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.
ASH Ireland very much welcomes the comprehensive article on cigarette
waste by Smith and McDaniel. This is an issue ASH Ireland has been
actively engaged with. In November 2009 ASH Ireland met with the Minister
for the Environment, Heritage and Local Government (Leader of the Green
Party in Ireland) and outlined the scale of the problem to him and his
department. Cigarette waste accounts for nearly half of all the litter...
ASH Ireland very much welcomes the comprehensive article on cigarette
waste by Smith and McDaniel. This is an issue ASH Ireland has been
actively engaged with. In November 2009 ASH Ireland met with the Minister
for the Environment, Heritage and Local Government (Leader of the Green
Party in Ireland) and outlined the scale of the problem to him and his
department. Cigarette waste accounts for nearly half of all the litter
pollution in Ireland over many years. This is due to the indifference of
both smokers and the tobacco industry as to how to dispose of cigarette
waste. ASH Ireland has also submitted its analysis of the problem to the
public consultation process for a new waste policy. In addition ASH
Ireland has asked that 50 cent be levied directly on the tobacco industry
for every pack of 20 cigarettes that they seek to sell and that it be paid
at source by the tobacco industry. The tobacco industry could then pass on
the levy to their customer base should they so wish. The key point here is
that the State, which has to clean up cigarette waste, would put the
responsibility on the tobacco industry to pay for the waste problems
caused by their products rather than putting the responsibility on the
consumer. The revenue raised by such a levy could then be used to support
local government in their efforts to prevent and clean up after cigarette
waste pollution. Some of the funding could also be used to raise awareness
among young people as to the environmental harm that tobacco use causes
both at home and abroad. ASH Ireland would urge other tobacco control
organisations to raise this issue with their respective governments so as
to broaden our tobacco control activities and involve a wider discussion
on the negative effects of tobacco use.
Dr Fenton Howell
ASH Ireland
Denshaw House
Dublin 2.
NOT PEER REVIEWED
We welcome the timely review published by Hill et al. [1], and agree
that more research is needed to assess the equity impacts of tobacco
control interventions. The results of the review indicated that "increases
in tobacco price have a pro-equity effect on socioeconomic disparities in
smoking", but that "evidence on the equity impact of other interventions
was inconclusive [...]". The inconclusiveness o...
NOT PEER REVIEWED
We welcome the timely review published by Hill et al. [1], and agree
that more research is needed to assess the equity impacts of tobacco
control interventions. The results of the review indicated that "increases
in tobacco price have a pro-equity effect on socioeconomic disparities in
smoking", but that "evidence on the equity impact of other interventions
was inconclusive [...]". The inconclusiveness of findings with regard to
smoking ban policies may be partly due to date limitations for the
database searches, which included evidence from January 2006 through
November 2010. It may also be partly due to the assessment of equity in
outcomes that related only to active smoking. Although a benefit of
smoking ban policy implementation may be a reduction in active smoking,
this outcome is dependent upon an individual's personal response to the
intervention. However, the primary purpose for implementing comprehensive
smoking ban policies is to reduce secondhand smoke exposure among the
population through environmental change. It is therefore important to
assess whether the successful implementation of smoking ban policies has
pro-equity health effects.
Our previous research indicated that the national smoking ban policy
in the Republic of Ireland was associated with immediate reductions in all
-cause and cause-specific cardiovascular, cerebrovascular, and respiratory
mortality, and that these mortality reductions were primarily due to
reductions in population exposure to secondhand smoke [2]. Our subsequent
assessment of the socioeconomic differentials of these mortality
reductions in the Republic of Ireland suggested that inequalities in
smoking-related mortality were immediately reduced following smoking ban
implementation [3]. Furthermore, given the higher rates of smoking-related
mortality in the most deprived group, even equitable reductions across
socioeconomic groups resulted in decreased inequalities in mortality [3].
Partial smoking ban policies do not fully protect health [4], and are
likely to yield negative equity effects as a result of policy exclusions
for workplaces and hospitality venues located in more deprived areas [5].
In contrast, comprehensive smoking ban policies provide equal protection
for all against secondhand smoke exposure. Indeed, previous studies have
indicated that comprehensive smoking ban policies are effective public
health interventions for reducing both exposure to secondhand smoke and
other indoor air pollutants [6-11], the benefits of which are experienced
by all employees and patrons of restaurants, bars, and other public
places, regardless of individual socioeconomic group. Therefore, we wish
to highlight that the evidence for pro-equity effects of comprehensive
smoking ban policies may be more conclusive when additional health-related
outcomes are considered.
