (Oct) ; 6 (4) : 150-2.
Prochaska and Velicer have commented on this trial(1), and, having
been alerted to this comment elsewhere, we feel we need to respond
belatedly. They suggest the study had important flaws but do not name
them. We drew attention to those flaws in the conduct of the study in the
report. The major flaw was that midwives in the control arm were less
enthused about the intervention and complied with the protocol less well,...
Prochaska and Velicer have commented on this trial(1), and, having
been alerted to this comment elsewhere, we feel we need to respond
belatedly. They suggest the study had important flaws but do not name
them. We drew attention to those flaws in the conduct of the study in the
report. The major flaw was that midwives in the control arm were less
enthused about the intervention and complied with the protocol less well,
which overstated the benefit of the intervention, which we addressed in
the report. In retrospect, it might also have been better to have had two
larger arms than three.
In addition, they state that this is a population-based trial and
this is partly true- we certainly intended that it should be so- but the
trial fell short of this ideal. We asked midwives to recruit every smoker
into the trial regardless of willingness to stop smoking, but, as is clear
from Figure 1, only a minority of smokers were approached. Nearly all
those who were approached agreed. This was a cluster-randomised trial
because we thought it would be difficult for midwives to switch
counselling styles between the TTM-based approach and their normal
approach. However, we trained midwives to approach participants in all
arms of the study in the same way. That is, we asked midwives not to say
to women in the control arm- you will receive my usual care- while for the
intervention arms, midwives were asked not to describe the specific
intervention a woman was to receive. Rather, midwives were trained to
present the possibility that a woman would potentially receive any of the
interventions, when in reality she could only receive one. To have done
otherwise would have risked biasing the trial. Thus, any differences in
the rate at which midwives approached women to participate in the trial
were nothing to do with the attractiveness of the intervention. They were
to do with the enthusiasm of the midwife as we discussed in the trial
report. This may sound subtle but it is important. If the NHS had chosen
to implement the TTM-based intervention, then as every midwife has to
raise smoking and record it on the maternity record, if her standard
intervention was now the TTM-based one, then all women who admitted to
smoking would receive this intervention. Differences in uptake in the
‘real world’ outside this trial would not occur. Consequently, the eight
times the population impact figure of Prochaska and Velicer is wrong, as
the main driver of it is the uptake rates which would not differ outside a
trial, where recruitment meant lots of extra work for the midwife.
Prochaska and Velicer state that we recommend programmes with no
evidence. Actually, the last sentence of our report was ‘Smoking in
pregnancy is currently a problem for which there is no good currently
available solution.’ We still believe this is true at a population level,
but it also reasonable to suggest that all midwives should discuss
smoking, as this seems like an ethical imperative. It seems reasonable
also for midwives to offer assistance to stop, mainly referral to a
specialist who can give that help, and there is good evidence that this is
effective(2). I am pleased to say that one local service manages to see
around half of all pregnant smokers, of whom a third of these set a quit
date and around a quarter of those sustain validated 4-week abstinence.
This clearly shows the small population impact- around 4% of all pregnant
smokers (see
http://www.uknscc.org/2005_UKNSCC/presentations/carmel_ogorman.html), but
this is better than the population impact of the TTM-based interventions
in our trial (where the comparable figure is 2-3%).
One way to better understand the population impacts of the TTM-based
interventions in pregnancy is to see more trials with similar
interventions. Prochaska, Velicer and colleagues completed such a trial
before ours was completed and it is still not published. Understanding
the efficacy of these interventions would be improved if it were.
Reference List
(1) Lawrence PT, Aveyard P, Evans O, Cheng KK. A cluster randomised
controlled trial of smoking cessation in pregnant women comparing
interventions based on the transtheoretical (stages of change) model to
standard care. Tobacco Control 2003; 12:168-177.
(2) Lumley J, Oliver S, Waters E. Interventions for promoting
smoking cessation during pregnancy (Cochrane Review). In: The Cochrane
Library, Issue 1, 2003.
As Professor Chapman has noted some have questioned the merits of
publishing papers that the tobacco industry funded. In the spirit of
Justice Brandeis who noted that, “Sunlight is the best disinfectant” I
believe that more not fewer tobacco industry consultants opinions should
see the light of day. For example I believe that court room opinions
offered under oath, by tobacco hired historians, physicians and others
sho...
As Professor Chapman has noted some have questioned the merits of
publishing papers that the tobacco industry funded. In the spirit of
Justice Brandeis who noted that, “Sunlight is the best disinfectant” I
believe that more not fewer tobacco industry consultants opinions should
see the light of day. For example I believe that court room opinions
offered under oath, by tobacco hired historians, physicians and others
should be published as often as possible perhaps as a regular TC offering
with pro and con commentary. This would permit real peer review of
opinions that have great importance in the creation of policy. I offer
your readers an example. Dr. Sanford H. Barsky gave this opinion on the
case of Mr. Vandenberg, a seventy-nine year old ex-marine and postal
worker who had a 75 pack-year smoking history.
“My opinion is that he has a fairly well differentiated squamous cell
carcinoma of the lung that's arising within a bronchiectatic focus of the
lung and that's going through the stages time [including] the stage of
metaplasia, dysplasia, in situ carcinoma and invasive carcinoma… I think
the squamous cell cancer is arising within this bronchiectatic focus. I
think the chronic inflammation and irritation of this focus is what's
giving rise to the squamous cell cancer; that it's a peripheral squamous
cell cancer, away from the main airways and that his tobacco smoking is
not causally related to the genesis of this particular tumor.” He noted
that, “no one has mentioned the term, bronchiectasis in the medical
records.” And based his opinion, “primarily on pathology” buttressed by
case reports and Spencer’s Textbook of pathology that had “commonly” note
the association between bronchiectasis and lung cancer. He went on to
state that smoking did not contribute to cause the cancer.
I invite your readers to shed light on this opinion.
I serve as an expert witness in Tobacco litigation
A reader has enquired about the funding source for this study. It was
the the National Cancer Institute of the US National
Institutes of Health.
SC- Editor
I would like to propose some additions to Carter’s excellent review
paper on
Tobacco document research reporting. That is a major contribution to
tobacco document research (TDR) methodology.
While discussing possible lessons from historical research to TDR
Carter
mentions the interpretation of facts. Occasionally the difficulty with
TDR
lies in establishing the facts (e.g. if plans were implemented). One
me...
I would like to propose some additions to Carter’s excellent review
paper on
Tobacco document research reporting. That is a major contribution to
tobacco document research (TDR) methodology.
While discussing possible lessons from historical research to TDR
Carter
mentions the interpretation of facts. Occasionally the difficulty with
TDR
lies in establishing the facts (e.g. if plans were implemented). One
method to
overcome the problem is to put the TDR information into context. The
more detailed the information, the more difficult is the task.
A basic method in historical research (also in journalism) is to
check the
information with the persons mentioned in the documents. That is rarely
seen
in TDR. However, some authors make explicit that they have not checked the
information with the persons concerned. Obtaining information from
(present
or former) tobacco industry employees is surely a difficult task but that
should not be ignored if more accuracy could be attained.
When it comes to evolution of search strategies it is obvious that it
is
connected to the availability of the documents. The sorting options and
optical character recognition as well as the addition of privileged
documents
to Legacy archive have made new search strategies possible. A fuzzy option
for key words would greatly benefit TRC on countries with ominous
characters as they tend to be misspelled.
I do applaud Carter’s recommendation of frame analysis. Several TDR
related
to tobacco lobbying. It seems that the debate on tobacco centers around
two
competing frames, individual liberty and public health. I’m sure that
there is
still a lot to be learned from the way the industry has manipulated the
language in smoking and health debate.
Carter SM. Tobacco document research reporting. Tobacco Control
2005;14:
368-376.
Manashe CL, Siegel M. The power of a frame: an analysis of newspaper
coverage of tobacco issues -- United States 1985-1995. Journal of Health
Communication 1998;4:207-25.
Simon Chapman's pictures on page 367 of the latest Tobacco Control
points out that the 7-11 chain of convenience stores in Thailand was
refusing to cover their cigarette products as required by the Ministry of
Health's requirements on advertising. They are now complying with the
regulation and do not have the open display of cigarette products. This
means that all retail shops in Thailand are no longer displaying any...
Simon Chapman's pictures on page 367 of the latest Tobacco Control
points out that the 7-11 chain of convenience stores in Thailand was
refusing to cover their cigarette products as required by the Ministry of
Health's requirements on advertising. They are now complying with the
regulation and do not have the open display of cigarette products. This
means that all retail shops in Thailand are no longer displaying any
tobacco packs or cartons at point of sale. This is an important
achievement in Thailand and comes at the same time that the tax on tobacco
has also just been raised by 4% to 79% of the base price. Price
increases, new picture warning labels, and a ban on point of sale
advertising is a combination that should accelerate the already declining
trend in smoking.
Since my original publication in 1995 reporting high rates of denial
of smoking in Japanese women,1 and Prof Yano's alternative assessment of
the evidence,2 there has been an ongoing correspondence between the two of
us.3-6 In his latest letter6 Yano asks whether my paper1 should have been
published because it suffers from "erroneous interpretations based on
invalid measurements."
Since my original publication in 1995 reporting high rates of denial
of smoking in Japanese women,1 and Prof Yano's alternative assessment of
the evidence,2 there has been an ongoing correspondence between the two of
us.3-6 In his latest letter6 Yano asks whether my paper1 should have been
published because it suffers from "erroneous interpretations based on
invalid measurements."
My calculations critically depended on the detection of high urinary
cotinine/creatinine ratios (CCR) of >100 ng/mg in 28 women who reported
that they were nonsmokers. Yano argues that the CCR measurement may have
been unreliable because the dry ice sent with the urine samples had
sublimated before it reached the laboratory (a problem I have no record or
memory of), and that, if the sample had been exposed to high temperature,
the measurement might have been inaccurate. Although other references7,8
argue that cotinine levels in unfrozen samples are reliable for research
purposes, Yano cites the results of one study9 which did show some
increase in cotinine levels in samples stored at high temperatures.
However, even at the highest temperature (60°C) and longest storage time
(30 days) tested, the increase was by less than 2-fold. In contrast, in
25 of the 28 women reclassified as current smokers, their CCR was more
than 2-fold above the, conservative, 100 ng/mg cut-off used, and in 23 of
them the CCR was over 500 ng/mg. I do not consider this doubt about
possible exposure of samples to high temperature is relevant. If Yano
thought it was, why was it not mentioned in his paper?2 I note that Yano
states that the potential problem only applied to the first batch of
samples. If so, it would be relevant to compare the results for the two
batches. My database does not have details of batch. Does Yano's?
Using 100 ng/ml as indicative of true smoking, I estimated that 28/98
= 29% of true smokers denied smoking. In contrast 8/298 = 2.7% of true
nonsmokers could be reclassified as smokers. The former misclassification
rate, which can cause
substantial bias to estimates of lung cancer risk in nonsmokers
associated with spousal smoking, is much higher than the reverse
misclassification rate, which in any case has a much lower biasing
effect.10
The calculations in Yano's latest letter6 are off the point as they
are based on the assumption that self reported smoking is 100% accurate
and that it is CCR which is subject to error. The whole point of the
study was to test the accuracy of self report using CCR as the gold
standard. Clearly CCR is not 100% accurate, but Yano gives no reason why
such inaccuracy should affect the major conclusion of my paper.1
Yano is concerned that my formula depends on the prevalence of
smoking. I am not sure why. One is attempting to answer the question
"What proportion of true smokers deny smoking?" and clearly the number of
true smokers must be the denominator in the calculation.
Yano states that Proctor "finally understood and accepted my point on
the misclassification formula," but that was before he had consulted me
and realized that Yano's approach was erroneous. Then, as now, my views
and Yano's seem irreconcilable, and as it was not possible to prepare a
paper satisfactory to all, I was asked by Proctor to prepare a paper under
my name. Clearly the situation is not ideal, but at least the data and
the differing interpretations are in the literature for scientists to form
their own judgement. I retain my view that my interpretation is correct
and that the measurements made are valid enough for the conclusions I
draw.
Peter N Lee
P.N. Lee Statistics and Computing Ltd.,
17 Cedar Road,
Sutton, Surrey, SM2 5DA, UK.
References
1. Lee PN. "Marriage to a smoker" may not be a valid marker of
exposure in studies relating environmental tobacco smoke to risk of lung
cancer in Japanese non-smoking women. Int Arch Occup Environ Health
1995;67:287-94.
2. Yano E. Japanese spousal smoking study revisited: how a tobacco
industry funded paper reached erroneous conclusions. Tob Control
2005;14:227-35.
3. Lee PN. Japanese spousal study: a response to Professor Yano's
claims [Commentary]. Tob Control 2005;14:233-4.
4. Yano E. Response to P N Lee [Commentary]. Tob Control
2005;14:234-5.
5. Lee PN. Response to E Yano and S Chapman [Letter]. Tob Control
14:430-1.
6. Yano E. Should a paper with erroneous interpretations based on
invalid measurements be published? [Letter]. Tob Control 2005;14:431-2.
7. Foulds J, Feyerabend C, Stapleton J, Jarvis MJ, Russell MAH.
Stability of nicotine and cotinine in unfrozen plasma. J Smoking-Related
Dis 1994;5:41-4.
8. Greeley DA, Valois RF, Bernstein DA. Stability of salivary
cotinine sent through the U.S. mail for verification of smoking status.
Addict Behav 1992;17:291-6.
9. Hagan RL, Ramos JM, Jr., Jacob PM, III. Increasing urinary
cotinine concentrations at elevated temperatures: the role of conjugated
metabolites. J Pharm Biomed Anal 1997;16:191-7.
10. Lee PN, Forey BA. Misclassification of smoking habits as a
source of bias in the study of environmental tobacco smoke and lung
cancer. Stat Med 1996;15:581-605.
Editor: This correspondence is now closed
Nathan K Cobb raises an important point. This paper has been reviewed
by the Centre for Reviews and Dissemination [1], which provides critical
assessments of the quality of economic evaluations. They raised this issue
along with some other noteworthy points relating to the costs of the
program. Specifically, the costs and the quantities were not reported
separately, which limits the generalisability of the authors' results...
Nathan K Cobb raises an important point. This paper has been reviewed
by the Centre for Reviews and Dissemination [1], which provides critical
assessments of the quality of economic evaluations. They raised this issue
along with some other noteworthy points relating to the costs of the
program. Specifically, the costs and the quantities were not reported
separately, which limits the generalisability of the authors' results.
Also, the date to which the prices related was not reported, hindering any
possible reflation exercises.
The review also reports an error in the cost-effectiveness ratio
calculated by the authors. To calculate this ratio the authors divided the
average cost per client of the counselling service ($60) by the
incremental effect on cessation rates (4.5%). In this incremental
analysis, the authors failed to include the costs incurred by patients in
the self-help group (i.e. those receiving the booklets only), which
amounted to $15 per client. Hence, the incremental cost-effectiveness
ratio of the telephone counselling service would be lower than that
calculated by the authors, and would be around $1,000 ($45 divided by
4.5%)[1]
References
1. Telephone assistance for smoking cessation: one year cost
effectiveness estimations [Abstract 20040366] NHS Economic Evaluation
Database, available http://nhscrd.york.ac.uk/welcome.htm [2005, 5
December]. Abstract of: Telephone assistance for smoking cessation: one
year cost effectiveness estimations, McAlister A, Rabius V, Geiger A,
Glynn T, Huang P, Todd R., Tobacco Control, 2004, 13(1):85-86.
In the latest issue of Tobacco Control, Radu and others report on
tobacco use among Swedish schoolchildren (Tobacco Control 2005;14:405-
408). As a Swede, I was surprised to read about some of their findings.
Children who smoke daily or almost daily are defined as “regular
smokers”. The percentage of regular smokers is reported to have decreased
to 4 per cent among 16-years-old boys and 15 per cent among girls by...
In the latest issue of Tobacco Control, Radu and others report on
tobacco use among Swedish schoolchildren (Tobacco Control 2005;14:405-
408). As a Swede, I was surprised to read about some of their findings.
Children who smoke daily or almost daily are defined as “regular
smokers”. The percentage of regular smokers is reported to have decreased
to 4 per cent among 16-years-old boys and 15 per cent among girls by 2003.
These figures differ significantly from the data found in the
original (Swedish) reports from the CAN (Swedish Council for Information
on Alcohol and Other Drugs). According to the latest CAN report (2005) the
percentage of “regular smokers” in 2003 was 7 per cent among boys and 13
per cent among girls. So, how can the authors reach the figure 4 per cent
for boys?
One explanation, which can be hypothesized from Figure 2 in the
paper, may be that “regular smokers” who also use oral snuff, have been
excluded from the category of “regular smokers”. If this is the case, I
find this to be a highly innovative method of presenting data in order to
make them support one’s favourite, preconceived conclusions. Smokers who
also use oral snuff – are they not smokers?
The “gender gap” in tobacco habits certainly exists – it has been
there ever since the early 1970s, when this series of surveys was started
and the use of oral snuff was practically non-existent among boys. The
main explanation for this gap seems to be the fact that 16-year-old girls
are – biologically and socially – more “grown-up” than boys of the same
birth cohort. Additional explanations may of course exist – tobacco
initiation is a complex development where several social, psychological
and other influences are active.
During the last few years there has been a marked decrease of regular
smoking among both boys and girls. At the same time, regular use of oral
snuff has also decreased among boys.
To reach – from these data – the conclusion that “snus use suppresses
smoking among boys”, appears to be a daring exercise. To me, the jump is
far to big.
Paul Nordgren
National Institute of Public Health,
Stockholm, Sweden
paul.nordgren@fhi.se
In a visit to Catalonia in Spain during October 2005, I noticed a
number of changes in the smoking culture and regulations, compared to a
visit in 2001.
Smokefree legislation is expected to be passed in 2006. The Catalonia
regional government plans to take up the same tough stance as Ireland, the
Netherlands and Norway. But there are already changes in Catalonia.
In a visit to Catalonia in Spain during October 2005, I noticed a
number of changes in the smoking culture and regulations, compared to a
visit in 2001.
Smokefree legislation is expected to be passed in 2006. The Catalonia
regional government plans to take up the same tough stance as Ireland, the
Netherlands and Norway. But there are already changes in Catalonia.
In comparison to 2001, I came across several cafes and restaurants
that had smokefree areas, (some locals cynically suggested that they were
there not there to protect staff but to please the tourists). In 2001,
many cafes had sawdust all over the floors, partly to cope with the
cigarette butts being ground under heel by smokers. This practice may
still exist, but was certainly not as extensive as previously. It was also
a pleasure to be served food and drink by people who were not smoking
while they worked.
I noticed the biggest difference in the Spanish airports. Most areas
of the Barcelona and Palma airports are smokefree, with the designated
areas for smoking being the occasional café and corners in the departure
lounge. Every so often, a voice would boom out in Spanish and in English:
“It is by decree of the King, order no ** sub section **, that this
airport is designated a smokefree building. It is an offence to smoke in
any area other than the areas that are designated for smoking.”
Some people by habit still lit up in the smokefree areas of the
airports, but others were quick to point out that they were breaking the
law. I was impressed how quickly smokers reacted and put out their
cigarette, or hurried over to the smoking area. There was no abuse by the
smokers, it was just done.
A friend of my son (who lives in Barcelona) gave up smoking while I
was there. He had taken to wearing his nicotine patch proudly, like a
tattoo! The patches cost 40 euros (per packet?).
Among my son’s friends the women are very clear that they will not
smoke while pregnant. However, there appeared to be still not too much
awareness of the dangers of second hand smoke, as the women were all sure
that they would start smoking again after the baby was born. This may not
be the norm, as the research sample was only six.
Official figures indicate that 50,000 people die from tobacco-related
diseases each year in Spain, comprising 16 percent of all deaths of people
over 35. Smoking kills more people than Aids, alcohol-related illnesses
and traffic accidents combined.
When we received the August 2005 issue of Tobacco Control, we found
much in it to help inform our work, as usual.
I am writing, however, because we have some concerns about one of the
articles published. “The perimetric boycott: a tool for tobacco control
advocacy,” is described as a comprehensive analysis of a number of
boycotts, including one organized by Infact (now Corporate Accountabi...
When we received the August 2005 issue of Tobacco Control, we found
much in it to help inform our work, as usual.
I am writing, however, because we have some concerns about one of the
articles published. “The perimetric boycott: a tool for tobacco control
advocacy,” is described as a comprehensive analysis of a number of
boycotts, including one organized by Infact (now Corporate Accountability
International).
A key point overlooked by the authors is that Corporate
Accountability International’s Boycotts are one strategy within a broader
campaign challenging life-threatening corporate actions. Though we lifted
the Kraft Boycott in June 2003 in celebration of the adoption of the WHO
Framework Convention on Tobacco Control, our Tobacco Industry Campaign
continues to build momentum—-using the most effective strategies at any
given time, and helping to make the WHO FCTC one of the most rapidly
embraced UN treaties of all time.
As a membership organization, Corporate Accountability International
has developed and carried out a number of grassroots consumer campaigns
that have altered the cost/benefit ratio for a corporation to engage in
irresponsible and dangerous practices. Our Nestlé Boycott is often cited
as pivotal to the emerging corporate accountability movement in the 1970s.
Some of the most significant documented costs to Philip Morris/Altria
from the Kraft Boycott included: harm to corporate name, reputation and
image—among the most valuable assets of any corporation; direct expenses
of salaries for management time spent dealing with the Boycott and its
impact; lost management time that could have been spent on acquiring new
sales and increasing shareholder value; public relations, advertising and
corporate giving to maintain goodwill with consumers, the media and
political leaders; and loss of employee morale, affecting both recruitment
and retention.
While thorough attention to the effectiveness of our strategies as a
movement is important for learning lessons as we move ahead, so too is
careful attention to detail and context when critiquing strategies that
have advanced our collective work.
Sincerely,
Patti Lynn
Campaigns Director
Patti Lynn
Campaigns Director
Corporate Accountability International (formerly Infact)
Campaign Headquarters
46 Plympton Street
Boston, MA 02118 USA
Phone: 617-695-2525
Fax: 617-695-2626
plynn@stopcorporateabuse.org
www.stopcorporateabuse.org
The recent article by Al-Delaimy et al (TC 14:359) makes two
conclusions. The first is that use of over-the-counter (OTC) nicotine
replacement therapy (NRT) for reasons other than smoking cessation is
uncommon. This result is consistent with several other studies not cited
in this letter (Nic Tobacco Research 6:79; Nicotine Safety and Toxicity (N
Benowitz, ed) p 147). The second conclusion is that "some smokers may be...
The recent article by Al-Delaimy et al (TC 14:359) makes two
conclusions. The first is that use of over-the-counter (OTC) nicotine
replacement therapy (NRT) for reasons other than smoking cessation is
uncommon. This result is consistent with several other studies not cited
in this letter (Nic Tobacco Research 6:79; Nicotine Safety and Toxicity (N
Benowitz, ed) p 147). The second conclusion is that "some smokers may be
questionning the efficacy of NRT for quitting." This conclusion is based
on the observation that among those who had ever used NRT, many had not
used it in their last quit attempt. This is not a necessary deduction
from this observation. For example, assume a) we have a treatment that is
proven effective but is effective in a minority of patients, b) that
patients have a chronic relapsing disorder that requires several treatment
episodes and c) most patients are reluctant to use any treatment that has
failed in the past. Under these conditions, all effective treatments will
be unlikely to be used in the last treatment episode. For example, I
would wager that most smokers who used behavioral therapy for smoking
cessation did not use behavioral therapy on their last attempt.
Concluding that this data means that patients are "questionning the
efficacy" suggests that over time the treatment is loosing its efficacy.
This is not a necessary deduction from the above observation. If so, then
we would have to conclude that all treatments effective in a minority of
patients are loosing efficacy over time.
When Hong and Bero published their study �"How the tobacco industry responded to an influential study of the health effects of secondhand smoke�" in 2002, I was supporting the law suit against a railway company
to get smoke-free environment for workers and passengers in Japan.
At that time, non-smokers had been annoyed by secondhand smoke for a long
time regardless of our many claims.
The company had been denying the harmfu...
When Hong and Bero published their study �"How the tobacco industry responded to an influential study of the health effects of secondhand smoke�" in 2002, I was supporting the law suit against a railway company
to get smoke-free environment for workers and passengers in Japan.
At that time, non-smokers had been annoyed by secondhand smoke for a long
time regardless of our many claims.
The company had been denying the harmful effects of second hand smoke,
because tobacco industry affiliated authors were publishing many studies
which denied the health effects of tobacco smoke and these studies were
used for the many other tobacco-related law suits by many companies to
reject the control of secondhand smoke.
So I carefully read the Hong� and Bero study and accessed to the tobacco
documents.
I thought Hong� and Bero's study was correct, because I found that the company had
used many studies produced by tobacco industry affiliated authors to
reject tobacco control.
Therefore I decided to use the tobacco documents which described the
conspiracy of tobacco industry affiliated author for the law suit.
Then I and lawyers submitted the evidence to the court. Amazingly, I
was successful in having the court admit the necessity of controlling secondhand smoke on
January 3, 2005. The court decided that tobacco industry
affiliated authors were unreliable and the studies produced by them were
incredible.
This judgment was an epoch-making success in Japan. It enabled us to
introduce more effective tobacco control measures very smoothly.
Thanks to Hong and Bero, Japan made a great progress in tobacco control.
In response to Mr. Lee’s comment1 which follows previous responses2,3
and my paper4, I offer further
explanation to resolve an apparent misunderstanding of the validity and
reliability of cotinine/creatinine ratio (CCR) measurement and his mishandling
of the formula of misclassification. I also express concerns about the lack of
scientific integrity in his reporting5 of the Japanese spousal study,
including his authorship.
As I demonstrated4, all indices of nicotine exposure (ambient
room,personal sampler monitors, and salivary
cotinine)
were well correlated but correlated poorly with CCR, raising doubts about the
validity of the CCR measurement.Yet
Lee maintains that CCR measurement in this study was the gold standard for
distinguishing true smokers from falsely reporting smokers.
There are several possibilities about why the CCR
measurement may have been invalid and unreliable in this study. In 1991 when I
sent the urine samples to the RJR laboratory (where the measurement was
performed), I was informed that all the dry ice sent with the sample had
sublimated before it reached the laboratory. This suggests that the sample was
not maintained at low temperature before analysis. Cotinine measurement is
temperature sensitive and measurement after the sample is exposed to high
temperature can make the measurement inaccurate6.
As I calculated4, the misclassification
and reverse misclassification were equally high suggesting inappropriateness of
the CCR measurements as the gold standard.Lee’s
neglect of reverse
misclassification, thusallows
him to claim an inflated false negative rate of smoking.Lee continues to justify his
misclassification formula by referring to his previous use of the formula.