References
1. Hill S, Amos A, Clifford D, Platt S (2014) Impact of tobacco
control interventions on socioeconomic inequalities in smoking: review of
the evidence. Tob Control 23: e89-e97.
2. Stallings-Smith S, Zeka A, Goodman P, Kabir Z, Clancy L (2013)
Reductions in cardiovascular, cerebrovascular, and respiratory mortality
following the national irish smoking ban: interrupted time-series
analysis. PLoS One 8: e62063.
3. Stallings-Smith S, Goodman P, Kabir Z, Clancy L, Zeka A (2014)
Socioeconomic differentials in the immediate mortality effects of the
national Irish smoking ban. PLoS One 9: e98617.
4. Tan CE, Glantz SA (2012) Association between smoke-free
legislation and hospitalizations for cardiac, cerebrovascular, and
respiratory diseases: a meta-analysis. Circulation 126: 2177-2183.
5. Lewis GH, Osborne DC, Crayford TJ, Brown AC (2006) Partial smoking
ban would worsen health inequalities. Bmj 332: 362.
6. Fong GT, Hyland A, Borland R, Hammond D, Hastings G, et al. (2006)
Reductions in tobacco smoke pollution and increases in support for smoke-
free public places following the implementation of comprehensive smoke-
free workplace legislation in the Republic of Ireland: findings from the
ITC Ireland/UK Survey. Tob Control 15 Suppl 3: iii51-58.
7. Connolly GN, Carpenter CM, Travers MJ, Cummings KM, Hyland A, et
al. (2009) How smoke-free laws improve air quality: a global study of
Irish pubs. Nicotine Tob Res 11: 600-605.
8. Goodman P, Agnew M, McCaffrey M, Paul G, Clancy L (2007) Effects
of the Irish smoking ban on respiratory health of bar workers and air
quality in Dublin pubs. Am J Respir Crit Care Med 175: 840-845.
9. Mulcahy M, Evans DS, Hammond SK, Repace JL, Byrne M (2005)
Secondhand smoke exposure and risk following the Irish smoking ban: an
assessment of salivary cotinine concentrations in hotel workers and air
nicotine levels in bars. Tob Control 14: 384-388.
10. Valente P, Forastiere F, Bacosi A, Cattani G, Di Carlo S, et al.
(2007) Exposure to fine and ultrafine particles from secondhand smoke in
public places before and after the smoking ban, Italy 2005. Tob Control
16: 312-317.
11. Eisner MD, Smith AK, Blanc PD (1998) Bartenders' respiratory
health after establishment of smoke-free bars and taverns. JAMA 280: 1909-
1914.
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)
INTRODUCTION
Mejia et al1 argue that a harm reduction strategy based on promoting snus,
the form of smokeless tobacco widely used in Sweden, is unlikely to result
in any substantial health benefit to the US population. They divide the
population into five tobacco groups (never tobacco users, former tobacco
users, current cigarette smokers, current snus users, and current dual
users), attaching to each group an estimate of...
INTRODUCTION
Mejia et al1 argue that a harm reduction strategy based on promoting snus,
the form of smokeless tobacco widely used in Sweden, is unlikely to result
in any substantial health benefit to the US population. They divide the
population into five tobacco groups (never tobacco users, former tobacco
users, current cigarette smokers, current snus users, and current dual
users), attaching to each group an estimate of the "tobacco-related health
effect" (TRHE). By definition, TRHE is 0 in never smokers and 100 in
current cigarette smokers, with other smoking groups having intermediate
TRHE values, proportional to their relative excess disease risk. Mejia et
al consider various scenarios (e.g. "aggressive smokeless promotion")
which result in different predicted distributions by tobacco use, and
hence different estimates of the overall average TRHE for the whole US
population. For the "base case", with tobacco use distributions as they
currently are, this is estimated as 24.2, and under the various scenarios
considered the estimates lie between 19.2 and 30.5.
Their conclusion that snus promotion probably provides little health
benefit seems surprising. Given the strong evidence that health risks from
snus are much less than from smoking, one would intuitively expect a
substantial benefit if increasing snus promotion led to many smokers
switching to snus. It is useful therefore to look at the methodology used
and assumptions made.