However, this formulais dependent
on the prevalence of smoking among the study population and thereby artificially
inflates the misclassification rate
ofpopulations with low smoking
prevalence. By way of illustration, consider two hypothetical populations of
1000 people each with smoking rates of 10% (A) and 30% (B).Suppose that, due to the inaccurate CCR measurement, just 3% of true
smokers are classified as non-smokers by erroneously low CCRand3% of true non-smokers are classified as smokers by erroneously high CCR
(for the sake of simplification, I assume no false reports by the subjects). We
will get the following results.
A: If 10% smoke
Self report
Smoker
Nonsmoker
Total
CCR
High
(>100ng/mg)
97
27
124
Lee’s
Misclassification formula
Low(<100ng/mg)
3
873
876
=27/124=0.21
Total
100
900
1,000
B:
If 30% smoke
Self report
Smoker
Nonsmoker
Total
CCR
High
(>100ng/mg)
291
21
312
Lee’s
Misclassification formula
Low(<100ng/mg)
9
679
688
=21/312=0.06
Total
300
700
1,000
As
can be seen, Lee’s formula for misclassification is dependent on the
prevalence of smoking. With only a
slight (3%) inaccuracy in CCR measurement, he can thereby easily get more than
three times higher (0.21
vs.0.06) misclassification in a population with lower smoking prevalence, such as with Asian women.
After a long discussion between Proctor and me, Proctor finally
understood and accepted my point on the misclassification formula7.
Our final draft of the misclassification paper8, which Proctor sent
to me on November 9, 1992 with my name as a sole author, clearly mentioned the
high proportion of misclassification in both sides (self-reported non-smoking
subjects with high CCR and self-reported smokers with low CCR).
Lee
insists that reverse misclassification is relatively unimportant in his
abundant mathematical publications. However, I note that he seems to have
realized his mistake of using 28/106 as the misclassification rate of
self-reported smokers in his original study5 , having quietly
switched to 28/98 for this rate1 after I pointed out his confusion.
Despite his claim that reverse misclassification is implausible, it was observed
as a fact.
Lee
states that as
far as he is aware the
data never belonged to Yano. He should be aware that I developed the
questionnaire, and selected the study areas and subjects. I supervised the
survey at the study area (Shizuoka), erroneously referred to in Lee’s paper as Shizoka5. I planned and ordered the
data input, performed the data analysis and sent the disk to Proctor. On
learning from the experience of possible sample damage (from dry ice
sublimation) by the commercial shipment at the first phase study in 1991, I even
transported the second phase samples myself to the RJR laboratory, Winston
Salem, NC where CCR was measured. I discussed the scientific content of the
study with Proctor many times and he accepted my points7 and revised
the draft many times, always with my name as the author, and never with Lee’s.
As can be seen in the final draft8, Proctor and I reached a certain
agreement on the misclassification formula and the importance of the reverse
misclassification rate.
Because
Lee never participated in the actual survey it may be that he was unaware of
details of the research such as the integrity of the sample which may have
seriously affected the interpretation of results. Nor did he participate in the
discussion which led Proctor and I to a deeper understanding of the analysis7.
Despite this, still Lee claims that because he proposed the research project, he
has aright to sole authorship
regardless of who actually conducted the research. This is a unique idea that
few scientists would accept.
Lee states: Had I not published the paper it seems that the findings
would never have appeared in the public domain at all.Did Yano also have sole rights to suppress the findings? Again, Iremind Lee thatProctor and I
agreed that the results did not indicate high misclassification in self-report
non-smokers but some failure in the study.7, 8 What both Proctor and
I prepared for publication, although Proctor ceased to contact me before we
could reach a final agreement, was totally different from what Lee eventually
published5. I consider that a description of a failed study
involving the inaccurate measurement of CCR was undeserving of publication.
Moreover, as a scientist committed to truth, I have a responsibility to be
critical of a report with erroneous interpretations based on invalid
measurements.
2.Yano E.Response
to P N Lee [Commentary].Tob
Control 2005;14:234-5.
3.Lee PN.Japanese spousal
study: a response to Professor Yano's claims [Commentary].Tob Control 2005;14:233-4.
4.Yano E. Japanese spousal smoking study
revisited: how a tobacco industry funded paper reached erroneous conclusions. Tob
Control 2005;14:227-35.
5.Lee PN. "Marriage to a smoker" may
not be a valid marker of exposure in studies relating
environmental
tobacco smoke to risk of lung cancer in Japanese non-smoking women.Int Arch Occup Environ Health 1995;67:287-94.
6.Hagan
RL, Ramos JM Jr, Jacob PM 3rd. Increasing urinary cotinine concentrations at
elevated temperatures: the role of conjugated metabolites. J Pharm Biomed
Anal. 1997;16:191-7.
7.Proctor
CJ. Fax to Dr E. Yano,
Teikyo
University
, October 26 1992.
I am the “WDE Irwin” quoted on page 67 as follows: “Years later
(1985), WDE Irwin, a technician with BAT in England, was asked how a
grooved filter could be made that would avoid criticism but also provide
good taste. He concluded: ‘Finally for cigarettes, I believe it to be a
self evident truth not only is there no smoke without fire, but also there
is no kick without smoke.’”
I am the “WDE Irwin” quoted on page 67 as follows: “Years later
(1985), WDE Irwin, a technician with BAT in England, was asked how a
grooved filter could be made that would avoid criticism but also provide
good taste. He concluded: ‘Finally for cigarettes, I believe it to be a
self evident truth not only is there no smoke without fire, but also there
is no kick without smoke.’”
“Technician” is not a correct identification of my status. At time
of the quote, I had 20 years experience in the tobacco industry and held
three quite separate primary degrees from British universities, majoring
in chemistry, economics and statistics. A quick search on Google would
have identified my status as “scientist”. My credibility as an iconoclast
could be compromised if I did not make this correction. Although no
longer in the tobacco industry, I may at some point seek to criticise a
report by the US Institute of Medicine, “Clearing the Smoke: The Science
Base for Tobacco Harm Reduction” published in 2001 and I shall need all
the credibility I can muster!
I read with great interest the article by Bjartveit and Tverdal
(2005), who investigated health consequences of smoking 1-4 cigarettes per
day. They found that in both sexes, smoking 1-4 cigarettes per day was
associated with a significantly higher risk of dying from ischaemic heart
disease and from all causes, and in women, from lung cancer [1].
Genetic studies suggest that all stages of tobacco...
I read with great interest the article by Bjartveit and Tverdal
(2005), who investigated health consequences of smoking 1-4 cigarettes per
day. They found that in both sexes, smoking 1-4 cigarettes per day was
associated with a significantly higher risk of dying from ischaemic heart
disease and from all causes, and in women, from lung cancer [1].
Genetic studies suggest that all stages of tobacco use and dependence,
maintenance of dependent smoking behavior and amount smoked are partially
under genetic control [2]. Many of cigarette smoke compounds and their
metabolites are substrates of phase I enzymes, represented by cytochrome
P450 enzymes, and glutathione S-transferases (GSTs). Although the study
investigating the association between smoking behavior and either
polymorphisms of GSTT1 or GSTM1, failed to show a significant association
[3], there are several reports indicating that genetic polymorphisms of
CYP2A6, CYP3E1, and CYP2D6 are associated with smoking behavior [4-6]. The
CYP2A6 poor-metabolizer genotypes result in altered nicotine kinetics [4].
Individuals lacking full function CYP2A6 alleles do not metabolize
nicotine and are less likely to become smokers and if they do, they smoke
fewer cigarettes per day in comparison with normal-nicotine metabolism
persons [4]. Therefore, slow inactivators may experience higher or longer
lasting levels of nicotine. This could increase effects of nicotine
toxicity. Also it is reported that the CYP2D6 ultra-rapid metabolizer
genotype may contribute to the probability of being addicted to smoking
[5]. Taken together, it is probable that the persons smoked 1-4 cigarettes
per day in the study of Bjartveit and Tverdal [1] belong to the slow
metabolizer genotypes. Therefore, the results of the study should be
interpreted with caution. Study with respect to polymorphisms of phase I
and II genes, might be find the threshold value for daily cigarette
consumption that must be exceeded before serious health consequences
occur.
REFERENCES
1 Bjartveit K, Tverdal A. Health consequences of smoking 1-4
cigarettes per day. Tob Control 2005;14:315-20.
2 Hall W, Madden P, Lynskey M. The genetics of tobacco use: methods,
findings and policy implications. Tob Control 2002;11:119-24.
3 Saadat M, Mohabatkar H. Polymorphisms of glutathione S-transferases
M1 and T1 do not account for interindividual differences for smoking
behavior. Pharmacol Biochem Behav 2004;77:793-5.
4 Tyndal RF, Sellers EM. Genetic variation in CYP2A6-mediated
nicotine metabolism alters smoking behavior. Ther Drug Monit 2002;24:153-
60.
5 Saarikoski ST, Sata F, Husgafvel-Pursianen K, et al. CYP2D6 ultra-
rapid metabolizer genotype as a potential modifier of smoking behaviour.
Pharmacogenetics 2000;10:5-10.
6 Yang M, Kunugita N, Kitagawa K, et al. Individual differences in
urinary cotinine levels in Japanease smokers: relation to genetic
polymorphism of drug-metabolizing enzymes. Cancer Epidemiol Biomarkers
Prev 2001;10:589-93.
We thank Dr Graham F Cope for his valuable remarks, and agree that
underreporting of daily cigarette consumption might be of importance when
assessing the risk in light smokers.[1]
Dr Cope refers to two papers: a cross-sectional randomised study on
smoking reduction in pregnant women, and an assessment of smoking status
in patients with peripheral arterial disease.[2][3] Our study did not
conc...
We thank Dr Graham F Cope for his valuable remarks, and agree that
underreporting of daily cigarette consumption might be of importance when
assessing the risk in light smokers.[1]
Dr Cope refers to two papers: a cross-sectional randomised study on
smoking reduction in pregnant women, and an assessment of smoking status
in patients with peripheral arterial disease.[2][3] Our study did not
concentrate on subgroups in need of regular medical attention; it covered
all residents aged 35-49, except people with a history or symptoms
indicating cardiovascular diseases (among them peripheral arterial
disease) and diabetes.[4] A general population in the 1970s may be less
inclined to underreport consumption, than present-day pregnant women and
sick people, who do not want to incur the disapproval of the healthcare
professionals.
Based on a review and meta analysis Patrick and co-workers found that
interviewer-administered questionnaires, observational studies, reports by
adults, and biochemical validation with cotinine plasma were associated
with higher estimates of sensitivity and specificity. Our study compares
favourably with these points: The study includes only adults, all
questionnaires were checked by a nurse in an interviewer situation, and in
one of the three counties, biochemical validation was carried out in all
participants by determination of serum thiocyanate.[5] Certainly, levels
of thiocyanate may be influenced by factors other than smoking;
nevertheless, the dose-response between mean levels of thiocyanate and
reported number of cigarettes is remarkable:
Number of cigarettes per day
MALES
FEMALES
No.
Mean (SD)
No.
Mean (SD)
0
6212
33.9 (14.0)
7908
33.5 (14.2)
1-4
169
45.3 (18.4)
515
52.0 (22.0)
5-9
855
59.6 (20.7)
1661
70.9 (24.5)
10-14
1570
69.6 (22.2)
1800
81.5 (24.0)
15-19
1056
76.3 (23.1)
569
90.8 (25.5)
20-24
699
81.5 (26.4)
247
96.1 (25.6)
25+
235
87.3 (27.9)
36
99.7 (28.3)
Finally, the attending persons reported their actual number of
cigarettes per day in a special box in the questionnaire. Here they were
allowed to give a range of daily consumption, for example, 10-15
cigarettes. In our analyses, however, we used the highest figure stated by
the participant. Hence, a report of 3-6 cigarettes per day was categorized
in the 5-9 cigarettes group.
We find it reasonable to conclude that the results presented in our paper
reflect a marked increased risk in light smokers.
References
1. Cope GF. Health consequences of smoking 1-4 cigarettes per day. Letter
to journal. Tob Cont 2005 http://tc.bmjjournals.com/cgi/eletters/14/5/315.
2. Cope GF, Nayyar P, Holder R. Feedback from a point of care test for
nicotine intake to reduce smoking during pregnancy. Ann Clin Bioch
2003;40:674-679.
3. Hobbs SD, Wilmink ABM, Adam DJ, Bradbury AW. Assessment of smoking
status in patients with peripheral arterial disease. J Vasc Surg
2005;41:451-456
4. Bjartveit K, Tverdal A. Health consequences of smoking 1-4 cigarettes
per day. Tob Cont 2005;14:315-320.
5. Patrick DL, Cheadle A, Thompson DC, Diehr P, Koepsell S, Kinne S. The
validity of self-reported smoking: a review and meta-analysis. Am J Public
Health 1994;84:1086-1093.
6. Foss OP, Lund-Larsen PG. Serum thiocyanate and smoking: interpretation
of serum thiocyanate levels observed in a large health study. Scan J Clin
Lab Invest 1986;46:245-251.
I read the paper by Bjartveit and Tverdal with a great deal of
interest(1). I welcome the fact that highlighting smoking, even a small
number of cigarettes has a significant effect on ischaemic heart disease.
However, these findings should be considered with a certain amount of
scepticism, as the findings are based entirely on self-reported smoking
habit. Biochemically validated research, both by ourselves(2), and
other...
I read the paper by Bjartveit and Tverdal with a great deal of
interest(1). I welcome the fact that highlighting smoking, even a small
number of cigarettes has a significant effect on ischaemic heart disease.
However, these findings should be considered with a certain amount of
scepticism, as the findings are based entirely on self-reported smoking
habit. Biochemically validated research, both by ourselves(2), and
others(3) have found that many smokers will admit to their habit, but will
significantly under-report their cigarette consumption; believing that
reporting a low number of cigarettes a day, say 1-4, will not incur the
disapproval of the healthcare professional. Also to be taken into account
is that biochemical analysis shows that the intake of nicotine and other
tobacco products is extremely variable within categories of cigarette
consumption, and is dependent on a number of variables such as smoke
topography (number, frequency and volume of puffs from a cigarette), depth
of inhalation, age, gender, yield of nicotine, etc. So some individuals
who consume a small number of cigarettes a day will ingest the same level
of tobacco products as other smokers with a higher daily intake.
Compensation, when a smoker cuts down on cigarette consumption, but smokes
more efficiently, is a factor mentioned in the text of the paper, is an
example whereby cigarette consumption does not reflect nicotine intake.
So, although the paper and ensuing publicity has brought to the attention
of the public the dangers of any level of smoking, using self-reported
information should be used with a certain degree of caution.
References
1. Bjartveit K, Tverdal A. Health consequences of smoking 1-4
cigarettes per day. Tob Cont 2005; 14: 315-320.
2. Cope GF, Nayyar P, Holder R. Feedback from a point of care test for
nicotine intake to reduce smoking during pregnancy. Ann Clin Bioch 2003;
40 : 674-679
3. Hobbs SD, Wilmink ABM, Adam DJ, Bradbury AW. Assessment of smoking
status in patients with peripheral arterial disease. J Vasc Surg 2005; 41:
451-456.
British American Tobacco (Nigeria) Limited (BAT) and their cohorts
the world over should come to terms with the fact that the truth cannot be
hidden forever even from the man on the streets.
Mr Kehinde Johnson did not need to comment at all because there was
nothing to comment about! He should have apologised for being a part of
this systematic elimination of defenceless people the world over.
British American Tobacco (Nigeria) Limited (BAT) and their cohorts
the world over should come to terms with the fact that the truth cannot be
hidden forever even from the man on the streets.
Mr Kehinde Johnson did not need to comment at all because there was
nothing to comment about! He should have apologised for being a part of
this systematic elimination of defenceless people the world over.
Dr. Chris Proctor's statement typifies the message that British
American Tobacco (Nigeria) Limited has tried to pass across to
unsuspecting people, that their tobacco is "safer" than smuggled
brands.This is most unfortunate because it is not based on any scientific
evidence. In fact, the scientific findings in this area are to the
contrary. A time will come in our developmental process in Nigeria that
such misrepresentation of facts will attract severe punishment!
Another trick which is employed by the company is the use of Nigerian
symbols of success and national pride such as historical materials as a
means of advertisement for their products. Advertising cigarretes under
the guise of promoting national pride is another slap in the face of the
Nigerian people by BAT (Nigeria) Limited. Nigerians know when to be
proudly Nigerian. Certainly, our national pride is not baased on tobacco
but on the legacy of our fore-fathers.
I take succour in the Yoruba saying that "If a lie goes on for twenty
years, the truth catches it in a day". This lies have gone on for more
than twenty years and the truth has caught up with them.
It is time for all those who know the truth to speak up. We need a
critical mass of determined and committed folks to finish this work and
make our world truly tobacco free!
Professor Eiji Yano raises a number of issues in his letter(1) which
responded to my commentary(2) on his article(3) about the Japanese spousal
study, as does Chapman in his editorial(4). Here I reply to the main
points raised.
INTERPRETATION OF THE DATA
Studies of environmental tobacco smoke (ETS) exposure and lung cancer
commonly identify a...
Professor Eiji Yano raises a number of issues in his letter(1) which
responded to my commentary(2) on his article(3) about the Japanese spousal
study, as does Chapman in his editorial(4). Here I reply to the main
points raised.
INTERPRETATION OF THE DATA
Studies of environmental tobacco smoke (ETS) exposure and lung cancer
commonly identify a group of self-reported non-smoking women and then
compare risk according to the smoking habits of the husband. If some true
smokers are erroneously included among the female subjects, an apparent
relationship of spousal smoking with lung cancer may be seen even when no
true effect of ETS exists. This has been mathematically demonstrated
(e.g.5), with attempts to correct for it made by major independent
authoritative reviews of the evidence on passive smoking and lung
cancer.(6-8) The magnitude of the bias depends (among other things) on
the extent to which women who smoke are misclassified as non-smokers. It
can also be shown mathematically(5) that a given rate of misclassification
of smokers as non-smokers is a much more important cause of bias than is
the same rate of the reverse misclassification, of non-smokers as smokers.
Since such reverse misclassification is also implausible, adult women
having little reason to claim erroneously to be smokers, the major
reviews(6-8) have all ignored its minor effects.
Given that in the Japanese spousal study (using a urinary
cotinine/creatinine ratio, CCR, above 100 ng/mg as an index of true
smoking), the reverse misclassification rate (8/298 = 2.7%) was anyway
much lower than the misclassification rate itself (28/98 = 28.6%), it
becomes abundantly clear that reverse misclassification is not relevant to
the passive smoking/lung cancer issue. It is difficult to understand why
Yano places such emphasis on it.
Yano(1) states that I am "confused with the calculation formula" and
that my "definition of misclassification was obtained by dividing those
with >100 ng/mg CCR (n = 28) by self-reported non-smokers (n = 318)."
It appears that Yano himself is confused. I had previously made it
clear(2) that the denominator should not be 318, but 98, the number of
women with a CCR value indicative of smoking (or perhaps 106, if one also
includes those women who claimed to smoke but had a CCR <100 ng/ml).
The misclassification rate calculation is clearly based on CCR
>100 ng/mg validly indicating smoking. Such an assumption is widely
used(9), though may be subject to some error, and was the best technique
available at the time. Most smokers admit to smoking, so that self-report
has some validity as an indicator of true smoking status, but this does
not help us estimate the magnitude of the misclassification bias. The
observed lack of correlation in the Japanese spousal study between CCR in
non-smokers (with CCR <100 ng/mg) and other indices of ETS exposure
suggests that inaccuracy in CCR measurement at low levels may be
important. However, such inaccuracy may not be relevant to the
misclassification rate calculation, which merely attempts to use CCR to
distinguish smokers from non-smokers. Over half the self-reported non-
smokers with values over 100 ng/mg actually had values of 1000 ng/mg, and
it would be very surprising indeed if errors in CCR measurement were so
huge that these women were really non-smokers.
Though I would be happy to see results of further studies using up-to
-date state-of-the-art chemical methods to detect nicotine metabolites in
self-reported non-smokers, the conclusion I reached in 1995 that
misclassification rates are much higher in Japanese than in Western
populations(10) seems to be correct. I note that the existence of high
misclassification rates in Asian women has in fact been independently
confirmed.(11)
RIGHTS TO PUBLICATION OF THE FINDINGS
Yano states(1) that I used his data without his consent. As far as I
am aware, the data never belonged to Yano. The study had been funded by
the industry who had carried out the cotinine analyses (blind of self-
reported smoking status). I had originally proposed that the study be
done, following conduct of a similar study in England, which the industry
supported at my request, and which I reported the results of.(12) The
original intention had been for Yano to be a major author, but problems
arose because his interpretation of the findings differed materially from
mine, due to his misunderstanding of the complexities of
misclassification. Discussions took place between Yano and Proctor, who
played an important role in planning and organisation of the study on
behalf of the tobacco companies who funded it, and I was told that these
discussions led to Yano deciding not to be an author, and to his
understanding that the work would be published by others.
I had assumed that Proctor would keep Yano informed about the status
of the publication and was surprised Yano did not find out about the
paper, published in 1995, until some 7 or 8 years later. Clearly, one of
us should have kept him informed, and for this I apologise. In his
original article,(3) Yano states that "at no stage in my interactions with
Proctor was Lee's name or role ever mentioned." This is surprising
inasmuch as the study proposal stated that I would assist in reviewing the
study design and in interpreting the data. Was Yano really unaware of the
previous literature on misclassification of smoking, in which I figured
prominently (see 2) when conducting a study, a major aim of which
concerned the determination of misclassification rates?
GHOST AUTHORSHIP
Chapman(4) considers that "it is hard to imagine a more flagrant example
of attempted ghost authorship". It is difficult to see why Chapman sees
the publication as ghost authorship at all, when I proposed the study,
helped in its design and then published it. The study was a joint
enterprise, as I saw it, and it is perfectly normal for some of the
scientists involved in a study to write a draft for others to agree to.
It would clearly have been better had a version acceptable to all, with
Yano in the author list, been published. However, Yano's failure to
understand the mathematics of misclassification made this impossible.
There was no agreement I am aware of that Yano had sole rights to
authorship. Had I not published the paper(10) it seems that the findings
would never have appeared in the public domain at all. Did Yano also
have sole rights to suppress the findings?
POSTSCRIPT
At the end of the day it is interesting that, though the evidence of high
misclassification rates in Japanese women has been independently
confirmed,(11) the relevance of this to the ETS/lung cancer relationship
has been ignored in recent major reviews of ETS and lung cancer
(e.g.8,13). I have demonstrated the major biasing effect of this finding
in detail elsewhere(14).
References
1. Yano E. Response to P N Lee [Commentary]. Tob Control
2005;14:234-5.
2. Lee PN. Japanese spousal study: a response to Professor Yano's
claims [Commentary]. Tob Control 2005;14:233-4.
3. Yano E. Japanese spousal smoking study revisited: how a tobacco
industry funded paper reached erroneous conclusions. Tob Control
2005;14:227-35.
4. Chapman S. Research from tobacco industry affiliated authors:
need for particular vigilance [Editorial]. Tob Control 2005;14:217-9.
5. Lee PN, Forey BA. Misclassification of smoking habits as a
source of bias in the study of environmental tobacco smoke and lung
cancer. Stat Med 1996;15:581-605.
6. Committee on Passive Smoking, Board on Environmental Studies and
Toxicology, National Research Council. Environmental tobacco smoke.
Measuring exposures and assessing health effects. Washington D.C.:
National Academy Press; 1986.
7. National Cancer Institute. Shopland DR, editor. Respiratory
health effects of passive smoking: lung cancer and other disorders. The
report of the US Environmental Protection Agency. USA: US Department of
Health and Human Services, Public Health Service, National Institutes of
Health; 1993. (Smoking and Tobacco Control. Monograph 4.) NIH Publication
No 93-3605.
8. Hackshaw AK, Law MR, Wald NJ. The accumulated evidence on lung
cancer and environmental tobacco smoke. BMJ 1997;315:980-8.
9. Lee PN, Forey BA. Misclassification of smoking habits as
determined by cotinine or by repeated self-report - a summary of evidence
from 42 studies. J Smoking-Related Dis 1995;6:109-29.
10. Lee PN. "Marriage to a smoker" may not be a valid marker of
exposure in studies relating environmental tobacco smoke to risk of lung
cancer in Japanese non-smoking women. Int Arch Occup Environ Health
1995;67:287-94.
11. Lee PN. Passive smoking and lung cancer: Strength of evidence
on passive smoking and lung cancer is overstated [Letter]. BMJ
1998;317:346-7.
12. Lee PN. Lung cancer and passive smoking: association an
artefact due to misclassification of smoking habits? Toxicol Lett
1987;35:157-62.
13. International Agency for Research on Cancer. Tobacco smoke and
involuntary smoking, Volume 83. Lyon, France: IARC; 2004. (IARC Monographs
on the evaluation of carcinogenic risks to humans.)
14. Lee PN, Forey BA, Fry JS. Revisiting the association between
environmental tobacco smoke exposure and lung cancer risk. III. Adjustment
for the biasing effect of misclassification of smoking habits. Indoor
Built Environ 2001;10:384-98.
Allowing the tobacco industry to define "reasonable regulation," an
industry whose economic survival will always depend upon finding new and
creative ways to entice children and teens into permanent chemical
enslavement, is like allowing Hitler to write health standards for dead
camps.
While awaiting fine-tuning of FDA regulatory bills, it's time for the
U....
Allowing the tobacco industry to define "reasonable regulation," an
industry whose economic survival will always depend upon finding new and
creative ways to entice children and teens into permanent chemical
enslavement, is like allowing Hitler to write health standards for dead
camps.
While awaiting fine-tuning of FDA regulatory bills, it's time for the
U.S. Congress to expressly allow cities and states to take immediate steps
to insulate youth from all corporate image, newspaper, magazine,
sponsorship, and point of sale tobacco industry marketing.
Two decades of selective binding technology could immediately allow
entire zip codes to be free of all magazine and newspaper tobacco ads, if
local governments were only granted authority to protect their youth.
Modern dependency science has taught us that history is a ridiculous
excuse for demanding that high grade ethanol products be sold in stand
alone liquor stores, while high grade nicotine delivery devices are
marketed inside a child's neighborhood candy, chip and soda store.
With almost a half a million annual U.S. deaths, it's beyond time
that point of sale marketing was no long visible from sidewalks or school
buses. It's beyond time to grant local government express authority to
exclude youth from all tobacco sales locations.