FAILURE PROPERLY TO ACCOUNT FOR PATTERNS OF TOBACCO USE
There are some deficiencies in the approach. First, there are clealy
more than five relevant tobacco groups. Limiting attention to snus use
and cigarette smoking, there are nine main groups, representing each
combination of never, former and current use of each product. And within
some combinations, there are subgroups by sequence of events. Why, for
example, should TRHE be assumed similar in former tobacco users regardless
of whether snus or cigarettes were previously used, or similar in current
snus users who have or have not previously smoked cigarettes? Other
deficiencies include failure to consider age, sex, amount used, and other
tobacco products such as pipes or cigars. However, these are minor
compared to the failure to account for time in its various guises - time
since quit, time since switch, and time used snus or cigarettes. It is
unsound to assume TRHE is the same for all former users of tobacco
regardless of time quit, or the same for current snus users regardless of
previous smoking history. Failure to consider time undermines the validity
of the TRHE estimates for the different tobacco groups.
ESTIMATES OF TRHE BY SMOKING GROUP
Quitters
No justification is given for the TRHE estimate of 5 used by Mejia et al.
It seems very low. Relative all-cause mortality rates for current, former
and never smokers from the well- known CPS-II study2, indicates former
smokers have about 40% of the excess all-cause mortality rate of current
smokers, not 5%. The appropriate TRHE would be higher still for short-
term quitters. Was the value of 5 intended to relate to long-term
quitting?
Snus users
The justification for the TRHE estimate of 11 is unclear. It is much too
low, if applied to recent switchers from cigarettes, particularly
following long-term smoking. However, if intended only to quantify effects
of snus, it seems too high. Updates of published meta-analyses for snus
use for heart disease3 and cancer4 (details available on request) suggest
little or no increased risk, with combined relative risk (95% confidence
interval) estimates of 1.01 (0.91-1.12) for ischaemic heart disease, 1.05
(0.95-1.15) for stroke, 0.97 (0.68-1.37) for oropharyngeal cancer, 1.10
(0.92-1.33) for oesophageal cancer, 0.98 (0.82-1.17) for stomach cancer,
1.20 (0.66-2.20) for pancreatic cancer, and 0.71 (0.66-1.76) for lung
cancer. Given it is implausible that snus use might increase COPD risk,
given the lack of confirmed reports of increased risks for other diseases,
and given the much stronger relationships seen with smoking, the excess
risk from snus use is probably no more than 2% of that from cigarette
smoking and not as great as 11%.
Dual use
The estimated TRHE of 90 derived from INTERHEART 5 is not relevant to
snus, the smokeless tobacco use reported in that study being predominantly
in Asian and African countries. Though data are lacking, one might
imagine that if lifetime dual users get about half their required nicotine
dose from each source, a TRHE of about 50 might be appropriate. Again,
however, this would not apply to those changing from long-term smoking to
dual use.
HIGH ESTIMATES OF DUAL USE
The proportion of dual users predicted in some of the scenarios of up to
about 20% seem implausibly high. Recent Swedish surveys (e.g.6,7 give
estimates less than 3%. While adolescents in Sweden often try both
products, adults usually only use one. Models based on studies in
adolescents that do not take this into account may result in misleading
predictions of the tobacco use distribution, especially when the data
used8 relate to smokeless tobacco use, not snus.
SNUS AND INITIATION OF SMOKING
Some Swedish retrospective studies9,10 claim snus users are less likely to
initiate smoking than never tobacco users. While these claims are
questionable (failing to adjust for time available to initiate), evidence
that few Swedish smokers used snus before they started smoking9,10, and
that most dual users started on cigarettes, suggest snus can be at most a
minor determinant of smoking.
SNUS AND QUITTING SMOKING
In theory snus use might discourage rather than encourage quitting. No
published study in Sweden suggests discouragement, but many 9,11-15suggest
encouragement. Although these studies have some limitations, concern
regarding discouragement seems unjustified.
FURTHER THOUGHTS AND A SIMPLER APPROACH
The approach of Mejia et al is complex and does not validly allow
assessment of the effect on health of the various scenarios considered.
One problem is that promotion of snus cannot affect the risk
resulting from past smoking (particularly so for those who quit before
the promotion started), so that inclusion of this risk in the overall TRHE
estimates obscures estimation of the effects of the various strategies
discussed. It would seem better to compare the decline in risk for the
given scenario of snus promotion with that in a comparable scenario where
those assumed to switch to snus quit instead.