Inside adult only sales locations, allow the industry to advertise
and market to its heart's content. But no pictures in ads or displays,
other than the product, and grant local government authority to demand
premises dependency warning signs.
I enjoyed Derek Yach’s editorial. I believe that the FCTC and new
research that will support its transnational aspects can make a big
difference. But will they?
I would warn against over optimism and for an understanding of the
commitment and sustained action that will be required. First, one must
face the fact that the primary governance of tobacco issues has been and
continues to be located in the tobacco...
I enjoyed Derek Yach’s editorial. I believe that the FCTC and new
research that will support its transnational aspects can make a big
difference. But will they?
I would warn against over optimism and for an understanding of the
commitment and sustained action that will be required. First, one must
face the fact that the primary governance of tobacco issues has been and
continues to be located in the tobacco business. This has been and could
continue to be the case for many years since the tobacco industry spends
more money than national and supranational bodies on controlling tobacco
governance. They also spend it using both legal and illegal means
necessary to their objectives. They also spend it with monopolistic focus
and agreement on core issues.
In contrast, to believe that there is some kind of international, or
even focused national governance of tobacco control is just not supported
by the evidence. Many countries have no central organization to forward
national tobacco control planning and policy, no plan for research, no
systematic monitoring of even the most basic indicators of importance to
tobacco control, and little or no money to fund tobacco control. And
while the fact that the FCTC requires more from these nations, without
adequate funding and sustained commitment, the lack of national governance
is likely to continue and the chance of global governance to be only a
remote dream.
How does a country get the necessary money and the necessary
commitment? Suppose you are from a poor country with a population of 25
million. What if you convinced society, including politicians and
scientists that they need to immediately bring tobacco use to a very
limited level? What if you could get $3 per person per year dedicated to
this job through taxing the tobacco industry? If you had the money and
the commitment, you could possibly make rapid progress through a
comprehensive approach to governing tobacco supply and demand.
Some countries have done so already. So where is the worldwide push
and coordination for all countries to generate funding and political will?
Until there is more effort in this direction, I doubt there will ever be a
global governance system for tobacco control. Urgency is appropriate, but
considering the historical record and present lack of money and
commitment, I believe slow progress is more likely. I wish I were wrong.
Erratum to Mandel, L; BC Alamar; and SA Glantz, “Smokefree Law did not affect revenue from
gaming in Delaware” Tobacco Control 14 (2005), 10-12.
The results in the original publication reflect a data entry error. The revised table in
this erratum present the results with this error corrected. Using the corrected data, White's test
for heteroskedasticity rejected homoskedasticity (p = 0.016) in t...
Erratum to Mandel, L; BC Alamar; and SA Glantz, “Smokefree Law did not affect revenue from
gaming in Delaware” Tobacco Control 14 (2005), 10-12.
The results in the original publication reflect a data entry error. The revised table in
this erratum present the results with this error corrected. Using the corrected data, White's test
for heteroskedasticity rejected homoskedasticity (p = 0.016) in the case of total revenues. We
corrected for the heteroskedasticity in total revenues by using a weighted least squares analysis
using the inverse of the number of video lottery machines as the weight. White's test of the
residuals from the weighted regression did not reject homoskedasticity (p=0.293). Average
revenues were homoskedastic (p=0.13) so we continued to use an unweighted regression, as in
the original paper. The analysis based on the corrected data confirms the results of the published
paper, that the smokefree law had no effect on revenue from gaming in Delaware.
In their article, Anderson, Glantz and Ling explore messages of
psychosocial needs satisfaction in cigarette advertising targeting women.
We agree with the authors that counter-advertising should attempt to
“expose and undermine the needs satisfaction messages of cigarette
advertising”. They mention that “a message of escape from life’s hassles
could be countered with a message that addiction further complicates an
al...
In their article, Anderson, Glantz and Ling explore messages of
psychosocial needs satisfaction in cigarette advertising targeting women.
We agree with the authors that counter-advertising should attempt to
“expose and undermine the needs satisfaction messages of cigarette
advertising”. They mention that “a message of escape from life’s hassles
could be countered with a message that addiction further complicates an
already hassle-ridden life”. During the past two years, the Healthy
Community Coalition (HCC) has conducted an anonymous survey in order to
gather data on the smoking behaviors of low-income, postpartum women and
their partners in rural Greater Franklin County, an area in western Maine
larger than Rhode Island with a population density of 17 people per square
mile. The study sample included every mother who gave birth during the
past two years at the sole hospital serving the area and completed the
self-administered survey. Their husbands/partners were given a very
similar survey to complete with questions addressing their own smoking
behaviors. Results show that smoking among the low-income, postpartum
women declined from 33.3% at baseline to 27.5% at end of study. One reason
for this decline can be attributed to the HCC program, “Tobacco Free
Franklin Families”, which uses funding from the American Legacy Foundation
to reduce smoking among low-income families through innovative approaches,
such as stress-reduction workshops for low-income mothers and their
partners.
Multivariate analysis of the mothers’ survey data showed that living
with someone who smokes was the most powerful risk factor associated with
postpartum smoking. Studies show that living with someone who smokes
increases up to four times the odds that the postpartum mother will return
to smoking. Multivariate analysis also indicated that a mother who was
unemployed or disabled was significantly more likely to smoke, as well as
a mother who was unmarried or did not have a partner. We recommend
innovative counter-advertising which shows that smoking only adds another
stressor to the women’s lives. Over a quarter of the mothers (26.5%)
reported that in the past twelve months, they or their husband/partner had
lost a job; 29.1% often worried that the food in their household would run
out before they had money to buy more; and 37.6% often worried about
heating their home during the winter. These statistics are consistent
with the latest U.S. Census data which show that 46.7% of the children in
Franklin County live in low-income families. The counter-advertising
might also include humor since 92% of the mothers who smoked were
interested in learning how to use humor to deal with stress. Other ad
campaigns targeting the partner are also strongly recommended since the
vast majority of studies have shown partner smoking to be the main
predictor of women smoking postpartum. The counter-advertisements should
address psychosocial needs of the husbands/partners. Like the mothers,
the partners reported a high prevalence of the same stressors: 23.9% often
worried that the food in their household would run out before they had
money to buy more and 40.2% often worried about heating their home during
the winter.
Kathleen J. Welch, Ph.D., MPH, Katherine A. Marble, CHES, TTS-c
About the authors: Dr. Kathleen Welch is the epidemiologist/evaluator
for the Healthy Community Coalition's project, Tobacco Free Franklin
Families. Katherine Marble is Program Coordinator for Tobacco Free
Franklin Families. The HCC is an affiliate of the Franklin Community
Health Network located in Farmington, Maine.
References
1. Anderson SJ, Glantz SA, Ling PM. Emotions for sale: cigarette
advertising and women’s psychosocial needs. Tobacco Control. 2005;14:127-
135.
2. U.S. Census Bureau. (2000). Current population survey. Retrieved
April 26, 2005, from http://www.census.gov/apsd/techdoc/cps/cpsmar00.pdf.
3. Cohen S, Lichenstein E. Partner behaviors that support quitting
smoking. Journal of Consulting and Clinical Psychology. 1990;58:304-309.
4. Maine Children’s Alliance, Maine KIDS COUNT (2004). Retrieved
April 26, 2005, from http://www.mekids.org
5. Ratner PA, Johnson JL, Bottorff JL, Dahinten S, Hall W. Twelve-
month follow-up of a smoking relapse prevention intervention for
postpartum women. Addictive Behaviors. 2000;25:81-92.
In June 2002, months before this column was published, I published an essay
in a number of Nigerian newspapers entitled: "The 17 Billion Poison House
In Ibadan." The piece was my own way of pouring out my spilling disgust
and accumulated indignation because of reports in the media earlier in
April of the same year that the Obasanjo Administration had celebratorily
granted permission to a so-called "leading cigarette comp...
In June 2002, months before this column was published, I published an essay
in a number of Nigerian newspapers entitled: "The 17 Billion Poison House
In Ibadan." The piece was my own way of pouring out my spilling disgust
and accumulated indignation because of reports in the media earlier in
April of the same year that the Obasanjo Administration had celebratorily
granted permission to a so-called "leading cigarette company", British
America Tobacco (BAT), to invest a "whopping $150 million (about 17
billion naira)" in the construction of a tobacco factory in Ibadan, "the
biggest and most modern" of its kind in Africa. The prominent attraction
of the company, according to reports, was that, when completed, it would
provide employment to 1,000 Nigerians.
Expectedly, the article provoked immense interest, and was rewarded
with an unimaginably wide circulation on the Internet. In fact, I have
continued to see several links to it on a number of internet sites,
including TOBACCO.ORG. Indeed, Op-Ed News which still maintains a link to
the piece describes it as "Talking about Tobacco like we Never See in
the US" (The piece is still available on the net at:
http://www.usafricaonline.com/tobaccongr.ugoejinke.html).
I even got a letter from an attorney in Houston requesting more
information about the activities of British America Tobacco and other
cigarette companies in Nigeria so he could commence legal action against
them in order to force them and their lethal business out of Nigeria.
What amazed me after the publications, was the panic reaction of BAT.
They immediately mounted an unprecedented image-packaging blitz through
countless full-page glossy adverts in several newspaper and magazines.
Today, I am reopening this battle, not just with BAT now, but with
all other cigarette manufacturers in this country, and I invite all
concerned Nigerians, health and environmental activists, to join this
clearly winnable struggle. The question I have always asked cigarette
producers is: can they boldly come out in the open and assure me that the
commodity they manufacture and distribute to hapless individuals cannot be
rightly classified as poison? Again, they should tell me just one single
benefit the human body derives from cigarette smoking. Has it not been
convincingly proved everywhere, and publicly admitted by tobacco
producers, that tobacco is a merciless killer, an unrelenting cannibal
that devours a man when his life is sweetest to him? If then tobacco is a
proven killer, can’t those who manufacture and circulate it in society be
classified as murderers? Hasn’t even our own Federal Ministry of Health
unambiguously endorsed this position by its insistence and persistent
warning that TOBACCO SMOKERS ARE LIABLE TO DIE YOUNG?
The implication of the Health Ministry’s statement is simple: If
tobacco smokers are liable to die young, then anyone offering you a
cigarette is only informing you that the best wish he could possibly make
to you is that your life be cut short! He is just telling you in very
clear terms: May you die young! And that is exactly what BAT, other
tobacco companies, and the government that licensed them to operate here
are wishing Nigerians! How wicked and heartless could they be!
I know that after this piece now, BAT and their co-poison
manufacturers will start again to erect new and more beautiful billboards,
and fill several pages of newspapers with glossy adverts. I see this as
nothing but the huge, shameless strategem of a smiling, gentle, but
ruthless murderer to persuade his victims to allow him to live among them
so he could strike when they least expected. Well, this time around, I am
waiting for them to boldly tell Nigerians that tobacco, the product they
manufacture and circulate in Nigeria, is no more the resilient,
implacable, silent killer, the lethal poison, and the heartless cannibal
that seeks accommodation in the midst of hapless humanity with the sole
intention of effecting their eventual decimation. I want to hear that
cigarettes are no longer generous distributors of devouring cancer,
tuberculosis, sundry terminal lung and heart diseases, etc.
Unfortunately, cigarette adverts are among the most alluring in
society. The pleasant pictures of vivacious achievers smiling home with
glittering laurels just because they are hooked to particular brands of
cigarette which we see on glossy billboards are proving irresistible baits
to several people, especially youths. The danger is so evident in the
unparalleled glee with which youths adopt these cigarette adverts stars as
their most cherished heroes and models. I was a victim too. As a youth,
the elegant, gallant, athletic rodeo man whose image marketed the 555
brand of cigarette was my best idea of a handsome, hard-working winner. My
friends and I admired him, carried his photographs about, and yearned to
smoke 555 in order to grow up and become energetic and vivacious like him.
One wonders how many youths that have been terminally impaired
because they went beyond mere fantasies and obsession with their cigarette
advert heroes and became chain-smokers and irredeemable addicts. Managers
of tobacco adverts are so adept in this grand art of deception that their
victims never suspect any harm until they have willingly placed their
heads on the slaughter slab. Indeed, only very few are able to look beyond
the deceptive pictures and the pernicious pomp of cigarette promotional
stunts and see the blood-curdling pictures of piecemeally ruined lungs and
other sensitive organs, murky, chimney-like breath tracts and heart
region, the looming merciless and spine-chilling fangs of an all devouring
cancer, tuberculosis, sundry lung and heart diseases, and their associate
unyielding killers. The warm reception given to BAT in Nigeria by both the
Federal and Oyo State governments is nothing but criminal, ungodly and
anti-people.
There were reports that BAT paid 2billoin naira tax in 2001. I have
even heard that it sponsors scholarships and community help projects. But
how many people have their lethal product sent to their early graves? How
many widows, widowers and orphans are they producing with alarming
rapidity? How many among their 1,000 employees are gradually ruined
daily because of the insidious fumes they inhale during production of
cigarettes? How many cancer, TB, lung disease patients do they produce in
a year?
Indeed, in civilized countries, Tobacco Companies and their owners
are being isolated and choked with harsh laws. Now, they have invaded
Nigeria with their filthy billions because we have an incompetent and
insensitive government that has no qualms welcoming urbane, but ruthless
killers in the name of “foreign investors.”
The development in the United States on June 7, 2001 where a Los
Angeles Superior Court in California slapped an unprecedented $3 Billion
in damages on Phillip Morris, another giant Tobacco Company in response to
a suit by a tobacco casualty, Richard Boeken, who had developed incurable
cancer of the brain and lungs after smoking two packs of Marlboro
cigarettes every day for 40 years should serve as eye opener to Nigerians
that with several class suits from victims of tobacco, these evil
merchants can be forced out of Nigeria. According to the New York Post
editorial of June 9, 2001, 56-year-old Boeken who began smoking as a
teenager in 1957 claimed that "he continued smoking not because it was
addictive, but he believed claims by Tobacco Companies that smoking was
safe." He told reporters in a post-trial interview: " I didn’t believe
they would lie about the facts that they were putting out on television
and radio."
That is exactly the point. Tobacco companies are deploying well
concocted lies to lure people into taking their fatally poisoned wraps
called cigarettes. Their billboards present vivacious winners and
achievers puffing away, instead of cancer patients treading the cold,
dark, lonely path to a most painful, slow death. Every society has a
responsibility to defend its unwary and the ignorant. Nigeria cannot be an
exception. The argument that smokers ought to be dissuaded from smoking by
the hardly visible warnings they put out, and that people are merely being
allowed to exercise their right and freedom to make choices, is akin to
endorsing suicide as a lawful __expression of freedom? Why allow a killer-
poison to circulate in the first place? Do we all have the same capacity
to discern and resist the allurement of danger? In court and in several
enquiries, tobacco producers have admitted that their product contains
very harmful substances. It is widely believed that many Tobacco producers
are non-smokers because they know too well how deadly their product is!
Tobacco is a killer. So are its manufacturers. Nigerians should rise and
resist this cannibal in our midst. Certainly in several families, there
have been tobacco victims. There are relevant laws under which these
people can be sued. You have a choice in this matter, to not only refuse
to patronize their lethal product but to help your hapless, less-
discerning neighbour do likewise. This fight is winnable.
P/S: For more information about the destructive mission of tobacco,
log on to http://www.tobaccofree.org/children.htm
To: BAT Nigeria Limited Mr. Kehinde Johnson Corporate &
Regulatory Affairs Director
"Should we swallow a bait and have a lethal hook thrust in our
throats just because the bait looked so appealingly delicious? What the
tobacco companies manufacture has no single benefit, no redeeming feature.
All it does is to kill and ruin .They are unwanted, loathsome and
unwelcome "(Ugochukwu D. Ejinkeonye- The Black Busi...
To: BAT Nigeria Limited Mr. Kehinde Johnson Corporate &
Regulatory Affairs Director
"Should we swallow a bait and have a lethal hook thrust in our
throats just because the bait looked so appealingly delicious? What the
tobacco companies manufacture has no single benefit, no redeeming feature.
All it does is to kill and ruin .They are unwanted, loathsome and
unwelcome "(Ugochukwu D. Ejinkeonye- The Black Business Journal )
Dear Sir,
Was the Standards Organisation of Nigeria (SON) able to determine:
• how many « risky » ingredients does BAT-Nigeria add to its
cigarettes ?
• how many toxic chemicals are there in BAT-Nigeria’s cigarettes’
smoke ?
• if there is more than the FDA 600 permitted additives to the
tobacco in the counterfeit cigarettes ?
• if there is more than 4000 toxic chemicals in the counterfeit
cigarettes’ smoke ?
What are the ‘prescribed limits for tobacco products’ in Nigeria ? Do
these limits guarantee the SAFETY of these products ?
Are the ‘genuine brands’ manufactured in BAT-Nigeria Ltd nicotine-
drug delivery devices that affect the health of smokers and that of the
people around them less than the counterfeit cigarettes do? How much less?
Do we have some comparative epidemiological studies on that issue?
Could your ‘well documented position on smoking and health and published
on our website’ give us these details?
BAT-Nigeria Ltd is ‘working in collaboration with the Nigerian
government’. Perhaps you mean the Minister of Commerce, Hon A.D Idris
Waziri who was present at the shameful BAT investor award ceremony or Hon
Kola Jamodu, the Minister of Industry
(http://www.summitreports.com/nigeria1/tobacco.htm), or the President
Olusegun Obasanjo who’s reforms ‘greatly encouraged BAT
(http://news.bbc.co.uk/2/low/business/1561228.stm)
However, the Minister of Health rightly abstained from your meeting
of your Social Report.
Your business is profit on a highly addictive, risky and lethal
product, our concern is health and quality of life.
Ms. Véronique Le Clézio Manager de ViSa- Mauritius ViSa Mauritius
Tobacco leaves which are used for manufacturing cigarettes are
cultivated by the tobacco industry themselves, throughout the world.
If the tobacco industry is honestly keen in stopping the availability of
counterfeit cigarettes on this earth, they should first of all stop
cultivating tobacco leaves. One of the strategies that the industry
employs to protect their business is to misuse the illicit cigarette
in...
Tobacco leaves which are used for manufacturing cigarettes are
cultivated by the tobacco industry themselves, throughout the world.
If the tobacco industry is honestly keen in stopping the availability of
counterfeit cigarettes on this earth, they should first of all stop
cultivating tobacco leaves. One of the strategies that the industry
employs to protect their business is to misuse the illicit cigarette
industry.
Also they use the illegal cigarette industry to get the maximum
support from the government, i.e. to justify the industry promotions being
launched to capture customers, especially the children, to reduce prices,
to increase the market share etc.
In many countries, tobacco industry is a monopoly. Therefore there is
no question of price decrease or the need to justify promotions. As such
the illegal cigarette industry represents as an invisible competitor. For
instance, in Sri Lanka Ceylon Tobacco Company (CTC) always insists the
government not to increase the price of cigarettes in an affecting amount,
put forwarding logics that such decision would increase the consumption
and availability of illegal cigarettes.
They then say that the government's revenue would go down, if the
availability of illegal cigarettes increases due to price increase of
legal cigarettes. As they put such arguments the government does not
increase the price of legal products at all.
The tobacco industry needs promotions to increase the consumption.
But amidst the protest being made against the company by several sectors
in the society, the government has to control it even to a certain extent.
In such circumstances carrying out of such promotions by the industry
effectively is not that easy. Therefore they always pressurize the
government that it needs to promote the legal industry in order to
decrease the market for illegal cigarettes.
The best strategy and the support for the tobacco industry throughout
the world is the illegal industry. It is how the industry earns huge
amounts of money to spend for their propaganda work, especially to capture
politicians, policy makers, media personnel etc. It is a known secret that
the illegal cigarette industry is being maintained by the legal industry!
I had the opportunity to interview the officials of the illegal cigarette
manufacturers in Sri Lanka and they revealed that it was the legal
cigarette industry who supported them to set up the industry and even raw
material and machinery were provided to them by the legal industry at the
initiation process of the business.
Finally, with regard to the statement made by the Managing Director
of British American Tobacco, Nigeria, "tobacco use is risky, but
counterfeit cigarettes are lethal." Mr. Manager could you please define
the extent of this risk and how would the risk affect the consumer and the
benefit of the product? Also, when you say ¡°lethal¡± how do you justify
this?
Ron Davis finds my analogy weak when I liken employers not hiring
smokers (because as a class they take more time off work) to not hiring
women of child-bearing age (because they may become pregnant or take time
off for childcare). He notes that in the USA (as indeed in many nations)
there are laws outlawing labour discrimination on the basis of sex or age,
but not discrimination based on smoking status. Some nations also...
Ron Davis finds my analogy weak when I liken employers not hiring
smokers (because as a class they take more time off work) to not hiring
women of child-bearing age (because they may become pregnant or take time
off for childcare). He notes that in the USA (as indeed in many nations)
there are laws outlawing labour discrimination on the basis of sex or age,
but not discrimination based on smoking status. Some nations also forbid
discrimination based on sexual preference, race and religion in such laws.
He adds that sex and age are immutable, whereas smoking is at least in
principle amenable to choice.
I would defend my analogy by pointing not to the differing legal
status of smoking and sex (or age) discrimination, but to the parallel
matters of principle that have been responsible for the outlawing of
various forms of discrimination. We have laws preventing sex, age and race
discrimination because to allow discrimination would be to allow non-
relevant and unjust barriers to intrude in decisions about capability and
suitability to do a job.
This principle is precisely that which I believe applies to the class
“smokers”. As I argued, while it is true that smokers as a class take more
time off (to smoke and when ill) than do non-smokers, this is not the case
for every smoker.
In my response to Nigel Gray, I was careful to emphasise that
employers have every right to select staff whose presentation and skills
accord with the needs of employers. I would concur completely with Ron’s
examples of some restaurateurs being unwilling to hire people with strange
appearance as being legitimate (although in my suburb, such appearance is
fast becoming mandatory!). However, such policies are all about work
performance and company image. Hair colour is seldom changed every
evening, but many smokers only smoke away from work.
Ron raises the practice of insurance companies levying higher policy
rates based on “class averages” (such as higher premiums for young
drivers, despite many individual young drivers having excellent driving
records and abilities), and argues that by the same reasoning, employers
could take the same “class risk” attitude to smokers. Again, I believe his
argument here is imperfect. It would, as he argues, be “impractical or
impossible” to predict which young drivers will crash, but it is not
impractical or impossible for an employer with good management systems and
skills to know which smoking employees are a drain on a company and which
are not. Indeed, many insurance companies annually adjust individual
policies depending on the insured person’s claims in a preceding period.
I have no problem whatsoever with an employer insisting that
employees do not smoke at work for reasons of corporate image, safety or
of course harming others. But what of the many highly valued and
productive smokers who only smoke away from work – the people I am talking
about in this debate? If this debate were oxygenated and it became common
practice for employers to not hire smokers, it is conceivable that this
“movement” would add extra pressure on smokers to quit. That would be a
good outcome, but it would be achieved by coercion which I do not regard
as ethical in the absence of preventing harm to others.
Ron also rejects what he calls my slippery slope analogies whereby
employers would -- by evoking the same concerns -- have the right to
enquire about whether employees engaged in high risk activities such as
skiing, motor-cycle riding, or body contact sport such as the game of
rugby (in which Australians dominate all other nations!), all of which
significantly increase the risk of time being taken off work. While Ron’s
philosophy professor shows how slippery slope arguments can violate logic,
I remain unconvinced that there are any errors in logic in an employer
reasoning “smokers are at higher risk of illness and time-off work. I will
not hire them” and “motorcyclists have a high risk of injury and
disability. I will not hire them.” My facetious example about voting for
conservative politics was intended as a reductio ad absurdum example of
how far employees might take an assumed right to know about out-of-working
-hours activities that might impact on employment.
I believe that out-of-hours smoking should be regarded as relevant to
a decision on employment of an individual (hiring or firing) only when
it can be shown to be affecting work performance. I have few problems with
an employer firing an employee whose record of sick leave was
significantly higher than normal, particular where that sick leave was
attributable to a smoking which I agree with Ron, should not be construed
as something that is impossible to stop.
It's so sad that you have joined your CEO to pretend
not to know the facts here.
The products you produce in your factory are extremely
poisonous apart from being addictive. All tobacco
products irrespective of where they are coming from
contain considerable quantities of nicotine and
alkaloids. It has also been proven that tobacco from
low or high yield cigarettes contain the sam...
It's so sad that you have joined your CEO to pretend
not to know the facts here.
The products you produce in your factory are extremely
poisonous apart from being addictive. All tobacco
products irrespective of where they are coming from
contain considerable quantities of nicotine and
alkaloids. It has also been proven that tobacco from
low or high yield cigarettes contain the same amounts of
nicotine. Moreover, it is not new that your CEO is
denying the toxicity of your product. Can you ever
have a 'less toxic product?' A toxin is a toxin either
it is being produced in a cosy environment or smuggled
through the borders.
You and I know that the romance that used to exist
between the Nigerian government and BAT would not
permit a fair assessment of the toxicity of your
product. I am not even sure of when your so-called SON
certification was issued. Or have you forgotten the
fanfare and jamboree that heralded the entry of your
company into Nigeria? The Federal Government of
Nigeria on September 24, 2001, at what it called the
first official Investment Summit, signed a Memorandum
of Understanding (MOU) with your company,
British-American Tobacco (BAT). Under the agreement,
the tobacco giant was to invest a whopping $150
million in the country. It was part of government’s
search for “foreign investors.” According to a widely
advertised statement by your company, the investment
was “to build a state-of-the-art factory in Ibadan,
Oyo State, Nigeria. According to government, the
investment was to be an integrative process that will
impact on all aspects of the tobacco industry, from
leaf growing to the manufacture and distribution of
tobacco products.” The factory, sited on the very
strategic Lagos-Ibadan expressway, and sitting on a
large expanse of land of approximately 26.5 hectares
has since been rolling out its toxins. The issue of
whether tobacco contributes to ill-health and causes
cancer and other diseases has always been denied by
the industry’s baron for a very long time.
I know the Nigerian government knows better now and this
is why the government signed the FCTC and banned advertising
of tobacco on billboards and media.
We are aware of the activities of BAT to
undermine the process of ratification of the FCTC in
Nigeria and I must say that the latest statements by
your CEO give us the opportunity to ask President
Olusegun Obasanjo that the time to ratify the FCTC in
Nigeria is now! This insult must stop. I know your
CEO's statements is another opportunity that will make
OBJ (President Obasanjo) regret having listened to
his advisers that asked him to open the door for BAT
in the first place. I'd advise you to start looking
for another job.
Cigarettes produced in your factory are not only
risky but equally LETHAL.
Time is up for tobacco in Nigeria.
Regards,
Babalola Faseru,
University College Hospital,
Ibadan, Nigeria.
Kehinde Johnson, Corporate & Regulatory Affairs Director, British
American Tobacco (Nigeria) Limited, writing on behalf of Dr. Chris
Proctor, of BAT's UK headquarters, fails to respond to the principal
questions asked by Professor Simon Chapman of the University of Sydney and
editor of the journal Tobacco Control.
In his posting to Tobacco Control's e-letters page, Mr. Johnson
relies heavily on the judgment o...
Kehinde Johnson, Corporate & Regulatory Affairs Director, British
American Tobacco (Nigeria) Limited, writing on behalf of Dr. Chris
Proctor, of BAT's UK headquarters, fails to respond to the principal
questions asked by Professor Simon Chapman of the University of Sydney and
editor of the journal Tobacco Control.
In his posting to Tobacco Control's e-letters page, Mr. Johnson
relies heavily on the judgment of the Standards Organisation of Nigeria
(SON), which has allegedly analysed some counterfeit cigarettes and
"confirmed that they have hugely higher levels of tar and nicotine beyond
the prescribed limits for tobacco products in Nigeria which constitutes
serious health hazards to unsuspecting Nigerians."
First, Mr. Johnson does not specify what "hugely higher" means and
provides no scientific basis on which to judge how much such counterfeit
cigarettes would increase risk for regular smokers. Second, although the
SON website describes its import inspection procedures and explains that
it issues "poor quality products reprimands," SON does not post any values
for 'safe' tobacco products among its hundreds of Nigerian Industrial
Standards (NIS).
The International Agency for Research in Cancer lists the following
as carcinogens present in tobacco products: aromatic amines (e.g. 4-
aminobiphenyl), polycyclic aromatic hydrocarbons (e.g. benzo[a]pyrene),
tobacco-specific nitrosamines, benzene, acrylamide and acrylonitrile. Are
these less dangerous when present in what Mr. Johnson terms "genuine
brands manufactured in factories under [SON] control and supervision"?
There are also hundreds of known additives to tobacco products, many
of which make tobacco products less harsh on the throat and, therefore,
easier to inhale, especially for first-time smokers, largely drawn from
the youth population. Therefore, could those "hugely higher levels of tar
and nicotine" referred to by Mr. Johnson not actually make counterfeit
cigarettes less dangerous, rather than more so, by discouraging
inhalation?
Mr. Johnson presents no clear evidence on disease risk, one way or
the other. He does, however, refer readers to the BAT Nigeria website,
where the section on smoking and health allows that tobacco use incurs
"real risks of serious diseases such as lung cancer, respiratory disease
and heart disease". However, the website information proclaims serious
doubts about the worth of epidemiological studies and notes that science
has "up till date, not been able to identify biological mechanisms which
can explain with certainty the statistical findings linking smoking and
certain diseases. Nor has science been able to clarify the role of
particular smoke constituents in these disease processes."
First, that is not entirely true, as some smoking disease mechanisms
have, in fact, been identified. However, a larger question again goes
begging: If BAT and its Nigerian subsidiary have so many doubts about the
"lack of complete understanding at a biological level of the disease
mechanisms and role of particular smoke constituents [that] creates
uncertainty for efforts to design less risky cigarettes", how can the firm
criticise counterfeit cigarettes? If you do not deny that thirty, forty or
fifty years of smoking will lead to lung and other cancers, plus
respiratory and heart disease, nor do you deny there are severe neonatal
risks from smoking in pregnancy (though nothing is said about the passive
smoking risks from parental tobacco use over much shorter spans), then,
again, how much riskier are those counterfeit products? Will they kill
more smokers in twenty years rather than thirty or forty? Will they lead
to 5.9 million tobacco deaths a year rather than the 4.9 million currently
estimated by the World Health Organization?
How exactly are you "working in collaboration with the Nigerian
government to support [informing people of the dangers of smoking] through
various initiatives" and, finally, when does merely "risky" behaviour
become "lethal"? Many lives depend on your answers.
BAT Nigeria Limited
Mr. Kehinde Johnson
Corporate & Regulatory Affairs Director
Re: Risky v. Lethal Cigarettes
Mr Johnson:
I am the former Vice President of R&D of one of your sister companies.
I read your response to Professor Chapman on the issue that counterfeit cigarettes are lethal, whereas genuine brands that you manufacture under controlled supervision are only "risky". Are you i...
BAT Nigeria Limited
Mr. Kehinde Johnson
Corporate & Regulatory Affairs Director
Re: Risky v. Lethal Cigarettes
Mr Johnson:
I am the former Vice President of R&D of one of your sister companies.
I read your response to Professor Chapman on the issue that counterfeit cigarettes are lethal, whereas genuine brands that you manufacture under controlled supervision are only "risky". Are you inferring that your manufactured product is safer or when used as intended does not kill?
Does your so called "risky" cigarette contain less combustion by-products, such as CO, polycyclic hydrocarbons, polyaromatic hydrocarbons, tobacco specific nitrosamines or any less human carcinogens?
In the manufacture of your product do you continue to use intentional additives on the tobacco, such as glycerol, chocolate, simple sugars, honey or ammonia based chemicals that when pyrolyzed produce a less toxic tar or less free nicotine?
Are the cigarettes that you manufacture under controlled manufacturing conditions free of burn retardants or accelerants to control the burn rate of the cigarette?
Are you inferring that when you manufacture your "risky" product that you remove the entire natural soil flora (microbes) and the unintentional additives derived from the agronomic process? In other words do you sterilize the tobacco prior to formulation into a cigarette to eliminate all the soil microbial spores or wash out the residual pesticides and herbicides? Have you cultured your tobacco after it has been made into a cigarette? Or have you assayed for residual agronomic pesticides or herbicides?
I also glean from your response that Mr. Hodgson agrees with the statements of SON or otherwise would not have repeated them. Does Mr. Hodgson have an independent thought on the issue or was he just conveying that the BAT Nigeria manufactured product is safer and therefore deliberately misleading the public?
Do you not have a moral imperative to clearly and succinctly communicate that all cigarettes are lethal or does this honesty not fall within the domain of your corporate responsibility statements?
To the excellent article by Bero, Glantz and Ling one may add the
classical observation of RE Thornton of BAT about women's smoking behavior
(1):
"[G]iven that women are more neurotic than men it seems reasonable to
assume that they will react more strongly to smoking and health
pressures.... [T]here may be a case for launching a female oriented
cigarette with relatively high deliveries of nicotine...."
To the excellent article by Bero, Glantz and Ling one may add the
classical observation of RE Thornton of BAT about women's smoking behavior
(1):
"[G]iven that women are more neurotic than men it seems reasonable to
assume that they will react more strongly to smoking and health
pressures.... [T]here may be a case for launching a female oriented
cigarette with relatively high deliveries of nicotine...."
(1) Thornton RE. "The Smoking Behavior of Women Report No. RD 1410."
12 November 1976. British American Tobacco/ Brown adn Williamson. Bates
No. 650008159/8191 (at -8183-3)
I am responding to your email to Dr. Chris Proctor concerning media
remarks
attributed to Richard Hodgson, Managing Director of British American
Tobacco Nigeria that, "tobacco use is risky but counterfeit cigarettes are
lethal" which was published in ThisDay of January 16 2005
The Standards Organisation of Nigeria (SON) is the regulatory body
focusing
on tobacco control in Nigeria,...
I am responding to your email to Dr. Chris Proctor concerning media
remarks
attributed to Richard Hodgson, Managing Director of British American
Tobacco Nigeria that, "tobacco use is risky but counterfeit cigarettes are
lethal" which was published in ThisDay of January 16 2005
The Standards Organisation of Nigeria (SON) is the regulatory body
focusing
on tobacco control in Nigeria, and SON has joined with the Nigerian
Customs
Service to try and eliminate counterfeit cigarettes.
SON has been analysing some seized counterfeit cigarettes, and their
published results confirmed that they have hugely higher levels of tar and
nicotine beyond the prescribed limits for tobacco products in Nigeria
which
constitutes serious health hazards to unsuspecting Nigerians.
The Head of Enforcement unit of SON has publicly described
counterfeit
cigarettes as lethal and suggested that they are more dangerous than
regular cigarettes. Furthermore SON has consistently communicated to the
Nigerian public through the media that smokers of counterfeit cigarettes
which usually contain microbes are exposed to a higher risk than those who
consume genuine brands manufactured in factories under their control and
supervision.
BAT Nigeria's factories manufacture products under the regulatory
supervision of SON
Mr Hodgson reported remarks at an interactive session with media
editors,
was made in the context of SON's views on the issue above.
Our position on smoking and health is well documented and published
on our
website www.batnigeria.com
We think national governments are the most respected voice in
informing
people of the dangers of smoking and in British Anrican Tobacco Nigeria,
we
are working in collaboration with the Nigerian government to support this
through various initiatives.
With kind regards
Kehinde Johnson
Corporate & Regulatory Affairs Director
British American Tobacco (Nigeria) Limited
35 Idowu Taylor Street
Victoria Island
Lagos
email: kehinde_johnson@bat.com
I believe that colleges and universities must provide ethical
leadership in research development, implementation, reporting and funding
(not accept tobacco industry research money or researchers that do). They
should not support tobacco industry investment or funding for
institutions, seminars or fiduciary requirements. Any and all tobacco
industry cooperation or collaboration is irresponsible because of the
underlying...
I believe that colleges and universities must provide ethical
leadership in research development, implementation, reporting and funding
(not accept tobacco industry research money or researchers that do). They
should not support tobacco industry investment or funding for
institutions, seminars or fiduciary requirements. Any and all tobacco
industry cooperation or collaboration is irresponsible because of the
underlying business motives and practices of the industry, past and
present.
While there is a long way to go, I have advocated the following for
educational institutions in the Asia-Pacific region:
1. Advocate and institutionalize a policy barring researchers and
research units from accepting funding from the tobacco industry or
organizations funded by the tobacco industry.
2. Advocate and institutionalize a tobacco free campus including a
universal ban on tobacco product sales and use both indoors and out on the
campus or at any event with institution sponsorship or co-sponsorship.
3. Advocate and institutionalize divestment of financial resources from
the tobacco industry, including investments for academic foundations,
scholarship funds, retirement/pension funds and credit unions.
4. Advocate and institutionalize certificate level training on ethical
research including requirements/prohibitions on tobacco industry research.
5. Advocate and institutionalize strong penalties for violation of ethical
research standards including conducting tobacco industry research.
A March 18th article in the Chronicle of Higher Education in the US
pointed out that tobacco companies are promoting smoking to college
students and "show no sign of stopping" this practice. Young people
deserve better than their institutions of higher learning aiding and
abetting tobacco industry promotions, addictions and deaths. It is about
time that accountability mean something more than how much money can be
made in the short run, at the expense of the wellbeing of the next
generation. But are colleges and universities willing to really address
the known fraud of the tobacco industry or only pretend they are doing so
with opportunistic leadership moves?
On Jan 19 2005, having been alerted to the extraordinary statement
shown on the cover of this issue of the journal (April 2005), I emailed
the letter below to Dr Chris Proctor at BAT in the UK. He replied the next
day asking when I would need the information sought. I replied immediately
that I would like it within a week. No further response has ever been
received from Dr Proctor.
On Jan 19 2005, having been alerted to the extraordinary statement
shown on the cover of this issue of the journal (April 2005), I emailed
the letter below to Dr Chris Proctor at BAT in the UK. He replied the next
day asking when I would need the information sought. I replied immediately
that I would like it within a week. No further response has ever been
received from Dr Proctor.
I invite him here publicly to now reply.
Simon Chapman
Editor
Dr C Proctor
BAT
UK
Dear Dr Proctor,
On January 16 2005, in an article in "This Day" (Lagos) headlined
'5.3m Nigerians Smoke Tobacco' a comment ("tobacco use is risky but
counterfeit cigarettes are lethal") was attributed to Mr Richard Hodgson,
Managing Director of British American Tobacco (BAT) Nigeria.
We intend commenting on this statement in a forthcoming issue of
Tobacco Control and would be grateful if you would answer the following
questions.
1. What is it that makes counterfeit cigarettes "lethal" but "tobacco
use" only "risky"?
2. Is Mr Hodgson's position consistent with official BAT global policy on
communicating with the public about the health consequences of smoking?
3. Do you believe that Mr Hodgson's statement would be interpreted by the
ordinary reader to mean that "use" of BAT's tobacco products in Nigeria
is less dangerous to health than the use of counterfeit cigarettes?
4. Do you agree that this statement is without foundation and so grossly
misleading and irresponsible?
5. What has BAT done to issue a public retraction of Mr Hodgson's highly
misleading statement and to discipline him?
My position in this debate, which has been a difficult one for the
tobacco control community, is that I neither condone nor condemn hiring
policies that favor non-smokers. However, I do support the employer's
right to adopt such a policy if the employer so chooses. I believe this
position—which is intermediate between the opposing views espoused by
Nigel Gray and Simon Chapman—is the most appropriate and defensible
po...
My position in this debate, which has been a difficult one for the
tobacco control community, is that I neither condone nor condemn hiring
policies that favor non-smokers. However, I do support the employer's
right to adopt such a policy if the employer so chooses. I believe this
position—which is intermediate between the opposing views espoused by
Nigel Gray and Simon Chapman—is the most appropriate and defensible
position for tobacco control advocates to articulate.
Many years ago the tobacco industry was lobbying forcefully in the
United States for passage of state laws banning employment discrimination
against smokers. From 1989 to 1993, 25 states enacted such "smokers'
rights" laws. Malouff et al published an analysis of those laws in TOBACCO
CONTROL in 1993,[1] and these authors provided a nice summary of reasons
why some employers might wish to hire only non-smokers:
"Why would anyone prefer to hire non-smokers? The answer may differ
from organisation to organisation and supervisor to supervisor. Some
possible reasons include evidence that smokers as a group have more job
accidents, suffer more work injuries, and create more disciplinary
problems at work than do non-smokers; a desire of some companies to avoid
worker compensation claims for lung damage that could be due to either
smoking or an occupational hazard, such as fighting fires; a desire for
physically fit employees, for jobs such as police officer and firefighter;
a desire to avoid the appearance of hypocrisy, when a smoker works in a
job to prevent or treat dependence on nicotine or some other addictive
substance; a need to maintain a super-clean workplace free of even the
tobacco on the breath of employees; the higher cost of employer-subsidised
life, health, disability, and worker compensation insurance when some
employees are smokers; the belief that smokers take more sick leave; the
fear that occupational toxins such as asbestos may interact with smoking
(even if limited to off-work time) to increase risks among employees; and
the desire of some religious organisations to hire employees who follow
off-work the non-smoking tenets of the religion. Also, the US tradition
has long been one of employment at will, meaning that employers can hire
and fire whomever they like for whatever reason they want. For instance,
employers might choose to hire employees who are relatives, who look or
act a certain way, or who seem to desperately need a job. A major
limitation on this employer freedom in modern times has been a series of
federal and state civil rights laws that prohibit employment
discrimination based on race, sex, age, and disability." (citations
omitted)
As noted by Malouff et al, the US Constitution and federal and state
civil rights legislation protect against discrimination based on race,
ethnicity, gender, age, and disability. To accord smokers (as a class) the
same level of protection against discrimination, as "smokers’ rights" laws
do, would be dangerous in my judgment.
Simon Chapman dismisses Nigel Gray’s argument that smokers are less
productive (as a class) than non-smokers, because "many smokers do not
take extra sick leave or smoking breaks." However, "discrimination" based
on class averages may be justifiable when measurement of individual
behavior or risk is impractical or impossible. For example, I pay much
higher automobile insurance premiums because I have two teenage sons who
drive, even though they may (theoretically) be the best drivers around.
Installing alarm systems and smoke detectors in homes reduces premiums for
homeowners’ insurance, even though some people don’t use or maintain these
devices after installation. Insurance companies assess risk and develop
fees based, in large part, on actuarial data and aggregate experience.
Employers may wish to use the same approach. It is more practical for
employers to refuse to hire ALL smokers, than to refuse to hire only
smokers who have worse health or higher risk of disease.
In defense of his position, Simon offers the analogy that employers
might refuse to hire younger women because they might get pregnant and
take maternity leave, and more time off later to look after sick children.
In the US, that policy would constitute illegal discrimination based on
age and gender, and would violate the spirit (if not the letter) of the
federal Pregnancy Discrimination Act.[2] The analogy is further weakened
by the fact that age and gender are inborn and immutable characteristics
(except for transgender surgery), whereas smoking is neither. Yes, of
course, smoking is addictive; but effective treatments exist and millions
of smokers have been able to quit.
Simon also presents a "slippery slope" argument that "employers might
... draw up a check list and interrogate employees as to whether they
engaged in dangerous sports, rode motorcycles, or voted for conservative
politics." A philosophy professor has called this type of argument an
illegitimate application of reductio ad absurdum.[3] Yes, all manner of
discrimination in employment occurs today, and will occur tomorrow, but
most of that discrimination is sub rosa. A restaurateur may not hire
waiters with purple hair and pierced lips, even if those characteristics
aren’t mentioned in the company’s employment manual. The issue at hand,
though, is EXPLICIT "discrimination" spelled out in corporate policy.
Weyco, Inc, a health-benefits management company based in my home state of
Michigan, informed its employees about the company’s new "smoker-free"
workplace policy 15 months before implementation.[4] It’s hard to imagine
widespread adoption of similarly announced hiring policies based on
Simon’s example of political ideology. (A rare exception might occur when
such ideology is central to the job’s responsibilities—for example,
editorial writers for conservative newspapers.)
Another problem with this "slippery slope" argument is that it
implies—wrongly, in my judgment—that employers cannot be trusted to adopt
hiring policies based on a careful consideration of the merits and
demerits of each policy option. A health insurer may decide to
"discriminate" against smokers—and smokers only—for reasons outlined by
Malouff et al.[1] The National Basketball Association’s standard player
contract prohibits motorcycle riding, a recent violation of which caused
disastrous consequences.[5] Contracts with theatrical stars often
prohibit dangerous activities such as hang gliding and skydiving because
of the difficulty of hiring an acceptable substitute when injuries
occur.[6] In each case, the employer chooses hiring policies tailored to
its own needs and circumstances, and cascades of discriminatory practices
rarely (if ever) flow down that less-than-slippery slope.
Sugarman discussed many types of off-duty worker behavior that may
clash with employers’ interests, including personal (social/sexual)
relationships, civic and political activities, leisure activities,
moonlighting, characteristics of daily living (eg, health behaviors,
personal appearance), and illegal acts.[6] The rationale for addressing
these behaviors in corporate hiring policies may be strong in some cases
and weak in others. But as Seligman noted, "Employers are not always
right, but they are guaranteed to do better than regulators and judges in
deciding which employees will be the most productive."[7]
Currently 30 states in the US have "smokers’ rights" laws on the
books.[4] Nevertheless, an estimated 6,000 employers no longer hire
smokers, according to the National Workrights Institute.[8] That number
may seem large, but it’s only a small fraction of the 20.8 million
businesses in the country.[9] Smokers can still find jobs, and employers
can decide for themselves whether to employ them. Tobacco control
advocates should oppose laws that give smokers special protection similar
to the protections afforded to groups defined by race, ethnicity, gender,
age, and disability.
Ronald M. Davis, MD
Director
Center for Health Promotion and Disease Prevention
Henry Ford Health System
Detroit, Michigan, USA
1. Malouff J, Slade J, Nielsen C, Schutte N, Lawson E. US laws that
protect tobacco users from employment discrimination. Tobacco Control
1993; 2: 132-138. http://tc.bmjjournals.com/cgi/reprint/2/2/132.pdf
2. US Equal Employment Opportunity Commission. Facts about pregnancy
discrimination. http://www.eeoc.gov/facts/fs-preg.html (accessed 25 March
2005)
3. Thompson B. Bruce Thompson’s fallacy page: slippery slope.
http://www.cuyamaca.net/bruce.thompson/Fallacies/slippery.asp (accessed 25
March 2005)
4. Peters JW. Company’s smoking ban means off-hours, too. New York
Times, 8 February 2005: C5.
5. Dodd M. Bulls' Williams likely to miss season after accident. USA
Today, 24 June 2003.
http://www.usatoday.com/sports/basketball/nba/bulls/2003-06-23-williams-
injuries_x.htm (accessed 25 March 2005)
6. Sugarman SD. "Lifestyle" discrimination in employment. Earl Warren
Legal Institute, 27 June 2002. Paper 1.
http://repositories.cdlib.org/ewli/1 (accessed 25 March 2005)
7. Seligman D. The right to fire. Forbes, November 2003.
http://www.forbes.com/forbes/2003/1110/126.html (accessed 25 March 2005)
8. Ozols JB. A job or a cigarette? Newsweek, 24 February 2005.
http://msnbc.msn.com/id/7019590/site/newsweek (accessed 25 March 2005)
9. US Census Bureau. 1997 Economic census: minority- and women-owned
businesses, United States. http://www.census.gov/epcd/mwb97/us/us.html
(accessed 25 March 2005)
I had a question about your measure of recall, which in effect
requires the ability to think abstractly and verbalize to in fact 'prove'
to the interviewer that the ad and its message were seen, heard, and
'digested'.
Our organization in NY, the Advertising Research Foundation, which
may not be familiar to you, has embarked on a series of studies about the
role tha...
I had a question about your measure of recall, which in effect
requires the ability to think abstractly and verbalize to in fact 'prove'
to the interviewer that the ad and its message were seen, heard, and
'digested'.
Our organization in NY, the Advertising Research Foundation, which
may not be familiar to you, has embarked on a series of studies about the
role that emotion plays in advertising effectiveness. As such, we are
growing in confidence regarding the use of 'forced recognition' of ads to
tap into a non-verbal and emotional layer of impact that is, in essence,
stripped away by the more cognitive-based recall methods. In short, we
feel these two techniques are measuring two different things - one, a
perhaps mostly unconscious recognition that remains in memory, and does
affect behavior - and, of course, the more common recall method, which is
definately precise if one wants to 'force' the respondent to prove they
have seen an ad, and even understood the message.
This forced recognition is fairy easy to do now with the use of
online surveys - to show the ad in as close as possible to its natural
setting.
Our concern is, particularly at younger ages (12-18)where teens are
not necessarily fully cognitively developed, that there may be two things
happening to descrease the accuracy of findings, and subsequent linkage to
ad costs:
1. respondents, particularly younger ones, who cannot verbalize an ad
which may have affected them deeply from an image perspective, will be
terminated from the surveys. Or, if forced by an interviewer to elucidate,
they may drop out. This results in the stickly problem of completely
missing, non-randomly, as you know a horrible state we try and avoid. And
nearly impossible to back track and figure out.
2. For all respondents, the fact that the early level of processing -
which we call recognition - is in effect over ruled with the recall line
of questioning, we may be missing a substantial opportunity to capture the
effect of the image, emotional, and unconscious on the effect of the ad on
a respondent. If respondents are merely presented the ad in, for example,
an MPEG file, and asked if they have seen it, you recieve a purer and
broader measure of the potential effect of the ad. In short, with
recongition you will get accuracy, with recall, precision.
The ARF has a concern with using media weight (here called GRPs) as a
measure for predicition purposes. In our opinion, media weight represents
what was bought - it is better, in our opinion, to focuse on what you
'got' in the form of psychological GRPs - frequency and reach. Then the
link to and justification for relating the cost of media to the 'results'
of the advertising can be calculated with more confidence.
I am very curious to hear your response to this, for my own
edification, and to share with my colleagues here. As you could guess, we
all operate in 'silos of knowledge' and it would be terrifcally
fascinating to see how we can cross -educate each other.
The highest nicotine concentrations of this study have been found in
Austria. Some background for this is given by
http://tc.bmjjournals.com/cgi/content/full/14/1/3. Most amazing, however,
was that these results had been presented to the Austrian press without
causing a reaction. A study of Moshammer et al. (2004)
Int.J.Hyg.Environ.Health 207, 4, 337-343 even showed high correlations of
nicotine with active particle sur...
The highest nicotine concentrations of this study have been found in
Austria. Some background for this is given by
http://tc.bmjjournals.com/cgi/content/full/14/1/3. Most amazing, however,
was that these results had been presented to the Austrian press without
causing a reaction. A study of Moshammer et al. (2004)
Int.J.Hyg.Environ.Health 207, 4, 337-343 even showed high correlations of
nicotine with active particle surface, indicating not only chronic risk
for employees but also acute risk for customers
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=15471097>,
but at a press conference on the occasion of the annual meeting of the
Austrian Society for Occupational Medicine there was little interest in
these news and journalists continue to write on the dangers of fine
particulates without mentioning indoor pollution by cigarettes. This can
only partly be explained by a high proportion of smoking journalists and
the business of the editors with tobacco advertising (which largely will
come to an end in Europe in July). Another main reason is to be seen in
the joint distribution of cigarettes and newspapers by tobacconists in
Austria. This is another reason why we should attempt to restrict the sale
of tobacco to stores licensed to sell tobacco products only. Nobody would
have to enter these places to buy newspapers, no child would have to go
there for a pencil and see the tobacco ads, which could be restricted to
the interior of stores for the addicted.
I have been a smoker for many years and have never attempted or had
the desire to stop.
I will willingly compare my health care costs with any non-smoker.
I will challenge any non-smoker to match my absenteeism due to
illness work record for the past 40 years.
Editor's comment: I can introduce the writer to alcoholics who have never had a car crash; to 5 winners in every game of Russian roulette; and to a person who walked across a busy highway blindfolded and did not get hurt. By the writer's logic, all these activities are not dangerous.
Wasim Maziak has concerns about the small number of papers published in the journal from less developed nations (LDCs) and urges that we send more LDC papers out for review and not reject them without review. The editors share his wish to see more papers in the journal from LDCs, but there are two problems. First, we don’t get very many submissions from LDCs, and second, like those submitted from authors in wealthy nations, we...
Wasim Maziak has concerns about the small number of papers published in the journal from less developed nations (LDCs) and urges that we send more LDC papers out for review and not reject them without review. The editors share his wish to see more papers in the journal from LDCs, but there are two problems. First, we don’t get very many submissions from LDCs, and second, like those submitted from authors in wealthy nations, we receive many papers which we reject for a variety of reasons that I summarized in my editorial.
The most common reason we reject papers without review is that they are describe very local populations and don’t take readers into any original areas that have obvious implications for others. A typical such paper might be a smoking prevalence or knowledge/attitudes/correlates of smoking study undertaken on the staff of a hospital, a group of medical students from one university or a population sample. We reject such papers all the time no matter where they come from, but unfortunately they mostly come from LDCs.