A second problem is that while their approach is complex, it ignores
many factors, such as time quit or switched, age, sex, and quantity used.
However, attempting to improve the model to account for these would likely
be valueless, given the uncertainties involved.
Also Mejia et al do not define what they call a substantial health
benefit. The strategy "aggressive promotion with most new users from
smokers" reduces the overall TRHE from 24.2 to 19.2, i.e by about 20%.
This seems quite substantial, especially so if it is a relatively short-
term effect. Would strategies directly encouraging quitting do better?
To my mind, they have obscured a simple situation. Complete
switching to snus seems likely to have a health effect virtually
equivalent to quitting, with partial switching (dual use) having an
intermediate effect. For smokers unwilling or unable to give up their
nicotine, switching to snus is clearly a much better health alternative
than continuing smoking. Promoting snus may produce some new tobacco
users, but these will have little or no excess risk of disease, and be no
more likely to take up smoking than are those who have never used tobacco.
(WORD COUNT: 1213)
REFERENCES
1. Mejia AB, Ling PM, Glantz SA. Quantifying the effects of
promoting smokeless tobacco as a harm reduction strategy in the USA. Tob
Control 2010;19:297-305.
2. US Surgeon General. Reducing the health consequences of smoking.
25 years of progress. A report of the Surgeon General. Rockville,
Maryland: US Department of Health and Human Services; Public Health
Services; 1989. DHHS Publication No. (CDC) 89-8411.
http://www.surgeongeneral.gov/library/reports/index.html
3. Lee PN. Circulatory disease and smokeless tobacco in Western
populations: a review of the evidence. Int J Epidemiol 2007;36:789-804.
4. Lee PN, Hamling JS. Systematic review of the relation between
smokeless tobacco and cancer in Europe and North America. BMC Med
2009;7:36:
5. Teo KK, Ounpuu S, Hawken S, Pandey MR, Valentin V, Hunt D, et al.
Tobacco use and risk of myocardial infarction in 52 countries in the
INTERHEART study: a case-control study. Lancet 2006;368:647-58.
6. Persson J, Sj?berg I, Johansson S-E. Bruk och missbruk, vanor och
ovanor. H?lsorelaterade levnadsvanor 1980-2002 (Health related habits of
life 1980-2002). Statistiska centralbyr?n; 2004, (Accessed Oct 2010).
(Levnadsf?rh?llanden (Living conditions).) 105.
http://www.scb.se/statistik/le/le0101/1980i02/le0101_1980i02_br_le105sa0401.pdf
With additional data supplied by E H?gstorp, Statistiska centralbyr?n,
2005.
7. Wadman C. Levnadsvanor - Tobaksvanor. Statens Folkh?lsoinstitut;
2009, (Accessed Oct 2010). http://www.fhi.se/sv/Statistik-
uppfoljning/Nationella-folkhalsoenkaten/Levnadsvanor/Tobaksvanor/
8. Severson HH, Forrester KK, Biglan A. Use of smokeless tobacco is
a risk factor for cigarette smoking. Nicotine Tob Res 2007;9:1331-7.
9. Furberg H, Bulik CM, Lerman C, Lichtenstein P, Pedersen NL,
Sullivan PF. Is Swedish snus associated with smoking initiation or
smoking cessation? Tob Control 2005;14:422-4.
10. Ramstr?m LM, Foulds J. Role of snus in initiation and cessation
of tobacco smoking in Sweden. Tob Control 2006;15:210-4.
11. Lindstr?m M, Isacsson S-O. Smoking cessation among daily
smokers, aged 45-69 years: a longitudinal study in Malm?, Sweden.
Addiction 2002;97:205-15.
12. Lundqvist G, Sandstr?m H, ?hman A, Weinehall L. Patterns of
tobacco use: a 10-year follow-up study of smoking and snus habits in a
middle-aged Swedish population. Scand J Public Health 2009;37:161-7.
13. Rodu B, Stegmayr B, Nasic S, Cole P, Asplund K. Evolving
patterns of tobacco use in northern Sweden. J Intern Med 2003;253:660-5.
14. Gilljam H, Galanti MR. Role of snus (oral moist snuff) in
smoking cessation and smoking reduction in Sweden. Addiction 2003;98:1183
-9.