Often these papers are well done, but they rarely say anything different other than reporting on another population in another place. Dr Maziak suggests that such papers “are likely to have implications on a wide sphere of health and economic research, usually transcending the country in focus.” I’m sorry to say that they rarely do. If we were to run such papers, we would clog up the journal with them very quickly which would mean we would be able to publish less of the papers that our judgement is increasingly showing to be of relevance to others, give our upwardly spiraling impact factor.
We do not send them out for review because we do not want to waste reviewers’ valuable time if we have no interest in publishing such papers.
Journals are not the only place that such data can be published. Websites and WHO collections allow people who are interested in such studies to gain access to such data.
The table below shows the distribution of all submissions to the journal since January 1992. The data has been adjusted to take into account papers which have been submitted as part of specially commissioned supplements, and so the third column shows the acceptance rate by country of origin of corresponding author for all papers submitted for routine consideration by the journal. These data do not of course reflect papers which are still under review and they do not take account of papers written by authors registered in countries whose papers concern another country. This often happens in cases where an author from (say) Nigeria, is working in the USA or where there are multiple authors from different countries.
The great majority of our submissions come from researchers in wealthy nations, particularly the USA, Australia, Canada, Great Britain, Scandanavian nations, and New Zealand. This undoubtedly reflects the extent of research support available in those nations and so the “health” of the research enterprise on tobacco control in those nations.
Interestingly, we have received 25 submissions from Turkey. Nearly all of these have been rejected as they were either very small, parochial studies (typically smoking prevalence in special, local populations) or had other problems.
All authors submit their paper with the hope that it will be published. The unavoidable fact of life about all (good) journals is that they receive far more papers than they can ever publish. So culling must occur. Rejection does not occur only on the basis of study quality. Competent but dull papers fare worse than competent but interesting papers. Papers that cause the editorial group to say "we already know this" do worse that those where we say "this is something new and interesting."
I reiterate that we would love to publish more papers from LDCs, but as Dr Maziak agrees, we should not do this at the expense of quality.
Country or region
Submissions
Acceptances
Adjusted acceptance rate
USA
364
150 (41.2)
28.6
Europe incl Turkey
135
22 (16.3)
16.3
Australia & New Zealand
119
85** (48.7)
37.8
Asia
89
22*** (24.7)
12.4
UK
78
24**** (30.8)
24.3
Canada
44
14 (31.8)
31.8
Middle East
19
0 (0)
0
Latin America
9
2 (22.2)
22.2
Africa
8
3 (37.5)
37.5
Total
865
322 (37.2)
25.4
Notes:
* includes 46 papers accepted for commissioned supplements
** includes 40 papers accepted for commissioned supplements
*** includes 11 papers accepted for commissioned supplements
***** includes 5 papers accepted for commissioned supplements
I start by expressing my earnest pride of Tobacco Control and the
status it acquired in a record time. I am certainly grateful for making it
access-free for developing countries. However, I have some reservation
regarding TC editorial policy that I have mentioned before, and for which
I want to provide my motivations, speaking only about research articles.
Obviously the quest for quality cannot be debated and...
I start by expressing my earnest pride of Tobacco Control and the
status it acquired in a record time. I am certainly grateful for making it
access-free for developing countries. However, I have some reservation
regarding TC editorial policy that I have mentioned before, and for which
I want to provide my motivations, speaking only about research articles.
Obviously the quest for quality cannot be debated and editors should
aim to include only high quality articles in their journals. Other
criteria for paper consideration however, such as interest, relevance, and
impact can be subjective and indeed debatable. We have to remember that
the biggest share of the smoking burden falls on developing countries and
that this situation is projected to worsen considerably in the coming
years. A quick look at published research articles in TC gives the
opposite impression, as they mostly pertain to developed countries. Of
course simple epidemiological studies are not interesting to the editors
as well as readers outside the relevant country, but the impact of such
research should be equally considered. For example, reliable simple
epidemiologic figures on health risks from a certain country are likely to
have implications on a wide sphere of health and economic research,
usually transcending the country in focus. Lessons from studying the
global burden of disease and risk factors, as well as understanding the
impact of certain risk factors (ETS) globally have stated time after time
that a major limitation of our today's knowledge lies in the lack of
reliable information from most of the world, the developing world. How
about the other side of the coin? I claim that a significant proportion of
high profile research currently published in TC concerns tobacco control
issues relevant only to functioning law-abiding democracies (policy,
advocacy, advertisement, litigation), while probably the most defining
feature of developing countries is being dysfunctional dictatorships. Do
the editors of TC consider how such high profile research is perceived by
those bearing most of the burden of the tobacco epidemic?
Understandably many published research from developed countries
provide a model for other countries, but one can equally argue that the
path of evolution of tobacco control may not be similar in different
societies. The tobacco epidemic currently exists at variable stages in
different parts of the world, and when most editors of TC are from
countries that have gone a long way in their tobacco control campaigns, it
is natural that their own perspective will influence what they judge as
relevant or interesting in research.
I don't think that TC should sacrifice quality, or be more relaxed in
accepting studies from developing countries, or stop considering papers'
interest for the readers, but I urge the editors to consider a broader
perspective and long term impact of research, when deciding what is
interesting or relevant. After all, for high quality papers that fill an
information gap, external peer review can balance the review process for
studies from developing countries. This is a time tested mechanism that
should not be much weakened by strong editorial preferences. I reiterate
my support to TC and would be happy to learn that my concerns are
exaggerated. Otherwise, the main scientific publication of the tobacco
control community should at least aim to reflect the global tobacco
epidemic.
Sincerely
If you wish me to answer questions, it would seem more appropriate to
write to me directly than to ask the questions in a journal without even
drawing the existence of such a letter to my attention. However, I will
explain the situation.
I met Enstrom for the first time in 2000 at a meeting which Philip
Morris organised in Richmond, Virginia. We both gave talks. One of his
talks...
If you wish me to answer questions, it would seem more appropriate to
write to me directly than to ask the questions in a journal without even
drawing the existence of such a letter to my attention. However, I will
explain the situation.
I met Enstrom for the first time in 2000 at a meeting which Philip
Morris organised in Richmond, Virginia. We both gave talks. One of his
talks concerned an analysis based on very long term follow up of the
California CPS-I dataset, but was not to do with ETS. I may have said
that it would be a good idea to study risk associated with ETS in this
dataset – I cannot remember now – but I certainly was not involved in the
actual analyses leading to the paper he published with Kabat in the BMJ in
2003. Indeed the first I ever knew of such a paper was when it appeared.
I have, as you say, commented on Enstrom’s publications before. This
was as part of a routine series of reviews of relevant epidemiological
papers I have conducted for the industry over many years. The fact that I
may have criticised one publication does not necessarily imply weaknesses
of other publications. The methodological issue with the Enstrom/Kabat
paper cited by Bero et al (in the paper to which your letter replies) is
that there was no real “unexposed” group in the CPS-I dataset. Surely
this is true of virtually all ETS studies? Enstrom and Kabat showed that,
among those never smoking men and women in their studies who survived to
1999, those who in 1959 reported they had a spouse who currently smoked
were very much more likely to report at home or at work ETS exposure in
1999 than did those who in 1959 reported they had a spouse who had never
smoked. Clearly their exposure index did indicate higher ETS exposure in
the exposed group and their finding of a lack of relationship with lung
cancer, CHD or COPD risk should not be dismissed – it should be taken into
consideration along with the evidence from all the other studies.
Your letter suggests that I may "develop" analyses to my "liking",
implying that I may give a deliberately biased interpretation of the data.
I find this insulting in that I always take great pains to try to give an
unbiased scientific view of evidence. I note the massive attempt by the
anti-smoking industry to rubbish the Enstrom/Kabat study. Could this
reflect the fact that its results were not to their "liking"?
I have analysed the US-funded review and I want to share some of my findings. I am afraid there are serious errors in this document and I will quote only two of them to give an idea of their scope.
ERRORS. “Waterpipe use likely increases the risk of bronchogenic carcinoma [68] as well as lung [16,20,69] oral,[8] and bladder [21,70] cancers.”
I will not discuss each of all the cited references bec...
I have analysed the US-funded review and I want to share some of my findings. I am afraid there are serious errors in this document and I will quote only two of them to give an idea of their scope.
ERRORS. “Waterpipe use likely increases the risk of bronchogenic carcinoma [68] as well as lung [16,20,69] oral,[8] and bladder [21,70] cancers.”
I will not discuss each of all the cited references because most of the volunteers were simultaneous or ex-users of different (tobacco) products. I will only focus on references 69 and 16.
Ref 69 is : Rakower J, Fatal B. Study of Narghile Smoking in Relation to Cancer of the Lung. Br J Cancer. 1962 Mar; 16:1-6.
In blatant opposition to the above interpretation, the two cited researchers clearly said from the outset how they surprisingly noticed that “there [was] an eightfold difference between the lowest lung cancer mortality rate for the immigrants [Jews] from Yemen [a majority of them being hookah smokers] and the highest for the immigrants from Europe [50% were smokers and most of them were cigarette users].” This strange fact led them to analyse the tar filtering properties of narghile (results: 84mg for 10g of tobacco ; 161mg without water in the vase). As it was not enough to explain the low rates they observed, they discussed, among other matters, the influence of inhalation patterns and the question of temperature.
Many other references not cited in this review tend to show that hookah actually reduces the risk of lung cancer. Should we also add that Rakower and his colleague were talking about was “tumbâk” which contains much more nicotine than the one (tobamel) which is gradually swamping the world? Or that the same hookah used by Yemenis (mada’a) is usually topped with tons of charcoal?
The other cited reference (#16) is Lubin JH et al. (Quantitative evaluation of the radon and lung cancer association in a case control study of Chinese tin miners. Cancer Res 1990; 50:174–80). But we are not told that the same Lubin, only two years later, concluded another study by : [water] “pipe smoking may be less deleterious than cigarette smoking. The reasons for this are unclear, but may be due to the filtration action of the water bath or to less vigorous inhalation of pipe smoke”. (Lubin JH, Li JY, Xuan XZ, Cai SK, Luo; Yang QS, Wang JZ, Yang L; Blot WJ. Risk of lung cancer among cigarette and pipe smokers in southern China. Int. J. of Cancer 1992; 51 (3)3: 390-5.)
Strangely enough, neither the last reference nor another chief one, Hazelton (*), are cited.
METHODOLOGY. A fair number of the cited references relies on a previous, also US-funded, Egypt-based review (**) which is actually a mix of Medline abstracts and summaries of local documents. The authors of the last report pretend that “many of the studies on these subjects [i.e. hookah use] are merely anecdotal or lack the necessary rigorous study design or the power needed to be certain of the results.” (Radwan)
Rigour, that’s the word. This new “review” tells us about its one-year “precursor” that it “focused on Egyptian waterpipe research”. I am sorry to say that this is a wrong statement because the scope of the latter was going far beyond Egypt and was as wide as the new one. This has to be said from an ethical point of view: the modest researchers of the American-Egyptian team (ESPRI Centre) should deserve our respect for their work and its scope. Besides, it must be clear that both their document and the new one, we are talking about now, contain errors, the latter however to a greater extent.
This new review also emphasises the fact that it is “comprehensive” and “critical”. However, let’s point out that key references (*) are strangely absent in this document not to mention the best introduction to the issue : a 420 page multi-disciplinary doctoral thesis the abstract of which has been widely advertised over the past years among the tobacco control community and Globalink members. This work contains the 4 first reviews in sociology, anthropology, history and tobaccology (health and pharmacological aspects) concerning hookah/narghile use.
Indeed, was Wolfram the relevant reference (number 3) to support the given figure of people using hookah in the world or the other fact that its use is multi-century ? Wolfram is the right specialist for the platelet function but did the authors really know where he got that data from ? Let us tell them: indirectly from the a.m. thesis.
Consequently, it would have been more respectful and relevant to quote the existence of that document.
As for the “criticical” side, the reader of that document will be informed of what happened to an unlucky fellow who used a hookah: aspergillosis… without knowing that the poor man did not change the water of his hookah for weeks…
Effectively, the authors did not deem it necessary to bring out such a “detail”. For those who don’t know how a hookah is served, let us make it clear here that the water inside the vase is changed at the end of each session.
PREVENTION. This is, in my opinion, the most important and pressing issue and I regret that no practical orientation is given whereas so many ideas could be put forward instead of untiringly awaiting sound scientific evidence-based results from humans or from God.
CONCLUSION. Finally, since this document has been advertised and will probably be “indexed” under Mother Medline, the loop is looped and the boucle est bouclée, as French would say. Consequently, I urge everybody interested in this topic to access that document and personally check what I have been saying through these lines. I am ready to provide any colleague with a commented list of all other serious errors (about nitrosamines, lead, etc.) I have picked up in the document and I am ready to defend my position in any public debate.
Unlike before, I now sometimes ask myself : what is the reason behind such a stakhanovist production of papers on hookah the outcome of which only leads to more and more confusion (“bizid ettin bellé”, would we say in Arabic) ?
- Do we need quantity or elementary common sense-based quality ?
- Do we need ideology (we regret that the authors also attack smokeless tobacco…), boycott and blind unprofitable competition or international multidisciplinary co-operation to face the new challenge the worldwide spread of hookah use represents?
I only hope all this hubble-bubble-toil-and-trouble is not a race for funds in this merchant world ? You see, I am very perplexed these days.
Thank you for your attention.
Kamal Chaouachi, author of:
- DOCTORAL THESIS: « Le narguilé : analyse socio-anthropologique. Culture, convivialité, histoire et tabacologie d’un mode d’usage populaire du tabac », Université Paris X, 2000, 420 pages.
(English free translation): “Narghile (hookah): a Socio-Anthropological Analysis. Culture, Conviviality, History and Tobaccology of a Popular Tobacco Use Mode”, 420 pages. This reference document can be ordered through www.anrtheses.com.fr (use capital letters to fill in the boxes).
- BOOK: “Le narguilé. Anthropologie d’un mode d’usage de drogues douces”, Ed. L'Harmattan, 1997, 262 pages. (English free translation): An Anthropology of Hookah. its Use and Soft Drugs, 262 pages.
_______________
Notes:
(*) For example, Hazelton’ s excellent study based on the use of a 2-stage clonal expansion model (incl. nested dose-response models for the parameters): “Smoking a bamboo waterpipe or a Chinese long-stem pipe appears to confer less risk than cigarette use, given equivalent tobacco consumption”. Why ? because “The arsenic-tobacco interaction also appears to be very important”, a point that previous studies (cited Lubin’s for instance), in the same country did not take into due consideration.
(Hazelton, W. D., Luebeck, E. G., Heidenreich, W. F. and Moolgavkar, S. H. Analysis of a Historical Cohort of Chinese Tin Miners with Arsenic, Radon, Cigarette Smoke, and Pipe Smoke Exposures Using the Biologically Based Two-Stage Clonal Expansion Model. Radiat. Res. 2001, 156: 78-94)
(**) Radwan GN et alii. Review on Waterpipe Smoking. J. Egypt. Soc. Parasitol. 2003 Dec;33 (3 Suppl):1051-71. Also note that this document is often referred to, in the related bibliography, as “cited in Israel” when it should be, if we mistake not, “cited in Radwan”.
The newly revived discussion of the Enstrom/Kabat California passive
smoke study and conflict of interest led me to cite some addiional
documents.
The results of the study, as Bero et al show, were presented at a Philip
Morris gathering, June 5-6 2000:
http://legacy.library.ucsf.edu/tid/urx85c00
This seminar was part of WSA/INBIFO programming, viz. to "organize
two-day seminar with Mr. Peter N. Lee an...
The newly revived discussion of the Enstrom/Kabat California passive
smoke study and conflict of interest led me to cite some addiional
documents.
The results of the study, as Bero et al show, were presented at a Philip
Morris gathering, June 5-6 2000:
http://legacy.library.ucsf.edu/tid/urx85c00
This seminar was part of WSA/INBIFO programming, viz. to "organize
two-day seminar with Mr. Peter N. Lee and Dr. James Enstrom to discuss CPS
-I and CPS-II results and develop possible approaches to analyzing the
data." PN Lee is a long time statistical consultant to the tobacco
industry (Philip Morris, BAT, German Verband). One may fairly ask if Lee
helped with the analyses as they finally appeared in the BMJ article:
http://legacy.library.ucsf.edu/tid/lfc39c00
PN Lee had sharply criticised two of Enstrom's earlier papers on
cessation and mortality, one of which used the same California CPS-I and
CPS-II data sets. In the first instance, Lee criticised Enstrom's failure
at risk-averaging over time, and in the second (the CPS data sets) called
Enstrom's analysis a "totally inappropriate age-adjustment procedure."
Since the BMJ article conclusions depended on both kinds of analyses
(age-adjustment wiped out the effects of passive smoke; declining exposure
occurred with time in California) one wonders if PN Lee did help develop
analyses more to his liking this time around.
After reading Editor Chapman’s description of the efforts that he and
other anti-tobacco activist colleagues went through to ensure that tobacco
companies are not involved in events regarding corporate social
responsibility, I was left with disenchanting thoughts. I recall a few
months ago while surfing on the web for information regarding corporate
social responsibility tactics of the tobacco industry, I came across
info...
After reading Editor Chapman’s description of the efforts that he and
other anti-tobacco activist colleagues went through to ensure that tobacco
companies are not involved in events regarding corporate social
responsibility, I was left with disenchanting thoughts. I recall a few
months ago while surfing on the web for information regarding corporate
social responsibility tactics of the tobacco industry, I came across
information on the 1st corporate social responsibility summit that was to
be held in Dubai on April 25-27 2004. Among the sponsors where Shell,
British American Tobacco , and McDonlad (The website is still active
http://www.iirme.com/csr/ ). Now, in a moment of self-criticism I regret
that I had not reacted. Chapman asks in his article “Why so easy?” in
reference to his ability to advocate for removal of tobacco industry
involvement. I want to ask: “Why so hard?” We have a long way to go in
the Region (Eastern Mediterranean Region). There has always been certain
apathy toward ability to change any prevailing situation (which may
explain my inaction). Advocacy for health is non-existent and policy
makers are oblivious of the industry attempts at undermining tobacco
control efforts. Looking back, I tried to think whom could I have
contacted for support in ending such travesty? A few colleagues come to
mind, which are mainly from academic institutions. Maybe Globalink could
have been one of the forums in which I could have voiced my concern or
solicited support. However Globalink has very few members from the Eastern
Mediterranean Region partly due maybe to language (partially relieved due
to introduction of Arabic Globalink), computer literacy, or Internet
access issues. The reality remains that an enabling environment and
support for change does not exist. It’s inspiring to see how colleagues in
other regions have been successful in their advocacy efforts. I do believe
firmly that it is my duty to change the existing reality and I would like
to call upon colleagues in the region to join me in doing so.
the Philip Morris website admits the damage did and continues to do -
they have to admit this given the massive amount of technical data
available to prove this
In the USA Big Tobacco has paid billions of dollars to settle
lawsuits issued by different States and to pay for the healthcare to treat
the effects of their product
It is high time the HK Government filed a similar lawsuit or fear
being sued it...
the Philip Morris website admits the damage did and continues to do -
they have to admit this given the massive amount of technical data
available to prove this
In the USA Big Tobacco has paid billions of dollars to settle
lawsuits issued by different States and to pay for the healthcare to treat
the effects of their product
It is high time the HK Government filed a similar lawsuit or fear
being sued itself for not acting sooner and for not invoking legislation
preventing passive smoking earlier - 5000 Hongkongers die a year from
smoking related illness - it's time to act and get the money off the
tobacco companies to pay for the treatmenmt of the addicts, for indeed
addicts they are Dangerous drugs are banned in Asia yet nicotine kills
far more than heroin
Mekemson, et al. [1] present a thorough study of the presentation of smoking in the top 50
grossing movies each year from mid-1991 to mid-2001 that concludes that the levels of smoking
was either constant or decreased slightly. (The small, but significant, drop with time they report
may be the result of the fact that the smoking was much higher than average at their first data
point, 1991-92, making it a leverage point).
Mekemson, et al. [1] present a thorough study of the presentation of smoking in the top 50
grossing movies each year from mid-1991 to mid-2001 that concludes that the levels of smoking
was either constant or decreased slightly. (The small, but significant, drop with time they report
may be the result of the fact that the smoking was much higher than average at their first data
point, 1991-92, making it a leverage point).
Their results are comparable to data collected during the same period by Glantz, et al. [2] as part
of a study that spanned a much longer time, 1950-2002, based on a smaller random sample of the
top 20 grossing films each year (Table). The longer-term data also show that the levels of
smoking in the movies in the 1990s was about twice the levels observed in the 1980s (p=.037 by
ANOVA).
Year of
Release
n
Tobacco incidents/min
Square root
tobacco incidents/min
Mean
SD
Mean
SD
1991-2001 [1]
497
0.168
0.207
0.318
0.259
1991-2001 [2]
55
0.142
0.120
0.330
0.179
1980-1990 [2]
26
0.071
0.053
0.241
0.116
References:
1.Mekemson C, Glik D, Titus K, Myerson A, Shaivitz A, Ang A, Mitchell S. Tobacco Use
in Popular Movies During the Past Decade. Tob Control 2004;13(4):400-402.
2.Glantz SA, Kacirk KW, McCulloch C. Back to the Future: Smoking in Movies in 2002
Compared with 1950 Levels. Am J Public Health 2004;94(2):261-3.
Thanks you for this excellent explanation of the reality behind
tobacco companies' dabbling in so-called CSR programmes.
Earlier this year INGCAT's member organisations agreed a position
statment on tobacco industry CSR programmes that purport to address health
and welfare issues, entitled "The socially responsible tobacco company -
another misleading descriptor". The thrust of the positio...
Thanks you for this excellent explanation of the reality behind
tobacco companies' dabbling in so-called CSR programmes.
Earlier this year INGCAT's member organisations agreed a position
statment on tobacco industry CSR programmes that purport to address health
and welfare issues, entitled "The socially responsible tobacco company -
another misleading descriptor". The thrust of the position is that:
"NGOs’ responsibility is to protect the interests of their
beneficiaries: partnerships that promote the interests of tobacco
companies as they currently operate are incompatible with that duty.
INGCAT members refuse to support, endorse or co-operate with tobacco
companies’ CSR activities on health or poverty relief, and call on other
health and welfare organisations to join us in this stance."
The position statement does not intend to discourage tobacco
companies from making genuine efforts to act as responsible businesses. It
is an attempt to expose the PR reality behind the programmes many tobacco
companies currently trumpet as CSR activity, and ensure that NGOs do not
become, through association with such programmes, unwitting PR agents for
tobacco companies.
The full position statement can be viewed at
http://www.ingcat.org/PDFs/CSRstatement.doc and I'd encourage
organisations to endorse it.
Best wishes
Doreen McIntyre, Director, INGCAT (International Non Governmental
Coalition Against Tobacco)
Competing interests: INGCAT is entirely funded by its member
organisations, who are international health NGOs.
Pokorny et al show that one must use a multilevel model to accurately
identify contextual influences, such as school characteristics, on the
behaviour of individuals. Neither aggregate models nor individual level
only models will be accurate(1). This is a good point well made.
Unfortunately, Pokorny et al use aggregated school level perceived
prevalence of smoking among peers as their contextual example variabl...
Pokorny et al show that one must use a multilevel model to accurately
identify contextual influences, such as school characteristics, on the
behaviour of individuals. Neither aggregate models nor individual level
only models will be accurate(1). This is a good point well made.
Unfortunately, Pokorny et al use aggregated school level perceived
prevalence of smoking among peers as their contextual example variable.
Using this variable makes the model difficult to interpret. A sentence
from the Discussion (p306) highlights this. Abbreviated, it reads
‘students in schools with higher …perceived tobacco use… were more likely
to be smokers than students in schools with lower …peer tobacco use.’
This statement could only be false if students’ perceptions of smoking
prevalence were totally inaccurate. The observers and the observed have
both been sampled and are reporting on one another. However, it is
tempting for authors and readers to interpret these findings as support
for the notion that peer perception is part of the mechanism for why some
schools have a higher prevalence than others, when it simply restates that
finding.
Aside from this, there is another important reason why the prevalence
of smoking among peers, either at the student level or the school level,
should not be included in a multilevel model seeking to understand inter-
school variation in smoking prevalence. Students’ perception of smoking
prevalence among their friends is a measure of actual school smoking
prevalence. If we are seeking to understand why inter-school variation in
smoking prevalence exists, then controlling for it will attenuate the
phenomenon that we are seeking to explain. The papers published by Moore
et al West et al illustrate this(2;3). In both cases, controlling for the
number of friends smoking vastly diminished the unexplained school
variation in smoking. This does not show that the phenomenon is
explained; it shows the circular reasoning above. West et al appreciated
this, and showed that turning the multilevel equation round to predict the
prevalence of friends smoking showed the same inter-school variation and
ranking of schools as was apparent when predicting individuals’ smoking
habit. Notable individual level risk factors, such as peer smoking and
sibling smoking, should not be included in multilevel models.
Many people I know feel that the school they attended shaped them as
individuals and it seems reasonable to assume that it influences
individuals’ smoking. It is welcome to have papers exploring this
underdeveloped area. We have recently reviewed this literature and made
suggestions as to which variables should be controlled in a multilevel
model exploring inter-school variation, which variables should be
excluded, and which variables should be used as potential causal variables
in mediation analysis(4). The paper by West et al should be essential
reading for anyone seeking to understand how schools influence students’
health behaviour(3).
Reference List
(1) Pokorny, S.B., Jason L.A., & Schoeny M.E. (2004) Current
smoking among young adolescents: assessing school based contextual norms.
Tobacco Control, 13, 301-307.
(2) Moore, L., Roberts C., & Tudor-Smith C. (2001) School smoking
policies and smoking prevalence among adolescents: multilevel analysis of
cross-sectional data from Wales. Tobacco Control, 10, 117-123.
(3) West, P., Sweeting H., & Leyland A. (2004) School effects on
pupils' health behaviours: evidence in support of the health promoting
school. Research Papers in Education, 19, 261-291.
(4) Aveyard, P., Markham W., & Cheng K.K. (2004) A methodological and
substantive review of the evidence that schools cause pupils to smoke.
Social Science & Medicine, 58, 2253-2265.
We have, as addiction scientists, as a goal, the desire to minimize
addictive behaviors and thereby reduce negative outcomes and consequences.
The AMA has this admirable goal in mind but their stated approach is not
likely to get them there. Reducing nicotine in cigarettes has already been
plainly demonstrated to increase tar and CO levels in smokers. We need to
accept this and move in the correct direction, understanding...
We have, as addiction scientists, as a goal, the desire to minimize
addictive behaviors and thereby reduce negative outcomes and consequences.