15. Ramstr?m L. Is snus a model for harm reduction: the scientific
evidence from Sweden. In: The 13th World Conference on Tobacco OR Health:
Building capacity for a tobacco-free world, The 13th World Conference on
Tobacco OR Health: Building capacity for a tobacco-free world. Washington
DC, July 12-15 2006. 2006;
Conflict of Interest:
I am a long-term consultant to the tobacco industry, and this work was supported by Philip Morris
NOT PEER REVIEWED I commend the authors on a significant effort involved in conducting
this rather insightful research.
Having conducted qualitative research on FCTC implementation in the
Pacific, I can provide comment in relation to the Cook Islands which may
explain why MPOWER measures mentioned here did not achieve decreases in
prevalence (at least in the figures obtained in this study).
NOT PEER REVIEWED I commend the authors on a significant effort involved in conducting
this rather insightful research.
Having conducted qualitative research on FCTC implementation in the
Pacific, I can provide comment in relation to the Cook Islands which may
explain why MPOWER measures mentioned here did not achieve decreases in
prevalence (at least in the figures obtained in this study).
Firstly, the Cook Islands Tobacco Control Act was introduced in 2007
and accompanying regulations in 2008, and stakeholders informed me that
compliance to these regulations was not strictly enforced until 2009 -
hence their implementation on the ground may not have been felt until the
latter period of or after this data was collected.
Secondly, accurate, timely, comparative data on prevalence is
extremely difficult to obtain in many small island nations such as those
in the Pacific. I am unsure of the exact calculations behind the MPOWER
reports and how these figures were extrapolated, but they are likely to be
an estimation that is rather different to what other (national) studies
suggest. The Cook Islands Census suggests a decrease in prevalence from
29% in 2006 to 20% in 2011. The Cook Islands GYTS (limited to those aged
13-15) suggests a decrease from 45% in 2003 to 35% in 2008, indicating the
trend in prevalence is contrary to the statistics obtained in MPOWER.
These potential limitations are duly noted in your study, but I
thought this additional information would (a) be of interest and provide
some context to these issues, and (b) serve to caution anyone who may
suggest that MPOWER measures have not been effective in the Cook Islands
(or elsewhere).
Of course it would also be great to see further points of data
collection beyond 2009, which would also give a better indication of
trends over time.
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
We refer to the article, "Did the tobacco industry inflate estimates
of illicit cigarette consumption in Asia? An empirical analysis" Chen J,
et al. published in Tobacco Control on November 25, 2014 (Tob Control
2015;0:1-7) and concur with the important points raised in this article.
While the article focuses on Hong Kong, other countries in South East Asia
also faced a similar experience.
The...
We refer to the article, "Did the tobacco industry inflate estimates
of illicit cigarette consumption in Asia? An empirical analysis" Chen J,
et al. published in Tobacco Control on November 25, 2014 (Tob Control
2015;0:1-7) and concur with the important points raised in this article.
While the article focuses on Hong Kong, other countries in South East Asia
also faced a similar experience.
The authors revealed that the tobacco industry-funded study on the illicit
trade of cigarettes in Asia, "Asia-11 Illicit Tobacco Indicator 2012" by
the International Tax and Investment Center (ITIC) and Oxford Economics
(OE) inflated the extent of illicit consumption in Hong Kong by 133-337
percent. Similarly, other scholars have also questioned the methodology
applied in this report. For example, Dr. Frank Chaloupka, Distinguished
Professor of Economics at the University of Illinois at Chicago,
criticized the reliability of the study's estimates in using an
inconsistent approach and the lack of details about the empty pack
surveys, the main source of data for the estimates.
In June 2014, the South East Asia Tobacco Control Alliance (SEATCA)
released a critique of the "Asia-11 Illicit Tobacco Indicator 2012"
showing how its estimates are being used to rescind tobacco tax policies.
As illustrated in Hong Kong's experience, the SEATCA critique revealed
that the ITIC-OE report overestimated the total illegal consumption in
other countries in South East Asia. In the case of Vietnam, it claimed
that in 2012 about 103.3 billion cigarettes consumed in Vietnam were
illegal, which amounted to 19.4% of total cigarette consumption. The
estimate was based primarily on the data of a tobacco industry group, the
Vietnam Tobacco Association (VTA), and the full details of the
methodology were not disclosed. The report admitted that data were
collected only in urban areas, but it failed to mention that 68.3% of the
Vietnamese population live in rural areas. This means that the findings
are not representative of the Vietnamese population and are very likely
biased since illicit cigarettes consumption is concentrated in big cities
and near borders.