The AMA has this admirable goal in mind but their stated approach is not
likely to get them there. Reducing nicotine in cigarettes has already been
plainly demonstrated to increase tar and CO levels in smokers. We need to
accept this and move in the correct direction, understanding that the
reduction of smoking will continue to occur through education but will not
reach zero in the near future. A proper approach toward the health of all
people, smokers and non alike, is to develop directives for the production
of low-tar and CO cigarettes that still deliver sufficient amounts of
nicotine so as not to offset the low-tar/CO benefit. Immediately
producible are cigarettes with 10mg tar and CO yet this has not been
coupled with one that has 1.0-1.3mg of nicotine. This range is what
addicts crave and will achieve even if the delivery system requires they
smoke two or in some manner impede the flow of air into the filter.
Providing such a cigarette as above, will give us an immediate positive
impact on health and buy us time to continue the education process in non-
addicted populations. Each company should be directed to carry such a
product as well as step-down products which further reduce tars, CO and
nicotine gradually allowing a transition point for smokers motivated
toward abstinence. As scientists we practice application of sound thought
and not be swayed by political agendas not even our own. Rational,
practical, progressive solutions triggered by insight and inspiration
have been the hallmark and foundation of science since the use of tools.
Let us not get caught up in the trap of popular opinion as to what works.
The author of this artice says, "These classic children's books were
first published in times when smoking was not widely acknowledged as
harmful and a smoking adult male was one of the sex stereotypes". While
this is true for the books cited, I have been looking for children's
picture books with smokers in the illustrations for several years and am
surprised how many current books as well as how many other older book...
The author of this artice says, "These classic children's books were
first published in times when smoking was not widely acknowledged as
harmful and a smoking adult male was one of the sex stereotypes". While
this is true for the books cited, I have been looking for children's
picture books with smokers in the illustrations for several years and am
surprised how many current books as well as how many other older books
include smokers of cigarettes, cigars and pipes. Sometimes the smokers
are not main characters but just in the background. Smoking is more often
in the illustration than in the text. I am in the process of creating a
bibliography of these books and also writing the illustrators to ask just
exactly why they have smokers in the illustrations. What is the message
the illustrator is trying to give?? If anyone is interested in the
results of this bibliography in progress, please feel free to contact me
at the above e-mail. I would also be interested in adding to my
bibliography any books you know of that I have missed. Hannah Pickworth
I was interested to note the links between the tobacco and gambling
industries outlined by Mandel and Glantz.(1)
I have recently discovered that at least one UK casino company is
working with Healthy Buildings International (HBI), the indoor air quality
consultancy firm part-funded by the Philip Morris tobacco company.(2)
Previous research has demonstrated how the tobacco industry has used...
I was interested to note the links between the tobacco and gambling
industries outlined by Mandel and Glantz.(1)
I have recently discovered that at least one UK casino company is
working with Healthy Buildings International (HBI), the indoor air quality
consultancy firm part-funded by the Philip Morris tobacco company.(2)
Previous research has demonstrated how the tobacco industry has used HBI
to prevent smoke-free workplaces.(3)
It is concerning that at a time when casino employees in the UK are
demanding smoke-free workplaces their employers are (knowingly or
unknowingly) working with a firm linked to the tobacco industry. But at
least we now know of this link, as do the Trade Union representatives who
are working with these casino companies. Hopefully the unions can use
this information to neutralise any influence the tobacco industry may have
had.
Yours faithfully,
Paul Pilkington
References
1.Hedging their bets: tobacco and gambling industries work against
smoke-free policies Tob Control 2004; 13: 268-276
2. Correspondance between Neil Goulden, Group Managing Director Gala
Group and Paul Pilkington, 1 March 2004.
3. Drope, J, Biolous, SA and Glantz, SA. Tobacco industry efforts to
present ventilation as an alternative to smoke-free environments in North
America, Tobacco Control 2004; 13, 41-47.
If blood lipid profile improves and weight increases with smoking
cessation (1) smoking might be causally related to both the development of
an abnormal blood lipid profile and the avoidance of weight gain or even
weight loss. How then might smoking have increased the risk of non-fatal
myocardial infarction in this study (2)? By reducing the capacity to
respond to reductive stress with a further increase in the degree of...
If blood lipid profile improves and weight increases with smoking
cessation (1) smoking might be causally related to both the development of
an abnormal blood lipid profile and the avoidance of weight gain or even
weight loss. How then might smoking have increased the risk of non-fatal
myocardial infarction in this study (2)? By reducing the capacity to
respond to reductive stress with a further increase in the degree of blood
lipid shift (3)?
The answer may lie in the next step in respoding to a progressive
increase in the degree of reductive stress. If this is reverting to
glucose as the preferred substrate for anaerobic glycolysis that would
mean reversing the increase in nutrient energy density achieved by the
antecedent lipid shift. In the case of an acute reductive stress
equivalent to 25% of dysoxia that could mean having to increase a cardiac
output of 4.7L/min that had been able to meet the tissues needs to as much
as 16.2 L/min to achieve the same objective. A cardiac output of that
magnitude is far in excess of the cardiovascular capacity of even a
healthy fit athlete.
There is another possibility. Anaerobic glycolysis might be averted
after the capacity for increasing nutrient energy density per unit volume
of flowing blood had plateaued by using amino acids for acetyl coenzyme A
synthesis in providing the substrate needed for oxidative phosphorylation
to proceed at the rate needed to meet the tissues needs for ATP
resynthesis at the time(4). But if NH3 is produced in the process the pH
could rise inhibitng oxidative phosphorylation and stimulating anaerobic
glycolysis and with it the demand of glucose(5). This too could incease
the demand for ATP resynthesis far in excess of the cardiovascular
capacity to meet the tissues energy needs.
Smoking might, therefore, have increased the risk of non-fatal
myocardial infarction in this study by limiting the capacity for
accommodating an acute reductive stress with a blood lipid shift and
increasing the likelihood of acute cardiovascular decompensation. In which
case smoking cessation can be expected to eliminate that risk once the
blood lipid profile had been restored to normality even though weight was
gained. What is more the gain in weight might be a compensatory response
that enhanced the capacity to mount a lipid response to acute reductive
stress. In other words a blood lipid shift revealed in blood lipid
profiles may conceal the real capacity for mounting a fatty acid response
to acute reductive stress.
If it is the capacity for mounting a fatty acid rsponse rather than
a shift in blood lipid profile per se that is the primary determinant in
meeting the metabolic demands of an acute reductive stress within
cardiovascular capacity then it may be compromised by the administration
of statins. Not only might the size of the mobile pool of fatty acids be
reduced by statins by the ability to release it in a timely manner in
acute reductive stress might be reduced by an accompanying reduction in
the capacity for steroid hormone synthesis. In which case the risk of non-
fatal acute myocardial infarction might be greatest in smokers taking
statins or even confined to them.
1. Botella-Carretero JI, Escobar-Morreale HF, Martin I, Valero AM,
Alvarez F, Garcia G, Varela C, Cantarero M. Weight gain and cardiovascular
risk factors during smoking cessation with bupropion or nicotine.
Horm Metab Res. 2004 Mar;36(3):178-82.
2. M S Mähönen, P McElduff, A J Dobson, K A Kuulasmaa, and A E Evans
Current smoking and the risk of non-fatal myocardial infarction in the WHO
MONICA Project populations
Tob Control 2004; 13: 244-250
3. Successful evolutionary adaptation to environmental stress?
Richard G Fiddian-Green
Heart Online, 14 Jul 2004 eLetter re: D A Lawlor, G Davey Smith, R
Mitchell, and S Ebrahim
Temperature at birth, coronary heart disease, and insulin resistance:
cross sectional analyses of the British women’s heart and health study
Heart 2004; 90: 381-388
4. Might biochemical fermionic complexities be dictated by antecedent
bosonic simplicities?
Richard G Fiddian-Green (26 August 2004) eLetter re: Rodrigo B.
Cavalcanti
Does perioperative lipid-lowering therapy reduce in-hospital mortality
after major noncardiac surgery?
CMAJ 2004; 171: 328
5. pNH3: a relevant pulmonary variable?
Richard G Fiddian-Green
Chest Online, 11 Aug 2004 eLetter re: pNH3: a relevant pulmonary variable?
Richard G Fiddian-Green
Chest Online, 11 Aug 2004
It's a relief to see the authors backing away from the previously advocated "remove-the-nicotine" approach to regulating cigarettes. This was a strategy that would surely have killed millions more as toxin-to-nicotine ratios worsened during a phase-out, while smokers continued to seek their established satisfactory nicotine dose. Making even dirtier delivery systems for nicotine was never the greatest public health idea, and no...
It's a relief to see the authors backing away from the previously advocated "remove-the-nicotine" approach to regulating cigarettes. This was a strategy that would surely have killed millions more as toxin-to-nicotine ratios worsened during a phase-out, while smokers continued to seek their established satisfactory nicotine dose. Making even dirtier delivery systems for nicotine was never the greatest public health idea, and now, thankfully, it has become a 'Prior Proposal'.
But as the authors say, there is good reason to stop tobacco companies having a free hand to do whatever product engineering they like. They have been given a unique exemption from virtually every law and norm of consumer protection and product safety. It is entirely right to stop them making products much more attractive than they would otherwise be - ie. systematically narrow the terms of the broad exemption they have.
But are there also dangers with the new proposal? If smoking is a behaviour based on seeking satisfaction from nicotine, isn't there a danger that reducing the addictiveness (ie. the pharmacological impact) will mean smokers seeking more nicotine for the same satisfaction? If more nicotine is required, then more toxins would be likely to be absorbed along with it, and so more harm caused.
Is there any evidence that, over time, it has become harder to quit smoking because the products have been engineered to be more 'addictive'? (I realise this might be difficult to gather). Have temporary withdrawal symptoms become more severe over time? These are the real harms associated with the addictiveness itself (as opposed to the co-exposure to toxins), so I think we ought to know what the behavioural changes have been before advocating a regulatory change.
Have all the strategies for subverting regulatory interventions available to smokers who are seeking a nicotine fix been considered...? Breaking off filters, switching to hand-rolled or cigars, compensatory smoking behaviour, bootlegging etc.
I don't know the answers to these questions. But to me, they say "not so fast". An approach to harm reduction that reduces the potency of the drug delivery system must consider the behavioural responses to these modifications, and this seems to me to be even more complex and risky than a more straightforward harm reduction strategy focussed on reducing toxins (which is probably pointless for combustible tobacco anyway).
Finally, is reducing addictiveness always right? If you could find a way to increase the addictiveness of medicinal nicotine or even smokeless tobacco, so that they compete better with cigarettes in nicotine delivery while doing orders of magnitude less harm, you may be able on to something that really would save millions of lives.
McAlister and his co-authors make an extremely valuable contribution
to the ongoing debates of health care costs in the form of their estimate
of the cost efficacy of a telephone quit line. The publication of this
data should provide new evidence to convince payors to cover cessation.
However, since recruitment costs were excluded, it is difficult to
make broader public health decisions based on these estimates....
McAlister and his co-authors make an extremely valuable contribution
to the ongoing debates of health care costs in the form of their estimate
of the cost efficacy of a telephone quit line. The publication of this
data should provide new evidence to convince payors to cover cessation.
However, since recruitment costs were excluded, it is difficult to
make broader public health decisions based on these estimates. The
decision not to include the costs from a controlled clinical trial is
undoubtably correct, as they are not generalizable to larger scale
promotion efforts. Most state funded quit lines in operations use multiple
outreach methods, including television, radio, print and physician
outreach to recruit patients into treatment.
To date there have been no estimates published of recruitment costs
into these large-scale quit lines, despite the proliferation of state
programs. This may be due to the fact that it is difficult to break out
costs for recruitment from overall costs for cessation promotion and the
normalization of quitting. None the less, until we have concrete estimates
of the actual cost to recruit participants into such programs it will be
impossible to actually calculate the true cost efficacy.
I am writing in response to the research paper, “Clearing the
airways: advocacy and regulation for smoke-free airlines” by Holm and
Davis, published in the March supplement of Tobacco Control, 2004. While
Holm and Davis present an apparently comprehensive narrative of the events
that lead to the legislative prohibition of smoking in aircraft cabins,
one is left with the sense from their research of...
I am writing in response to the research paper, “Clearing the
airways: advocacy and regulation for smoke-free airlines” by Holm and
Davis, published in the March supplement of Tobacco Control, 2004. While
Holm and Davis present an apparently comprehensive narrative of the events
that lead to the legislative prohibition of smoking in aircraft cabins,
one is left with the sense from their research of “historical documents,
journal and popular press articles, the world wide web and some tobacco
industry documents” that the successful passage of the legislation was due
to clever political maneuvering and the actions of “health advocates”. I
would like to suggest that the flight attendants themselves, as
individuals and members of unions, played a more central role in the
passage of the legislation than was represented by the paper. In fact, the
flight attendants were the critical element in getting congressional
action.
Prior efforts to pass federal legislation on smoke-free worksites had
not found Congress a friendly environment for such bills. One would
therefore question why health advocates had failed to get federal
legislation for smoke-free worksites but were successful in the airlines
case? What was so different about the airline smoking ban case? Holm and
Davis did not answer this question, nor did they bring any insight into
the relationship between the tobacco industry and unions, key players in
this battle. Rather, the paper simply painted a picture of flight
attendants and the Association of Flight Attendants (AFA) as “scenery”,
presenting personal testimonies of their ailments due to years of exposure
to tobacco smoke. Union involvement in the issue is absent from the
discussion and conclusions of this paper. Yet the presence and
participation of the AFA was critical because with the unquestionable
hazards to flight attendants on board, the issue was successfully reframed
as one of “worker health and safety”, rather than the industry’s approach
of “smokers’ rights” and accommodation.
The AFA has had a long history of concern over air quality in
aircraft cabins. The AFA reasoned that advocating for smoking bans was an
avenue to bring forth flight attendant health and safety concerns, since
they feared that “without the intervention of Congress, the National
Academy of Sciences study [on Cabin Air Quality] will end up on one of the
(FAA’s) burners that is so far back you cannot even tell if it is on.”(1)
The authors of this paper attribute the defeat of the tobacco
industry to (i) the industry’s limited leverage over the CAB and FAA, (ii)
their inability to mobilize on a grassroots level and (iii) the lack of
scientific basis to support their position. Absent from Holm and Davis’
discussion is the key role that the AFA played in thwarting industry
efforts to win allies within organized labor. Industry documents reveal
years of strategizing to woo organized labor and in the airlines case, the
AFA and the Air Line Pilots Association (ALPA). The industry had actually
underestimated the power of the flight attendants as they were duly warned
in 1993 in light of smoking bans in bars and restaurants that “an anti-
smoking position developed by HERE (Hotel Employees and Restaurant
Employees International Union), similar to that adopted by the Association
of Flight Attendants could present a major setback. However, HERE as an
ally in this effort, would be a very powerful voice.”(2)
Holm and Davis conclude that the “single-issue focus” in advocacy
work should be a lesson for future health advocacy work. The ownership of
this success is debatable and, perhaps a more important “lesson” to
reflect upon is how a single-issue focus in this instance has helped to
create an alliance between health advocates and unions, while this has not
always been the case. Perhaps a more valuable lesson is that unions are
key players in tobacco policies in the workplace and that health advocates
must consider how this coalition may be strengthened in future battles
over workplaces such as restaurants and bars.
Charles Levenstein, Ph.D., M.Sc.
Professor Emeritus of Work Environment Policy; and
Co-Director, Organized Labor and Tobacco Control Network
University of Massachusetts Lowell
Lowell, MA
References
1. Achenbaugh N, Finucane M. FAA Should Create An Office To Address
Crewmember And Passenger Health. R.J. Reynolds. September 19, 1986. Access
Date: October 23, 2002. Bates No.:506294126/4131. URL:
http://legacy.library.ucsf.edu/tid/hje71d00.
2. Ogilvy Adams & Rhinehart, Savarese and Associates. Restaurant
Smoking Ban Strategy. Tobacco Institute. August 23, 1993. Access Date:
July 8, 2003. Bates No.:TI01621153/1159. URL:
http://legacy.library.ucsf.edu/tid/cyr30c00.
I have recently completed a doctoral thesis exploring the
epistemological challenges associated with the inclusion of health
promotion in medical undergraduate education.
Those challenges reflect the dilemmas associated with teaching about
smoking cessation. It is in fact only recently that the UK NHS plan has
suggested a consistent approach for the delivery of smoking cessation
services and previous to that th...
I have recently completed a doctoral thesis exploring the
epistemological challenges associated with the inclusion of health
promotion in medical undergraduate education.
Those challenges reflect the dilemmas associated with teaching about
smoking cessation. It is in fact only recently that the UK NHS plan has
suggested a consistent approach for the delivery of smoking cessation
services and previous to that there had been a lack of consensus about not
only about how to respond to and support the smoker who wants to stop but
also whether or not such a provision should be part of the clinicians’
role.
Intervention is the essence of health promotion activity but its
evidence base has been contested, the theories underpinning and informing
activity are eclectic and few clinicians will have engaged with this
discipline in any depth.
For educationalists the inclusion of health promotion, and
specifically smoking cessation, in curricular content has been fraught
with difficulties and your findings reflect this. However based on my
ethnographic research findings I have constructed a new working definition
of health promotion which should assist both medical educators and medical
teachers in the development of the learning outcomes and objectives as
well as the approaches to assessment. The definition is as follows; Health
promotion is the study of, and the study of the response to, the
modifiable determinants of health. By using this definition, exploring
what is arguably modifiable as well the evidence base for response or
intervention, medical educators can progress in the generic field of
health promotion teaching as well as the specific field of smoking
cessation (1).
I would argue, however, that those medical teachers, who will be
charged with the responsibility to teach medical students the current
approaches to smoking cessation will need to have the opportunities to
familiarise themselves with, and engage with, the debates associated with
health promotion theories, evidence and practice.
At this medical school we intent to look at the needs of our medical
teachers in this regard and hope to be able to have pragmatic approaches
to assessment by 2007 for senior medical students.
Reference List
(1) Wylie A. Health promotion and medical education; An exploration
of the epistemology and the challenge. King's College, London,
2003.Unpublished
In their e-letter of 19 December 2003, Tomar et al promised that
"Many of the specific comments of Foulds et al. will be addressed in a
subsequent response". No response has since been forthcoming.
Given that Tomar et al's contribution managed to avoid peer review
and to appear in the paper edition of Tobacco Control as apparently the
last word on the subject, I think it is beholden upon them to say what
they...
In their e-letter of 19 December 2003, Tomar et al promised that
"Many of the specific comments of Foulds et al. will be addressed in a
subsequent response". No response has since been forthcoming.
Given that Tomar et al's contribution managed to avoid peer review
and to appear in the paper edition of Tobacco Control as apparently the
last word on the subject, I think it is beholden upon them to say what
they accept and don't accept in the criticisms of their article that
followed on e-TC. Obviously, if competing interests could also be declared
that would be a bonus. I have none.
Sir,
I read with interest the paper by Cains et al. (2004) on the effect of “no
smoking” areas in licensed clubs in the metropolitan area of Sydney. They
found only an insufficient effect of “no smoking” zones especially when
this was only a subsection of the whole room without separation.
In spite of this finding this poor protection of the non-smokers is still
much favoured in the hospitality industry around the world. T...
Sir,
I read with interest the paper by Cains et al. (2004) on the effect of “no
smoking” areas in licensed clubs in the metropolitan area of Sydney. They
found only an insufficient effect of “no smoking” zones especially when
this was only a subsection of the whole room without separation.
In spite of this finding this poor protection of the non-smokers is still
much favoured in the hospitality industry around the world. Therefore I
want to support the Australian findings with our preliminary data from
Vienna, Austria.
The Viennese cuisine is well recognised for tasty and fine meals. But the
pleasure of dinners in restaurants is often diminished because of
environmental tobacco smoke (ETS). Neither innkeepers nor guests seem to
be fully aware of this problem. As part of a larger project (Moshammer and
Neuberger, 2004) we did measure nicotine concentration also in some
restaurants and pubs in Vienna in 2002. Only few (and usually vegetarian)
restaurants are truly “non-smoking” in Vienna. We did select 6 restaurants
of different standards (pubs and cheaper restaurants for the working class
people and more expensive restaurants) with no separation of smokers and
non-smokers and collected nicotine on a filter using a calibrated pump
during lunch or dinner (in total 9 measurements). We also found two
restaurants that provide a “no smoking” area but without functional
separation from the smoking area: One café has declared a few tables near
the entrance as “no smoking” (where the ventilation of the whole room
apparently is mostly via this entrance door) and a restaurant (at the
university hospital) partly separates the dining room into two parts by a
shield that does not reach the ceiling.
In the restaurants with no separation we found nicotine levels
ranging from below 0.1 to 193.1 µg/m³, with an arithmetic mean of 37.1 and
a median of 15.7 µg/m³. The two values obtained in the “no smoking” area
of the café were 17.7 and 43.4 while the only value from the “smoking”
area in the same room was only 15.7 µg/m³.
In the restaurant at the hospital we measured concentrations between 6.8
and 39.5 µg/m³ (mean: 21.8, median: 19.8, in total 4 values) and in the
“smoking” area (with 3 measurements) between 16.8 and 28.6 µg/m³ (mean:
23.1, median: 23.9).
Although we can provide only few spot measurements it seems obvious that
under certain conditions the customers in the “no smoking” area could even
be more exposed than where smoking is allowed. In the other case the
separation at least was not very sufficient. Any differences between the
two areas were less pronounced than day-to day variations or between
different restaurants with no separation at all.
References:
Cains T, Cannata S, Poulos R, Ferson MJ, Stewart BW. Designated “no
smoking” areas provide from partial to no protection from environmental
tobacco smoke. Tobacco Control 2004; 13: 17-22
Moshammer H, Neuberger M. Nicotine and surface of particulates as
indicators of exposure to environmental tobacco smoke in public places in
Austria. Int. J. Hyg. Environ. Health 2004; in press.
The findings presented by Roddy et al. [1] paint a dim picture of
tobacco
training in the UK, but rosier than that in U.S. schools of public health
(SPH).
As part of the Association of Schools of Public Health(ASPH)/American
Legacy
Foundation “STEP UP” initiative, we administered an ASPH survey to the 27
faculty members of the San Diego State University Graduate School of
Public
Health (SDSU GSPH) and also to...
The findings presented by Roddy et al. [1] paint a dim picture of
tobacco
training in the UK, but rosier than that in U.S. schools of public health
(SPH).
As part of the Association of Schools of Public Health(ASPH)/American
Legacy
Foundation “STEP UP” initiative, we administered an ASPH survey to the 27
faculty members of the San Diego State University Graduate School of
Public
Health (SDSU GSPH) and also to 13 members of other departments. We also
reviewed the course catalog, and extramural research records.
Of the 76 classes offered by the GSPH, only 10 addressed tobacco in
any
form. Most of the 10 used tobacco only as illustrations of other content,
such
as research methods. None emphasized tobacco as a serious risk factor, or
control methods. Only two courses offered to the university’s 32,000
undergraduate students included tobacco content, one in health education
and one in psychology. Psychology and nursing had two and three graduate
classes, respectively, that mentioned tobacco. It is unlikely non-
responders
provided tobacco education, and department chairs confirmed this
conclusion.
With over 1,069 full-time equivalent faculty at SDSU, only 11 are
conducting
tobacco research. The GSPH has nine tobacco grants. Two full time faculty
teach most of the classes that include tobacco content, reaching about 35
students/year.
Undergraduate and graduate students have little exposure to tobacco
content
and little opportunity for tobacco-related research training. Similar to
Roddy
et al. [1], the ASPH survey of member schools indicated that about half
included some form of tobacco-related content [2], but few had a strong
tobacco control program.
Physicians leaving medical school feel unprepared to provide tobacco-
related
assistance to patients [3,4,5]. Dental schools may be the exception, yet
leave
considerable room for improvement [6]. Lack of tobacco control training
may
be true of schools of law, business, social sciences, biology and liberal
arts
programs. If so, the vast majority of students are not obtaining basic
education about the risks of or means of controlling tobacco.
The NIH spends about 1% of its research funds on tobacco-related
research,
possibly due to under-representation of tobacco control proposals [7] or
to
under-promotion by NIH. A search of NIH websites produced zero current
RFP/RFAs and zero training opportunities specific to tobacco.
Efforts are under way to increase professional education about
tobacco [8,9],
but extramurally supported programs may not be sustainable without
support from intramural sources. In the face of an industry that actively
undermines tobacco control efforts and that funds legislators, academic
administrators, and investigators in schools of medicine, dentistry,
public
health and basic science departments [10], we challenge university faculty
and academic administrators to dramatically increase the emphasis on
tobacco-control. We challenge tobacco control investigators to more
actively
promote research assistantships, and to make better use of available pre-
and post-doctoral fellowships as a means to recruit and support future
investigators. For one of the greatest public health crises, this is a
tragedy of
academic planning and government support.
References
1 Roddy E, Rubin P, Britton J, on behalf of the Tobacco Advisory
Group of the
Royal College of Physicians. A study of smoking and smoking cessation on
the curricula of UK medical schools. Tobacco Control 2004;13:74–77.
2 ASPH Tobacco Studies Survey 2001-2002. Association of Schools of
Public
Health/American Legacy Foundation. Available online: http://www.asph.org/
document.cfm?page=788. Accessed March 1, 2004.
3 Ferry LH, Grissino LM, Runfola PS. Tobacco dependence curricula in
US
undergraduate medical education. Journal of the American Medical
Association 1999;282:825-9.
4 Khurana S, Batra V, Kim V, Patkar A, Leone FT. Attitudes and
beliefs of
physicians-in-training regarding nicotine addiction and treatment. Chest
2002;122:S9.
5 Teaching Smoking Cessation: An Expert Interview With Vikas Batra,
MD, and
Frank T. Leone, MD. Medscape 12/30/2002. Available online: http://
www.medscape.com/viewarticle/446283?mpid=8129. Accessed April 3,
2003.
6 Weaver RG, Whittaker L, Valachovic RW, Broom A. Tobacco control
and
prevention effort in dental education. Journal of Dental Education
2002;66:
426-9.
7 Hughes J, Liguori A. A critical review of past NIH research funding
on
tobacco and nicotine. Nicotine and Tobacco Research 2000;2:117-20.
8 Tobacco Control in the 21st Century. University of Sydney,
Australia.
Available online: http://www.health.usyd.edu.au/tob21c. Accessed April 3,
2003.
9 Curricular innovation grant abstracts. Association of Schools of
Public
Health/American Legacy Foundation. Available online: http://www.asph.org/
document.cfm?page=791. Accessed March 1, 2004.
10 Chapman S, Shatenstein, S. The ethics of the cash register: taking
tobacco
research dollars. Tobacco Control 2001;10:1-2.
Cains et al., studying the extent to which designated "no smoking"
areas provide protection from environmental tobacco smoke (ETS), conclude
that such areas achieve some reduction in the level of exposure of
individuals to ETS. They indicate an average 53% reduction in nicotine
levels and 52% reduction in PM10 levels. These numbers, although not
marginal, are not sufficient to provide an adequate level of protection....
Cains et al., studying the extent to which designated "no smoking"
areas provide protection from environmental tobacco smoke (ETS), conclude
that such areas achieve some reduction in the level of exposure of
individuals to ETS. They indicate an average 53% reduction in nicotine
levels and 52% reduction in PM10 levels. These numbers, although not
marginal, are not sufficient to provide an adequate level of protection.
It should be added that these numbers probably overestimate the
actual exposure reduction obtained by introducing a division of the space
between a "smoking" and a "no smoking" area. To estimate such a reduction,
one would need to compare exposure to ETS in a situation where smoking is
permitted in the entire space versus the exposure level in the "no
smoking" area when the space is split. This difference is the real measure
of improvement (if any) brought by the introduction of separated areas.
Comparing the exposure to ETS between the "smoking" and "no smoking" areas
after such introduction has taken place is not equivalent. Such comparison
takes as its reference the "smoking area" in which the level of smoking
per unit volume may be much higher than in a space in which smoking is
permitted everywhere. It is indeed reasonable to expect that the "smoking"
area be occupied by a higher proportion of smokers, who probably smoke
more (owing to the social validation of smoking that such an area
provides). This situation may even have over time have a self-exacerbating
effect, since some (light) smokers may prefer to go to the "no smoking"
area as even they get growingly incommodated by the high level of ETS in
the "smoking" area.
On 24 February 2004, the United States Supreme Court, by a vote of 6
to 2, affirmed the judgment of the U.S. Court of Appeals for the Ninth
Circuit in Olympic Airways v. Husain, a case mentioned in this article
under the heading "Negligence." With no other avenue of appeal, Olympic
Airways is now required to pay $1.4 million to the Estate of Dr. Abid
Hanson because of its negligence.
On 24 February 2004, the United States Supreme Court, by a vote of 6
to 2, affirmed the judgment of the U.S. Court of Appeals for the Ninth
Circuit in Olympic Airways v. Husain, a case mentioned in this article
under the heading "Negligence." With no other avenue of appeal, Olympic
Airways is now required to pay $1.4 million to the Estate of Dr. Abid
Hanson because of its negligence.
Dr. Hanson's tragic death aboard a smoke-filled Olympic Airways
flight comes to mind whenever I hear or read the false claim that
secondhand smoke has never killed anyone.
I always enjoy new research describing how medical students are not
taught about tobacco use and smoking cessation. I teach medical students
about tobacco use. One of the first things I teach students about tobacco
use is that it is best considered a disease, not a risk factor. In the
American Society of Addiction Medicine's Public Policy Statement on
Nicotine Dependence and Tobacco in the Journal of Addictive Disease,...
I always enjoy new research describing how medical students are not
taught about tobacco use and smoking cessation. I teach medical students
about tobacco use. One of the first things I teach students about tobacco
use is that it is best considered a disease, not a risk factor. In the
American Society of Addiction Medicine's Public Policy Statement on
Nicotine Dependence and Tobacco in the Journal of Addictive Disease,
1993;12(1), it states:
"Although the medical profession has traditionally viewed tobacco use as a
risk factor for other diseases, and not as a primary problem in itself,
this approach has impeded, rather than promoted, the development of
optimal treatment methods for patients addicted to nicotine. Nicotine
dependence is best regarded as a primary medical problem, with tobacco-
related diseases viewed as direct consequences of nicotine dependence."
Recently I have been helping a student medical doctor study for the
Clinical Skills Assessment required as part of the USMLE process for
medical residency qualification to study in the United States. Materials
prepared for such study indicate patients should be told about smoking
cessation when the medical case indicates smoking is a risk factor. Yet,
smoking is not included as a "vital sign" to be asked about, nor is there
much recognition that nicotine dependence requires any kind of rigorous
response from doctors presented with patient conditions. So, in the case
of a patient with pneumonia, the doctor is to "discuss tobacco cessation
with the patient."
Sadly, I get little support from clinicians with my emphasis that
tobacco use is a primary condition. Generally, they all see tobacco use
as a distant "risk factor," far from their focus on strictly curative
concerns. With no understanding of tobacco use as a primary medical
problem and little reward for counseling/caring for patients to overcome
it, I see little prospect for change in physician training or practice in
this area.
Physicians wonder why patients increasingly seek help from
unqualified healers, counselors, but seem to continue to put preventive
and promotive care of primary medical conditions aside because their
profession does not support such action. I hope somewhere along the line,
the disease and death effects of tobacco use begin to register. Until
then, I shall continue teaching my two hours of unorthodoxy.
Stephen Hamann, MPH, MEd, EdD
Asst. Dean, Medical Education
Rangsit Medical School
Bangkok, Thailand
I think the most important point to address in Tomar et al’s e-response [1] is their call for more evidence before any change to the status quo (the status quo is a ban on oral tobacco in the EU, and public health disinformation in the US). They say that “neither we nor the IOM Report are ready to accept extant data as sufficient for endorsing smokeless tobacco for harm reduction”. This stance does not reflect the real...
I think the most important point to address in Tomar et al’s e-response [1] is their call for more evidence before any change to the status quo (the status quo is a ban on oral tobacco in the EU, and public health disinformation in the US). They say that “neither we nor the IOM Report are ready to accept extant data as sufficient for endorsing smokeless tobacco for harm reduction”. This stance does not reflect the real-world policy choices and inverts the natural burden of proof.
First, “endorsing smokeless tobacco for harm reduction” in Europe means unbanning and regulating the product as part of the tobacco market. In the US, it would involve health advocates no longer misleading the public about it – as regrettably the Surgeon General recently did. It does not involve doctors prescribing it, health advocates advocating it, or guest slots for UST at the Washington World Conference. What does ‘endorsing’ actually mean in Europe? In reality, there are some quite concrete decisions in Europe which we must take on the available evidence. These include: continue the oral tobacco ban or lift it? Tell the truth or mislead smokers about it? Whether to regulate oral tobacco, and if so, in what way? These are questions that cannot be ducked on the back of too little evidence – the ‘do nothing’ philosophy is simply a decision in favour of the status quo. This amounts to an active endorsement of the ”quit or die” approach, in which smokers are denied less hazardous alternatives to cigarettes, which themselves remain practically unregulated. There is no supporting evidence for leaving the market to the most dangerous products, and it seems illogical to me.
Second, let us be clear about the burden of proof. The 'intervention' in Europe is to ban oral tobacco while not banning cigarettes. It is that intervention that requires an evidence base – a point not considered by the IOM. The burden of proof naturally falls on those making and sustaining this intervention (the EU), but three reasons make the demand for supporting evidence more pressing:
It is highly irregular to ban a less hazardous variant of a product, thereby deliberately denying users of the more hazardous product the choice of a switch and so preventing an individual risk reduction response. There are no precedents for this, and for that reason alone I would expect good evidence to support such an unorthodox approach to consumer safety.
Common sense suggests that it is plausible that addicted smokers would use oral tobacco as an alternative to smoking and to quit, thus reducing harm. Given there is a reasonable hypothesis that smokeless tobacco will reduce harm, there is a commensurate need to show that hypothesis to be flawed if one is to support a ban on oral tobacco without banning smoking tobacco.
The evidence from Sweden shows a compelling public health case against banning the product and no-one in their right mind would seek to extend the EU ban to Sweden. Sweden sends a powerful cautionary signal to the rest of the EU about perverse consequences of clumsy interventions. If it is not right to ban it in Sweden, how can we be so confident that it is right to ban it in the rest of the EU? Given the hypothetical opportunity, would American campaigners really ban smokeless tobacco in the US, while leaving cigarettes under the current weak regulatory regime?
If this was a controlled trial and the intervention (rest of EU, ban on oral tobacco) had consistently worse results than the control (Sweden, no intervention), we would stop the trial and abandon the intervention. To continue with the trial and intervention, the burden of proof would clearly fall on those supporting the intervention to prove that Sweden was not representative or that some other factors are at work in the rest of the EU. Tomar et al haven't any evidence and don't even seem to think they should supply it – perhaps relying on an a priori argument that any ban on any tobacco product represents some sort of progress. Sweden is not a controlled trial of course, but snus is not a medicine and long term changes in market structure do not lend themselves to such trials. Sweden shows us what is possible, and we forego that potential at our peril and at the expense of unfortunate people addicted to smoking and nicotine.
Sweden almost certainly is different to the rest of Europe – if only by virtue of history and the length of time this market has been established. But that is a reason to expect the benefits in the rest of Europe to be less and slower, not a reason to prevent that change in market structure ever occurring or a basis for believing that the effects would be the opposite in the rest of Europe. The EU justified its ban on the basis of a assumption that smokeless tobacco would unleash a plague of oral cancer and be a major gateway into smoking. Though this was muddled thinking from the outset, the evidence is clear from Sweden, and the opposite appears to be the case - there is no gateway and apparently little risk (and minimal compared to smoking). As the economist John Maynard Keynes famously said: “When the facts change, I change my mind. What do you do?”. In Europe, many of us are changing our minds.
So, let me restate the question – where is the evidence base that justifies this highly irregular intervention, especially in the face of evidence from Sweden that not banning the product contributes to a public health gain there? How do Tomar et al know their implicit backing for the highly irregular oral tobacco intervention in Europe isn’t simply killing more Europeans? Given what we know about how it works in Sweden, and given that the evidence shows relatively low risk of serious harm from using this product compared to smoking, don’t they think it would be wise to have some evidence to back the case for maintaining this intervention in the rest of the EU? I say they have implicit support for the EU ban because they raise difficult to impossible evidential hurdles to justify a move away from the ban, while offering no evidence to support it.
Tomar et al worry that people that would otherwise never use tobacco might use oral tobacco if it was unbanned in Europe. The question should be inverted – especially because of what we know in Sweden. How do they know that there are not people that would use snus instead of smoking or quit smoking using snus had it not been banned? Tomar et al pose this question as if it is a ‘red line’ and that it must be shown that no-one who would not otherwise use tobacco would use an oral tobacco product if it was unbanned. What if, more realistically, there was less smoking as smokers switched to snus or quit but some people that did use oral tobacco that would otherwise not have been tobacco users? The balance of risk and benefit (and civil liberties) is on the side of unbanning oral tobacco because oral tobacco is not especially harmful and there is little sign of a gateway to smoking. On the other hand, anyone displacing smoking or quitting with oral tobacco use experiences a considerable reduction in risk. Tomar et al offer no thoughts on this balance, though it is a central concern and has been discussed in Tobacco Control [2].
Tomar et al also resort to setting impossible evidential hurdles – "If smokeless tobacco has played any overall positive role in Swedish health, what is the relevance of the experience to other countries?" I have discussed above how the burden of proof is really with them, but how could anyone prove to their satisfaction how the tobacco market would respond to the unbanning of snus in Europe without unbanning it and conducting market surveillance? But they want the proof as a pre-condition for unbanning it. The most sensible way forward is to unban the product and conduct market surveillance, adjusting the regulatory regime if needed - and, yes, banning it again if it all goes wrong or the manufacturers behave badly. One could even envisage a 'sunset' clause on the lifting of the ban, requiring it to be reaffirmed in 10 years time.
Tomar et al use contradictory arguments at different times. For example they raise the (evidence-free) theory that smokeless tobacco may help smokers deflect the pressure to quit arising from smoke-free policies. In their e-response, they worry about "deadly delays in quitting smoking with the support of smokeless tobacco to manage smoking restrictions." But in their initial commentary [3] they attribute the low smoking prevalence in Sweden to the effectiveness of smoke-free policies specifically amongst men despite their high use of snus, suggesting that: "therefore, men would be more likely than women to be impacted by smoke-free workplace regulations". Hmmm… now which is it?
Let us also address the question of regulation. Yes it is true that a regulatory regime for smokeless tobacco and all tobacco products would be ideal. But the real issue is what should happen in what could be a long (or indefinite) interim period before such a regulatory regime is in place. Should the absence of a comprehensive regulatory regime justify the European ban or American disinformation? I believe not, because even without regulation these products are far less hazardous than cigarettes. The difference between smokeless tobacco products is small compared to the difference between smokeless products and cigarettes. Regulation is highly desirable, but not essential to justify a change from the status quo in the EU. If the EU simply moved to the same position as the US, that would represent progress in the EU because smokers would no longer be denied this option and would at least have the choice available in Sweden, if not the ‘endorsement’ of elements of the public health community.
However, there is a very good opportunity in unbanning snus to introduce world-leading regulation in the EU. There is a risk that the opportunity will be bungled, either because the public health community remains in denial and slumbers through the opportunity, or because there will be excessive zeal in applying regulation. In the latter case, the danger is that over-strong regulation would leave in place counter-productive asymmetries in regulation between smoking and smokeless tobacco. Regulation shouldn’t be so exacting and one-sided that it prevents the market functioning for public health in the way it has so far succeeded in Sweden. The same argument applies to pharmaceutical nicotine, where the excessive caution of regulators and manufacturers and over-zealous regulation is a barrier to clean nicotine maintenance products and competitors to tobacco and so, paradoxically, works against the wider public health interest [4].
The EU already has a regulatory regime for marketing – tobacco advertising, sponsorship and promotion is not regarded as legitimate free speech, and is banned. The more challenging regulatory question is whether smokeless companies should have some tightly defined partial exemption from that in order target smokers to switch.
Finally, please note that this response and my others are only from me, not ‘Bates et al’, and therefore do not include my fellow authors of the printed article.
[1] Tomar et al, A Reply to Bates et al. and Foulds et al. Tobacco Control e-response, 19 December 2003.
[2] Kozlowski L. et al. Applying the risk/use equilibrium: use medicinal nicotine now for harm reduction Tob Control 2001;10:201 -203
[3] Tomar SL, Connolly GN, Wilkenfeld J, Henningfield JE. Declining smoking in Sweden: Is Swedish Match getting the credit for Swedish tobacco control’s efforts? Tobacco Control2003; 12:368-59
[4] McNeill A, Foulds J, Bates C. Regulation of nicotine replacement therapies (NRT): a critique of current practice. Addiction 2001; 96: 1757-1768.
I read with interest the recent article by Graham and Owen (1), which
explores the socioeconomic differentials in underreporting of smoking
during pregnancy. The authors are to be congratulated for preparing such
an interesting, thought-provoking, and timely study on this subject.
However, it seems important to emphasize that in addition to self-
underreporting (or denial) of smoking status in pregnancy the problem also
li...
I read with interest the recent article by Graham and Owen (1), which
explores the socioeconomic differentials in underreporting of smoking
during pregnancy. The authors are to be congratulated for preparing such
an interesting, thought-provoking, and timely study on this subject.
However, it seems important to emphasize that in addition to self-
underreporting (or denial) of smoking status in pregnancy the problem also
lies in low level of suspicion on the part of health care providers for
addiction to tobacco in pregnant women.
While the illicit drug use in pregnancy has received significant attention
over the past two decades far too little attention has been given to the
consequences of the use of “social drugs” such as tobacco, ethanol and
caffeine, which are by far the most commonly used substances in pregnancy.
While the deleterious effects of cocaine, amphetamines, and opioids on the
mother and the fetus are more pronounced and easier to detect, the
addiction to tobacco, ethanol and caffeine is usually subtle and more
difficult to diagnose (2). As a result recreational use of tobacco in
pregnancy may continue undetected, significantly effecting pregnancy
outcome and obstetric and anesthetic (labor analgesia) management of these
patients.
Approximately 80% of women who smoke before pregnancy continue to smoke
when pregnant (2). Low cigarette consumption prior to pregnancy is the
best predictor for smoking cessation in pregnancy. The majority of
patients with a history of drug use in pregnancy (including tobacco) deny
it when interviewed by primary care physicians, obstetricians and/or
obstetric anesthesiologists (3). Risk factors suggesting tobacco use in
pregnancy include lack of prenatal care, respiratory complications and
history of premature labor. A high index of suspicion for tobacco (as well
as other social and illicit drug) use in pregnancy, combined with non-
judgmental questioning of every parturient is therefore necessary.
REFERENCE:
1. Graham H, Owen L. Are there socioeconomic differentials in under-
reporting of smoking in pregnancy? Tob Control 2003: 12: 434.
2. Kuczkowski KM. Tobacco and ethanol use in pregnancy: implications for
obstetric and anesthetic management. The Female Patient 2003; 28: 16-22.
3. Kuczkowski KM. Labor analgesia for the drug abusing parturient: is
there cause for concern? Obstet Gynecol Surv 2003; 58: 599-608.
An important discussion of issues is being missed in a rash of name
calling. Let’s back up, recognize our common goals and see if we can
discuss issues and skip the personalities. We believe that the letters of
Foulds et al and Bates et al badly mangled our comments and took
statements out of context. Foulds et al. and Bates et al. obviously feel
the same about our article. This issue has precipitated name calling,
qu...
An important discussion of issues is being missed in a rash of name
calling. Let’s back up, recognize our common goals and see if we can
discuss issues and skip the personalities. We believe that the letters of
Foulds et al and Bates et al badly mangled our comments and took
statements out of context. Foulds et al. and Bates et al. obviously feel
the same about our article. This issue has precipitated name calling,
questioning of integrity, even rather defamatory slogans used to attack
those with differing opinions ranging from “quit or die” to “flat earth
believers”. Clearly, we disagree on several aspects of the issue, even
while agreeing on others (such as the importance of efforts to reduce
death and disease in those who continue to use nicotine without
undermining prevention and cessation). This core point of agreement is
shared by many of us engaged in this debate. It is unfortunate, and
frankly very discouraging, that the differences seem to be resulting in
more vitriol than are the common values resulting in constructive dialog.
Many of the specific comments of Foulds et al. will be addressed in a
subsequent response. Here we would like to briefly address some of the
main issues. Our commentary takes issue with the position of Bates et al.
and Foulds et al. which calls for a role for smokeless tobacco in tobacco
control efforts to reduce smoking. We believe that Bates et al. and
Foulds et al. overstate the benefits and generality of the Swedish snus
experience and that they understate the risks and areas of uncertainty.
Not surprisingly, they imply that we have overstated the risks and
understated the benefits in our urge for caution and a regulated playing
field. As we note in our commentary:
“If there is a role for oral tobacco in a comprehensive effort to
reduce the death toll from tobacco use, then its manufacture and marketing
must be overseen by an agency with comprehensive regulatory authority. A
regulatory agency should be open to all strategies that are scientifically
based and that will save lives. However, the decision about what role
oral tobacco plays in that overall scheme is a decision that can only be
made by an agency that has all of the relevant information.”
The fact that a population of persons using exclusively smokeless
tobacco is at overall lower risk of most forms of smoking caused disease
is not disputed by us. We do assert that smokeless tobacco has been
repeatedly demonstrated to be a deadly addictive product that causes a
variety of serious and life-threatening diseases as documented in the
Institute of Medicine Report (IOM) (see pages 426-429 and 563-564 for a
review of widely accepted oral diseases and attributable cancer). With
regard to Swedish smokeless tobacco, at least as marketed in Sweden, we
concur with the conclusion of that report on page 167 as follows: “It may
be considered that such products could be used as PREPs [potentially
reduced exposure products] for persons addicted to nicotine, but these
product should undergo testing as PREPs using the guideline and research
agenda contained herein.” Neither we nor the IOM Report are ready to
accept extant data as sufficient for endorsing smokeless tobacco for harm
reduction. Furthermore, we support the general strategies recommended by
the IOM Report to develop the data that would enable such and endorsement.
We apparently differ from Foulds et al. and Bates et al. in our call for
such data. We stand by our position.
Perhaps the most important issue implicit in our concerns about our
colleague’s characterizations of the Swedish experience is their explicit
or implicit judgment that it is relevant outside of Sweden. Bates et al.
do not recite their analysis of the Swedish experience solely for
rhetorical purposes or to support its continuation in Sweden. They cite
it in support of its application outside of Sweden to greater Europe and
beyond. Similarly, because we were asked to provide a commentary for the
Tobacco Control issue as Americans, we responded to this analysis with our
concerns about the application of the Swedish experience to the United
States and elsewhere. We noted that the U.S. Smokeless Tobacco Company
(UST) did not cite the Swedish snus experience in its pleadings before the
Federal Trade Commission in order to gratuitously commend Sweden: UST was
making a pitch to expand its marketing of smokeless tobacco in the United
States, armed with government endorsed harm reduction claims which it
argued could then be made for all if its products, including those known
to be gateways to tobacco use among youth and those that are among the
highest in cancer-causing nitrosamines. In fact, neither the Foulds et
al. nor Bates et al. reviews noted that outside of Sweden, even Swedish
Match products are higher in cancer-causing nitrosamines than they sell in
Sweden.
Thus, a fundamental question for all tobacco control experts is as
follows: If smokeless tobacco has played any overall positive role in
Swedish health, what is the relevance of the experience to other
countries? Moreover, what questions should tobacco control leaders
consider before endorsing smokeless tobacco as a component of
comprehensive tobacco control strategies? We have many questions about
the benefits attributable to snus in Sweden. Moreover, we are very
concerned about the potential for expanded smokeless tobacco marketing in
the absence of comprehensive tobacco and nicotine product regulation,
particularly if endorsed by public health advocates, to cause more damage
to public health than it will to improve public health. The potential
risks are numerous and include: Deadly delays in quitting smoking with
the support of smokeless tobacco to manage smoking restrictions. Uptake
of smokeless tobacco by persons who would not have otherwise used any
tobacco product. Substitution of the most popular high nitrosamine
smokeless products in the U.S. and as available most everywhere but Sweden
for cigarettes as an alternative to complete tobacco cessation.
Graduation from smokeless tobacco use to cigarette smoking as has already
been well documented in the United States.
Finally, it is not as if there are no alternatives to reducing
smoking prevalence. As demonstrated in California, Florida, Mississippi,
and Massachusetts, dramatic reductions in youth smoking initiation and
adult smoking prevalence can occur, as compared to surrounding states,
without advocating snuff use or trading cigarettes for snuff, but rather
on the basis of comprehensive tobacco control efforts.
Other tobacco control experts will need to carefully examine the
data, weigh their concerns, and come to their own conclusions. We remain
concerned about the place of smokeless tobacco in tobacco control and will
continue to insist that that comprehensive tobacco regulation should be
the prerequisite for its further consideration.
Scott L. Tomar,
University of Florida, Division of Public Health Services and Research,
Gainesville, Florida, USA
Greg N. Connolly,
Massachusetts Tobacco Control Program, Boston, Massachusetts, USA
Judith Wilkenfeld,
Campaign for Tobacco-Free Kids, Washington, DC, USA
Jack E. Henningfield,
Pinney Associates, Bethesda, Maryland; and Johns Hopkins University School
of Medicine, Baltimore, Maryland, USA
Dr Gupta’s letter suggests that the reduction in lung cancer in both Sweden and Connecticut is highly likely to be due to a reduction in smoking in both places. This is entirely unsurprising, and as far as Sweden is concerned is precisely what we suggested in the original paper he referred to:
“There has been a larger drop in male daily smoking (from 40% in 1976 to 15% in 2002) than female daily smoking (34% in...
Dr Gupta’s comparison of trends in lung cancer mortality and smoking prevalence in Sweden and Connecticut purports to undermine the claim that increasing snus use in Sweden has contributed to declining lung cancer rates there.
Dr Gupta argues that some factor other than snus must have been at work because the ratio of lung cancers between Sweden and Connecticut has remained constant despite the large differenc...
Dear Editor
Some tobacco control community members believe that advocating the use of snus, a form of Swedish smokeless tobacco said to be less harmful than cigarettes, would prove an effective harm reduction strategy against tobacco related diseases. One important basis for such a claim is the fact that snus is widely used in Sweden (23% men used snus daily in 2002), where the incidence of cancer caused by tob...
Reduction as a permanent solution may give people false expectations Thanks to Dr. John R Hughes for his interesting remarks of 20 January 2007 to our article (TC 15:472-480). We have the following comments: 1. Dr. Hughes states that our main finding (no health benefit from reducing cigarettes) has not been found in the few prior prospective studies of this topic. This is not correct. Based on a large study population in C...
The recent study by Tverdal and Bjartveit (TC 15:472-480, 2006) that found no health benefit from reducing cigarettes had several assets not found in the few prior prospective studies of this topic; e.g. the reducers had reduced by over 50% and several outcomes were measured.
I would, however, like to make two comments. First, one asset of the study was the examination of "sustained reducers;" i.e., those who...
My attention has been drawn to an error in our paper. At reference #3 we state that Addisson Yeaman was legal counsel to Philip Morris. He was in fact legal counsel to Brown & Williamson. The mistake arose because the document was in the Philip Morris collection and was misinterpreted as being a Philip Morris document. Also, it dates from 1963, not 1964 as stated.
After nearly two-fold efficacy over placebo in most clinical studies, NRT has proven no more effective than quitting without it in all real-world quitting surveys conducted since adoption of the June 2000 Clinical Practice Guideline (CPG): Minnesota 2002, California 2003, London 2003, Quebec 2004, Maryland 2005, UK NHS 2006, and Australia 2006.[...
As the public interest attorney and law professor who first developed the concept of using legal action as a weapon against the problem of smoking (e.g., getting antismoking messages on TV and radio, driving cigarette commercials off the air, starting the nonsmokers’ rights movement, etc.), I was delighted to read a paper suggesting the feasibility of using legal action to more effectively prod physicians to warn patient...
I find the argument provided in the paper to be non-compelling because it fails to provide any reasonable argument for how the 3rd showing in a medical malpractice case - that there is a causal relationship between the breach of duty and the incurred injury - could possibly be met in a smoking malpractice case. This would require proving to the jury that the physician's failure to warn the patient to quit smoking was th...
The paper by Henningfield, Rose and Zeller is an important contribution to understanding the all-too-clever manipulation of language by tobacco industry in defending its manufacture and marketing of an addictive product. It is useful to note, as on the authors' Table 1, that while the industry now publicly acknowldeges that cigarette smoking is addictive, it never mentions nicotine as the principal addictive agent. The...
Table 1 contains two errors. The observed death rate from all cancers combined among women in 1991 was 175.3 per 100,000 in 1991 (not 173.3). The percentage decrease in the death rate from 1991 to 2003 was 8.4%. We noted and corrected both errors in the galleys but the corrections were not picked up by the copy editor.