Unfortunately, as in Hong Kong, the glossy ITIC-OE study took its
toll on tobacco tax policy in Vietnam. The Government of Vietnam
considered the results of the study and opted for a less than ambitious
tobacco tax rate increase. When the Ministry of Finance proposed a rather
moderate tobacco tax roadmap in March 2014 (an increase from 65% to 75% in
July 2015 and to 85% in January 2018), they noted that their decision was
influenced by the illicit cigarette issue. The scope of illicit cigarettes
consumption and the associated government revenue loss continued to be
highlighted both in the press and during the policy debates until November
2014, when the National Assembly adopted an even weaker excise tax law: an
increase to 70% in Jan 2016, and to 75% in 2019. Since these taxes are
based on ex-factory price, and the tobacco industry is in full control of
that price, the full impact on cigarette retail prices and tax revenue is
likely to be minuscule. The average real retail cigarettes prices are
expected to increase by less than 1% per year in the period from 2015 to
2020 (5.8% in 6 years), which, given the 5-6% annually per capita real
income grows, is insufficient to prevent cigarette consumption from
rising.
In summary, the Asia-Illicit Tobacco Indicator 2012 report was as non-
transparent in Hong Kong as it was in Vietnam and nine other countries
covered by the report. It was used to undermine a pro-health tobacco tax
policy supported both by public health advocates as well as the general
public. We thank Tobacco Control for publishing the findings of Hong Kong
colleagues, which successfully challenged the invalid evidence and
arguments supported by the tobacco industry. We hope that other countries
in Asia and elsewhere will follow Hong Kong's initiative and expose the
tobacco industry's tactic to undermine pro-health tobacco tax policies
that signatories to the WHO FCTC are committed to under Article 6 of the
Convention.
Thank you
Sincerely,
Son Dao , Hana Ross and Sophapan Ratanachena
We are mildly flattered that Philip Morris found it worthwhile to
have Peter Lee criticize our framework [1] for assessing the likely
population effects of aggressive promotion of smokeless tobacco as a harm
reduction strategy in the USA. Peter Lee is a longtime tobacco industry
consultant who has a history spanning decades criticizing important
studies demonstrating the harms of tobacco and secondhand smoke [2],
inclu...
We are mildly flattered that Philip Morris found it worthwhile to
have Peter Lee criticize our framework [1] for assessing the likely
population effects of aggressive promotion of smokeless tobacco as a harm
reduction strategy in the USA. Peter Lee is a longtime tobacco industry
consultant who has a history spanning decades criticizing important
studies demonstrating the harms of tobacco and secondhand smoke [2],
including the landmark Hirayama study [3-5] and publishing papers or
letters to the editor contesting the health effects of secondhand smoke on
cardiovascular disease [6], cancer [7], SIDS [8] and more recently the
health effects of smokeless tobacco [9, 10] and menthol [11]. Lee's role
in industry efforts to discredit the Hirayama study has been well
documented in the literature [12, 13]. As Lee notes, "one would
intuitively expect a substantial benefit if increasing snus promotion led
to many smokers switching to snus." The whole point of our analysis was
to move beyond "intuition" and make predictions based on data in a way
that explicitly accounts for the uncertainty in the data on tobacco use
behavior and the associated health costs. The fact that the likely health
cost ranges overlap is what leads to the conclusion that, accounting for
this uncertainty, the market changes likely to accompany aggressive
smokeless promotion would not confer population-level health benefits.
Lee, a statistician, simply ignores the uncertainty associated with
the estimates that form the core of the model.
He criticizes the fact that we do not account for the temporal
dynamics of changes in tobacco use behavior and the associated risks over
time. He is correct that our model is a steady-state, not a dynamic,
model. We considered a dynamic model, but doing so conflicted with our
fundamental goal of basing the results on data rather than the rhetoric
and "intuition" that have characterized the harm reduction debate to date.
We were unable to find the data necessary to model the dynamics Lee seeks.
It is noteworthy that Lee did not provide citations to the data that one
could use to develop the model he desires.