The recent article by Gilpin, et al.,[1] reported the major initial impact of California’s tobacco control efforts was to initially reduce cigs/day among continuing smokers and this was followed by an increase in quitting.[1] We would like to make three comments on this paper.
First, this study was one of the first to decompose the effects of tobacco control into effects on initiation, cessation and reducti...
Care is needed when using aggregate smokeless tobacco (SLT) consumption data to examine the potential for SLT being used as a potential reduced exposure product. As far as I am aware very few people, if any, are suggesting that traditional chewing tobacco be used as an aid to smoking cessation; any hopes in this area have been focused on moist smokeless tobacco (MST).
Data from the US Alcohol and Tobacco Tax an...
The eletter entitled "A Personal Experience with Goza and Shisha Smoking is authored by only FOUAD A. Al-BELASY. The names of other co- workers were mistakenly entered during submission from below the bar displaying how to enter other colleagues.
Shisha, Goza, Hashish and Street Children: What the Egyptian Scene Teaches Us
For historical, sociocultural and health reasons, Egypt is cer...
Shisha vs. “Water-pipe” : The Question of a Unifying Term
...Dear Editor,
This is to comment on the following recently published eletter:
The issue of nomenclature: Wasim Maziak (17 June 2006)
In a dictionary search for Hookah, Hubble-bubble, Narghile, Arghile, Water-pipe and Shisha, the Oxford Paperback Dictionary [1] defines Hookah as an oriental tobacco pipe with a long tube passing through a glass container that cools the smoke as it is drawn thr...
I thank the authors of letters regarding our published work (Ward et al, 2006) on their useful remarks. It is self-understandable that no one uses the world waterpipe when asking the public about this tobacco use method, but use the local word for it. The same way that we never ask the public about ischemic heart disease but use this term extensively in research papers about this problem. It is also understandable that t...
Dear Editor,
This is to comment on the following recently published eletter:
Chaouachi K: Syria, Lebanon, Tobacco Research in General and Narghile (Hookah, Shisha) Smoking in Particular. TC Online 8 June 2006.
I completely agree with the statement that Shisha is now used internationally because of the global hookah craze whereas “waterpipe” is no hypostasis and adhere to the notice that this wo...
Being a son of a famous well-qualified owner of a café shop, I have been, since the early days of my perception, in direct contact with Goza and Shisha smokers. Goza is a modified form of Shisha. It has its head, body, water-container, and hose [1]. However, Goza has no mouth-piece separated from the hose and no disposable plastic mouth-piece is served or commonly used. Yet, the water-container of Goza was and still is ma...
Dear Editor,
This is to comment on the following recently published study:...
When I was 16-years, I lived a very rough life and found myself in the foster-care pool. I came to live with Gloria and Bill Tuttle, and stayed for a few months. I was a very disturbed and distraught child, and I did not get along well with Gloria at all. (In hindsight it wasn't because she was mean, it was because she was in charge!!!) Bill was another story all together. He was quiet. Almost serene. He was tired a lot...
Would sildenafil (Viagra) or tadanafil (Cialis) ameliorate ED in men who smoke? Was use of these medications asked about in the study?
Norbert Hirschhorn MD
Dear Editor,
Studying the social context of cigarette smoking was acknowledged as a pressing need in tobacco control. However, with new emerging health concerns like the growing use of the hookah (narghile) in the world, the social context, which bear similarities in both individual and collective smoking, also shows great differences that need to be reviewed. This letter introduces the reader to the specificit...
Less Harmful cigarettes do exist, but the majority of the smoking public is unaware that they are available. Isn't it about time that our government establish an agency that would regulate all tobacco products? I have recently been made aware of a new company that makes a less harmful cigarette. The companies name is Wellstone Filters(lowertar.com), and they have a developed a special cigarette filter that is patented and...
It would have to be seen as the most intriguing question of our era; to understand how, with all the most educated of scholarly voices abdicating for world wide smoking bans, how not one of those participants has the vision to see outside the box. To understand with very little imagination how beneficial it could be to society as a whole to simply look at the product before punishing it’s victims. When we view tobacco a...
I read the article by Offen et al with great interest. It is an excellent elucidation of the concepts of ‘boycott,’ ‘buycott,’ and ‘perimetric.’ One opportunity for perimetric action not mentioned is the option each academic has to boycott and/or draw attention to universities and medical schools that accept tobacco industry funds or hold tobacco stock. (1) The converse is equally appropriate; ‘buycott’ centers that hav...
The trial testimony of Sanford Barsky, offered by David Egilman in his email letter to Tobacco Control, provides an illustrative example of why tobacco industry sponsored research should not be published in Tobacco Control or other responsible scientific periodicals. In the testimony Barsky argues for non-tobacco causation of a case of squamous cancer of the lung. Examination of tobacco industry documents housed in the...
While I'm delighted that these tobacco industry trial products of unproven merit continue to "taste like s__t" (-a reference to the RJR president's famous quote in "Barbarians at the Gate"), I hope that we'll not see much more of OSH's time spent on what amounts mostly to market research valuable to the tobacco malefactors.
I certainly agree with most of the comments of Dr Kamal Chaouachi but the need to develop one generic name for the different types of this form of tobacco smoking is definite and we tend to prefer the term water- pipe smoking as it denotes the similarity that links all these forms and shapes and local names. Certainly these different names are associated with local geographical languages and idenified best in the reps...
Dear Editor,
We wish to draw your attention to some misconceptions in the following study:
Rima AFIFI SOWEID. Lebanon: water pipe line to youth. Tobacco Control 2005;14:363-4.
>"In Lebanon, youth and women are the target of a marketing campaign featuring a new tobacco product for use with the more traditional water pipe."
The caption for the embedded picture is a an erroneous int...
Prochaska and Velicer have commented on this trial(1), and, having been alerted to this comment elsewhere, we feel we need to respond belatedly. They suggest the study had important flaws but do not name them. We drew attention to those flaws in the conduct of the study in the report. The major flaw was that midwives in the control arm were less enthused about the intervention and complied with the protocol less well,...
As Professor Chapman has noted some have questioned the merits of publishing papers that the tobacco industry funded. In the spirit of Justice Brandeis who noted that, “Sunlight is the best disinfectant” I believe that more not fewer tobacco industry consultants opinions should see the light of day. For example I believe that court room opinions offered under oath, by tobacco hired historians, physicians and others sho...
A reader has enquired about the funding source for this study. It was the the National Cancer Institute of the US National Institutes of Health. SC- Editor
I would like to propose some additions to Carter’s excellent review paper on Tobacco document research reporting. That is a major contribution to tobacco document research (TDR) methodology.
While discussing possible lessons from historical research to TDR Carter mentions the interpretation of facts. Occasionally the difficulty with TDR lies in establishing the facts (e.g. if plans were implemented). One me...
Simon Chapman's pictures on page 367 of the latest Tobacco Control points out that the 7-11 chain of convenience stores in Thailand was refusing to cover their cigarette products as required by the Ministry of Health's requirements on advertising. They are now complying with the regulation and do not have the open display of cigarette products. This means that all retail shops in Thailand are no longer displaying any...
Since my original publication in 1995 reporting high rates of denial of smoking in Japanese women,1 and Prof Yano's alternative assessment of the evidence,2 there has been an ongoing correspondence between the two of us.3-6 In his latest letter6 Yano asks whether my paper1 should have been published because it suffers from "erroneous interpretations based on invalid measurements."
My calculations critically depe...
Nathan K Cobb raises an important point. This paper has been reviewed by the Centre for Reviews and Dissemination [1], which provides critical assessments of the quality of economic evaluations. They raised this issue along with some other noteworthy points relating to the costs of the program. Specifically, the costs and the quantities were not reported separately, which limits the generalisability of the authors' results...
In the latest issue of Tobacco Control, Radu and others report on tobacco use among Swedish schoolchildren (Tobacco Control 2005;14:405- 408). As a Swede, I was surprised to read about some of their findings.
Children who smoke daily or almost daily are defined as “regular smokers”. The percentage of regular smokers is reported to have decreased to 4 per cent among 16-years-old boys and 15 per cent among girls by...
In a visit to Catalonia in Spain during October 2005, I noticed a number of changes in the smoking culture and regulations, compared to a visit in 2001.
Smokefree legislation is expected to be passed in 2006. The Catalonia regional government plans to take up the same tough stance as Ireland, the Netherlands and Norway. But there are already changes in Catalonia.
In comparison to 2001, I came across sev...
Dear Editor,
When we received the August 2005 issue of Tobacco Control, we found much in it to help inform our work, as usual.
I am writing, however, because we have some concerns about one of the articles published. “The perimetric boycott: a tool for tobacco control advocacy,” is described as a comprehensive analysis of a number of boycotts, including one organized by Infact (now Corporate Accountabi...
The recent article by Al-Delaimy et al (TC 14:359) makes two conclusions. The first is that use of over-the-counter (OTC) nicotine replacement therapy (NRT) for reasons other than smoking cessation is uncommon. This result is consistent with several other studies not cited in this letter (Nic Tobacco Research 6:79; Nicotine Safety and Toxicity (N Benowitz, ed) p 147). The second conclusion is that "some smokers may be...
When Hong and Bero published their study �"How the tobacco industry responded to an influential study of the health effects of secondhand smoke�" in 2002, I was supporting the law suit against a railway company to get smoke-free environment for workers and passengers in Japan. At that time, non-smokers had been annoyed by secondhand smoke for a long time regardless of our many claims. The company had been denying the harmfu...
...
I am the “WDE Irwin” quoted on page 67 as follows: “Years later (1985), WDE Irwin, a technician with BAT in England, was asked how a grooved filter could be made that would avoid criticism but also provide good taste. He concluded: ‘Finally for cigarettes, I believe it to be a self evident truth not only is there no smoke without fire, but also there is no kick without smoke.’”
“Technician” is not a correct id...
To the Editor,
I read with great interest the article by Bjartveit and Tverdal (2005), who investigated health consequences of smoking 1-4 cigarettes per day. They found that in both sexes, smoking 1-4 cigarettes per day was associated with a significantly higher risk of dying from ischaemic heart disease and from all causes, and in women, from lung cancer [1]. Genetic studies suggest that all stages of tobacco...
Dear Editor,
We thank Dr Graham F Cope for his valuable remarks, and agree that underreporting of daily cigarette consumption might be of importance when assessing the risk in light smokers.[1]
Dr Cope refers to two papers: a cross-sectional randomised study on smoking reduction in pregnant women, and an assessment of smoking status in patients with peripheral arterial disease.[2][3] Our study did not conc...
I read the paper by Bjartveit and Tverdal with a great deal of interest(1). I welcome the fact that highlighting smoking, even a small number of cigarettes has a significant effect on ischaemic heart disease. However, these findings should be considered with a certain amount of scepticism, as the findings are based entirely on self-reported smoking habit. Biochemically validated research, both by ourselves(2), and other...
British American Tobacco (Nigeria) Limited (BAT) and their cohorts the world over should come to terms with the fact that the truth cannot be hidden forever even from the man on the streets.
Mr Kehinde Johnson did not need to comment at all because there was nothing to comment about! He should have apologised for being a part of this systematic elimination of defenceless people the world over.
Dr. Chri...
Response to E Yano and S Chapman
P N Lee
Professor Eiji Yano raises a number of issues in his letter(1) which responded to my commentary(2) on his article(3) about the Japanese spousal study, as does Chapman in his editorial(4). Here I reply to the main points raised.
INTERPRETATION OF THE DATA
Studies of environmental tobacco smoke (ETS) exposure and lung cancer commonly identify a...
An excellent PM documents review! Thanks!
Allowing the tobacco industry to define "reasonable regulation," an industry whose economic survival will always depend upon finding new and creative ways to entice children and teens into permanent chemical enslavement, is like allowing Hitler to write health standards for dead camps.
While awaiting fine-tuning of FDA regulatory bills, it's time for the U....
I enjoyed Derek Yach’s editorial. I believe that the FCTC and new research that will support its transnational aspects can make a big difference. But will they?
I would warn against over optimism and for an understanding of the commitment and sustained action that will be required. First, one must face the fact that the primary governance of tobacco issues has been and continues to be located in the tobacco...
Erratum to Mandel, L; BC Alamar; and SA Glantz, “Smokefree Law did not affect revenue from gaming in Delaware” Tobacco Control 14 (2005), 10-12.
The results in the original publication reflect a data entry error. The revised table in this erratum present the results with this error corrected. Using the corrected data, White's test for heteroskedasticity rejected homoskedasticity (p = 0.016) in t...
We would like to correct reference #68 in this article. The correct reference for the document is:
Brown and Willamson. (1980). No Title. Bates No. 544000497/544000504. http://legacy.library.ucsf.edu/tid/mgh10f00.
In their article, Anderson, Glantz and Ling explore messages of psychosocial needs satisfaction in cigarette advertising targeting women. We agree with the authors that counter-advertising should attempt to “expose and undermine the needs satisfaction messages of cigarette advertising”. They mention that “a message of escape from life’s hassles could be countered with a message that addiction further complicates an al...
In June 2002, months before this column was published, I published an essay in a number of Nigerian newspapers entitled: "The 17 Billion Poison House In Ibadan." The piece was my own way of pouring out my spilling disgust and accumulated indignation because of reports in the media earlier in April of the same year that the Obasanjo Administration had celebratorily granted permission to a so-called "leading cigarette comp...
To: BAT Nigeria Limited Mr. Kehinde Johnson Corporate & Regulatory Affairs Director
"Should we swallow a bait and have a lethal hook thrust in our throats just because the bait looked so appealingly delicious? What the tobacco companies manufacture has no single benefit, no redeeming feature. All it does is to kill and ruin .They are unwanted, loathsome and unwelcome "(Ugochukwu D. Ejinkeonye- The Black Busi...
Tobacco leaves which are used for manufacturing cigarettes are cultivated by the tobacco industry themselves, throughout the world.
If the tobacco industry is honestly keen in stopping the availability of counterfeit cigarettes on this earth, they should first of all stop cultivating tobacco leaves. One of the strategies that the industry employs to protect their business is to misuse the illicit cigarette in...
Ron Davis finds my analogy weak when I liken employers not hiring smokers (because as a class they take more time off work) to not hiring women of child-bearing age (because they may become pregnant or take time off for childcare). He notes that in the USA (as indeed in many nations) there are laws outlawing labour discrimination on the basis of sex or age, but not discrimination based on smoking status. Some nations also...
Dear Mr Kehinde Johnson,
It's so sad that you have joined your CEO to pretend not to know the facts here.
The products you produce in your factory are extremely poisonous apart from being addictive. All tobacco products irrespective of where they are coming from contain considerable quantities of nicotine and alkaloids. It has also been proven that tobacco from low or high yield cigarettes contain the sam...
Kehinde Johnson, Corporate & Regulatory Affairs Director, British American Tobacco (Nigeria) Limited, writing on behalf of Dr. Chris Proctor, of BAT's UK headquarters, fails to respond to the principal questions asked by Professor Simon Chapman of the University of Sydney and editor of the journal Tobacco Control.
In his posting to Tobacco Control's e-letters page, Mr. Johnson relies heavily on the judgment o...
BAT Nigeria Limited Mr. Kehinde Johnson Corporate & Regulatory Affairs Director
Re: Risky v. Lethal Cigarettes
Mr Johnson:
I am the former Vice President of R&D of one of your sister companies.
I read your response to Professor Chapman on the issue that counterfeit cigarettes are lethal, whereas genuine brands that you manufacture under controlled supervision are only "risky". Are you i...
To the excellent article by Bero, Glantz and Ling one may add the classical observation of RE Thornton of BAT about women's smoking behavior (1):
"[G]iven that women are more neurotic than men it seems reasonable to assume that they will react more strongly to smoking and health pressures.... [T]here may be a case for launching a female oriented cigarette with relatively high deliveries of nicotine...."
...
Dear Professor Chapman
I am responding to your email to Dr. Chris Proctor concerning media remarks attributed to Richard Hodgson, Managing Director of British American Tobacco Nigeria that, "tobacco use is risky but counterfeit cigarettes are lethal" which was published in ThisDay of January 16 2005
The Standards Organisation of Nigeria (SON) is the regulatory body focusing on tobacco control in Nigeria,...
I believe that colleges and universities must provide ethical leadership in research development, implementation, reporting and funding (not accept tobacco industry research money or researchers that do). They should not support tobacco industry investment or funding for institutions, seminars or fiduciary requirements. Any and all tobacco industry cooperation or collaboration is irresponsible because of the underlying...
On Jan 19 2005, having been alerted to the extraordinary statement shown on the cover of this issue of the journal (April 2005), I emailed the letter below to Dr Chris Proctor at BAT in the UK. He replied the next day asking when I would need the information sought. I replied immediately that I would like it within a week. No further response has ever been received from Dr Proctor.
I invite him here publicly to n...
My position in this debate, which has been a difficult one for the tobacco control community, is that I neither condone nor condemn hiring policies that favor non-smokers. However, I do support the employer's right to adopt such a policy if the employer so chooses. I believe this position—which is intermediate between the opposing views espoused by Nigel Gray and Simon Chapman—is the most appropriate and defensible po...
Thank you for your well done study.
I had a question about your measure of recall, which in effect requires the ability to think abstractly and verbalize to in fact 'prove' to the interviewer that the ad and its message were seen, heard, and 'digested'.
Our organization in NY, the Advertising Research Foundation, which may not be familiar to you, has embarked on a series of studies about the role tha...
The highest nicotine concentrations of this study have been found in Austria. Some background for this is given by http://tc.bmjjournals.com/cgi/content/full/14/1/3. Most amazing, however, was that these results had been presented to the Austrian press without causing a reaction. A study of Moshammer et al. (2004) Int.J.Hyg.Environ.Health 207, 4, 337-343 even showed high correlations of nicotine with active particle sur...
I have been a smoker for many years and have never attempted or had the desire to stop.
I will willingly compare my health care costs with any non-smoker.
I will challenge any non-smoker to match my absenteeism due to illness work record for the past 40 years.
Editor's comment: I can introduce the writer to alcoholics who have never had a car crash; to 5 winners in every game of Russian roulette...
I start by expressing my earnest pride of Tobacco Control and the status it acquired in a record time. I am certainly grateful for making it access-free for developing countries. However, I have some reservation regarding TC editorial policy that I have mentioned before, and for which I want to provide my motivations, speaking only about research articles.
Obviously the quest for quality cannot be debated and...
I have been looking for age progression software, do you have any suggestions on where I can purchase it?
Dear Dr Hirschhorn,
If you wish me to answer questions, it would seem more appropriate to write to me directly than to ask the questions in a journal without even drawing the existence of such a letter to my attention. However, I will explain the situation.
I met Enstrom for the first time in 2000 at a meeting which Philip Morris organised in Richmond, Virginia. We both gave talks. One of his talks...
I have analysed the US-funded review and I want to share some of my findings. I am afraid there are serious errors in this document and I will quote only two of them to give an idea of their scope.
ERRORS. “Waterpipe use likely increases the risk of bronchogenic carcinoma [68] as well as lung [16,20,69] oral,[8] and bladder [21,70] cancers.”
I will not discuss each of all the cited references bec...
The newly revived discussion of the Enstrom/Kabat California passive smoke study and conflict of interest led me to cite some addiional documents. The results of the study, as Bero et al show, were presented at a Philip Morris gathering, June 5-6 2000:
http://legacy.library.ucsf.edu/tid/urx85c00
This seminar was part of WSA/INBIFO programming, viz. to "organize two-day seminar with Mr. Peter N. Lee an...
It should have been noted that the research for this topic was sponsored in part by the World Health Organization.
Norbert Hirschhorn
After reading Editor Chapman’s description of the efforts that he and other anti-tobacco activist colleagues went through to ensure that tobacco companies are not involved in events regarding corporate social responsibility, I was left with disenchanting thoughts. I recall a few months ago while surfing on the web for information regarding corporate social responsibility tactics of the tobacco industry, I came across info...
the Philip Morris website admits the damage did and continues to do - they have to admit this given the massive amount of technical data available to prove this
In the USA Big Tobacco has paid billions of dollars to settle lawsuits issued by different States and to pay for the healthcare to treat the effects of their product
It is high time the HK Government filed a similar lawsuit or fear being sued it...
Mekemson, et al. [1] present a thorough study of the presentation of smoking in the top 50 grossing movies each year from mid-1991 to mid-2001 that concludes that the levels of smoking was either constant or decreased slightly. (The small, but significant, drop with time they report may be the result of the fact that the smoking was much higher than average at their first data point, 1991-92, making it a leverage point).
...Dear Norbert
Thanks you for this excellent explanation of the reality behind tobacco companies' dabbling in so-called CSR programmes.
Earlier this year INGCAT's member organisations agreed a position statment on tobacco industry CSR programmes that purport to address health and welfare issues, entitled "The socially responsible tobacco company - another misleading descriptor". The thrust of the positio...
Editor Chapman's report gives us great courage that the written word is in the end the most powerful tool for change, truth and enlightenment.
We know too from tobacco industry documents that some of the closest readers of TC are the executives of those companies.
Kudos and congratulations to the editorial team at TC.
Norbert Hirschhorn MD
Pokorny et al show that one must use a multilevel model to accurately identify contextual influences, such as school characteristics, on the behaviour of individuals. Neither aggregate models nor individual level only models will be accurate(1). This is a good point well made.
Unfortunately, Pokorny et al use aggregated school level perceived prevalence of smoking among peers as their contextual example variabl...
We have, as addiction scientists, as a goal, the desire to minimize addictive behaviors and thereby reduce negative outcomes and consequences. The AMA has this admirable goal in mind but their stated approach is not likely to get them there. Reducing nicotine in cigarettes has already been plainly demonstrated to increase tar and CO levels in smokers. We need to accept this and move in the correct direction, understanding...
The author of this artice says, "These classic children's books were first published in times when smoking was not widely acknowledged as harmful and a smoking adult male was one of the sex stereotypes". While this is true for the books cited, I have been looking for children's picture books with smokers in the illustrations for several years and am surprised how many current books as well as how many other older book...
Dear Editor,
I was interested to note the links between the tobacco and gambling industries outlined by Mandel and Glantz.(1)
I have recently discovered that at least one UK casino company is working with Healthy Buildings International (HBI), the indoor air quality consultancy firm part-funded by the Philip Morris tobacco company.(2) Previous research has demonstrated how the tobacco industry has used...
If blood lipid profile improves and weight increases with smoking cessation (1) smoking might be causally related to both the development of an abnormal blood lipid profile and the avoidance of weight gain or even weight loss. How then might smoking have increased the risk of non-fatal myocardial infarction in this study (2)? By reducing the capacity to respond to reductive stress with a further increase in the degree of...
McAlister and his co-authors make an extremely valuable contribution to the ongoing debates of health care costs in the form of their estimate of the cost efficacy of a telephone quit line. The publication of this data should provide new evidence to convince payors to cover cessation.
However, since recruitment costs were excluded, it is difficult to make broader public health decisions based on these estimates....
Dear Editor,
I am writing in response to the research paper, “Clearing the airways: advocacy and regulation for smoke-free airlines” by Holm and Davis, published in the March supplement of Tobacco Control, 2004. While Holm and Davis present an apparently comprehensive narrative of the events that lead to the legislative prohibition of smoking in aircraft cabins, one is left with the sense from their research of...
I have recently completed a doctoral thesis exploring the epistemological challenges associated with the inclusion of health promotion in medical undergraduate education.
Those challenges reflect the dilemmas associated with teaching about smoking cessation. It is in fact only recently that the UK NHS plan has suggested a consistent approach for the delivery of smoking cessation services and previous to that th...
In their e-letter of 19 December 2003, Tomar et al promised that "Many of the specific comments of Foulds et al. will be addressed in a subsequent response". No response has since been forthcoming.
Given that Tomar et al's contribution managed to avoid peer review and to appear in the paper edition of Tobacco Control as apparently the last word on the subject, I think it is beholden upon them to say what they...
Sir, I read with interest the paper by Cains et al. (2004) on the effect of “no smoking” areas in licensed clubs in the metropolitan area of Sydney. They found only an insufficient effect of “no smoking” zones especially when this was only a subsection of the whole room without separation. In spite of this finding this poor protection of the non-smokers is still much favoured in the hospitality industry around the world. T...
The findings presented by Roddy et al. [1] paint a dim picture of tobacco training in the UK, but rosier than that in U.S. schools of public health (SPH).
As part of the Association of Schools of Public Health(ASPH)/American Legacy Foundation “STEP UP” initiative, we administered an ASPH survey to the 27 faculty members of the San Diego State University Graduate School of Public Health (SDSU GSPH) and also to...
Cains et al., studying the extent to which designated "no smoking" areas provide protection from environmental tobacco smoke (ETS), conclude that such areas achieve some reduction in the level of exposure of individuals to ETS. They indicate an average 53% reduction in nicotine levels and 52% reduction in PM10 levels. These numbers, although not marginal, are not sufficient to provide an adequate level of protection....
On 24 February 2004, the United States Supreme Court, by a vote of 6 to 2, affirmed the judgment of the U.S. Court of Appeals for the Ninth Circuit in Olympic Airways v. Husain, a case mentioned in this article under the heading "Negligence." With no other avenue of appeal, Olympic Airways is now required to pay $1.4 million to the Estate of Dr. Abid Hanson because of its negligence.
Dr. Hanson's tragic death...
I always enjoy new research describing how medical students are not taught about tobacco use and smoking cessation. I teach medical students about tobacco use. One of the first things I teach students about tobacco use is that it is best considered a disease, not a risk factor. In the American Society of Addiction Medicine's Public Policy Statement on Nicotine Dependence and Tobacco in the Journal of Addictive Disease,...
I think the most important point to address in Tomar et al’s e-response [1] is their call for more evidence before any change to the status quo (the status quo is a ban on oral tobacco in the EU, and public health disinformation in the US). They say that “neither we nor the IOM Report are ready to accept extant data as sufficient for endorsing smokeless tobacco for harm reduction”. This stance does not reflect the real...
I read with interest the recent article by Graham and Owen (1), which explores the socioeconomic differentials in underreporting of smoking during pregnancy. The authors are to be congratulated for preparing such an interesting, thought-provoking, and timely study on this subject. However, it seems important to emphasize that in addition to self- underreporting (or denial) of smoking status in pregnancy the problem also li...
An important discussion of issues is being missed in a rash of name calling. Let’s back up, recognize our common goals and see if we can discuss issues and skip the personalities. We believe that the letters of Foulds et al and Bates et al badly mangled our comments and took statements out of context. Foulds et al. and Bates et al. obviously feel the same about our article. This issue has precipitated name calling, qu...
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