Lee found the justification for the health cost we used for snus as
11 to be "unclear." In our paper, we clearly stated that this estimate
came from an expert consensus panel estimate of the health effects,
reference 9 in our paper [14]. As we noted in our paper, the estimate
that this panel produced is probably low because subsequent research has
found higher risks for heart disease, that are larger than those
considered in this reference, a case that has only grown stronger as
evidence has continued to accumulate [15]. If anything, we are almost
certainly underestimating these risks.
Lee questions our assumption of a risk of 90 for dual use. He is
correct that there is little data available on dual use (a subject worthy
of study). The reason we assumed a modest reduction in risk was that
there might be less exposure to cigarette smoke, which could lower cancer
risk but would have little effect on heart disease risk because of the
highly nonlinear relationship between smoking and heart disease risk, with
most effect occurring at low levels of smoking.
Lee criticizes us for including what he sees as unacceptably high
levels of dual use (i.e., concurrent use of smokeless tobacco and
cigarettes) in our scenarios. (It is important to define "dual use" as
use of either product on some days rather than both products on all days.
This latter definition does not reflect actual dual use, particularly as
the snus products are being promoted for use when one cannot "light up",
and substantially underestimates dual use.) The base levels of dual use
we used in our model are from surveys of actual use patterns in the USA.
The fact that we model large increases in dual use reflects the actual
marketing of smokeless products by the tobacco companies, who are
promoting snus products as cigarette line extensions, packaging them
together, and explicitly promoting dual use in their marketing. Dr. Lee
could make a real contribution to the debate if he were to present an
analysis based on the market targets that his client, in this case Philip
Morris, has established for both Marlboro snus and dual use of Marlboro
snus and cigarettes together.
Finally, we were surprised that Dr. Lee did not simply put the health
costs he asserts are accurate into the model and present the results to
demonstrate that his assertions are correct and supported by actual data.
(The full model is available on the Tobacco Control website at
http://tobaccocontrol.bmj.com/content/19/4/297/suppl/DC1, something we
pointed out to him when he contacted us asking for a copy of the model.)
The whole object of this enterprise is to move beyond the "intuitive"
arguments Lee presents to making decisions based on quantitative estimates
of likely population effects: Lee failed to provide credible estimates
demonstrating that smokeless promotion would actually be likely to reduce
harm on a population level.
Adrienne Mejia
Pamela M. Ling
Stanton Glantz
University of California, San Francisco
San Francisco, CA 94143
REFERENCES
1. Mejia AB, Ling PM, Glantz SA. Quantifying the Effects of Promoting
Smokeless Tobacco as a Harm Reduction Strategy in the USA. Tob Control.
2010 Aug;19(4):297-305.
2. Lee PN. Many Claims About Passive Smoking Are Inadequately
Justified. BMJ. 1997 Feb 1;314(7077):371.
3. Hirayama T. Non-Smoking Wives of Heavy Smokers Have a Higher Risk
of Lung Cancer: A Study from Japan. Br Med J (Clin Res Ed). 1981 Jan
17;282(6259):183-5.
4. Lee PN. "Marriage to a Smoker" May Not Be a Valid Marker of
Exposure in Studies Relating Environmental Tobacco Smoke to Risk of Lung
Cancer in Japanese Non-Smoking Women. Int Arch Occup Environ Health.
1995;67(5):287-94.
5. Ong E, Glantz SA. Hirayama's Work Has Stood the Test of Time. Bull
World Health Organ. 2000;78(7):938-9.
6. Lee PN, Forey BA. Environmental Tobacco Smoke Exposure and Risk of
Stroke in Nonsmokers: A Review with Meta-Analysis. J Stroke Cerebrovasc
Dis. 2006 Sep-Oct;15(5):190-201.
7. Lee PN, Hamling J. Environmental Tobacco Smoke Exposure and Risk
of Breast Cancer in Nonsmoking Women: A Review with Meta-Analyses. Inhal
Toxicol. 2006 Dec;18(14):1053-70.
8. Lee PN. Passive Tobacco Exposure and Sudden Infant Death Syndrome.
Pediatrics. 1993 Sep;92(3):505-6.
9. Lee PN, Hamling J. Systematic Review of the Relation between
Smokeless Tobacco and Cancer in Europe and North America. BMC Med.
2009;7:36.
10. Sponsiello-Wang Z, Weitkunat R, Lee PN. Systematic Review of the
Relation between Smokeless Tobacco and Cancer of the Pancreas in Europe
and North America. BMC Cancer. 2008;8:356.
11. Werley MS, Coggins CR, Lee PN. Possible Effects on Smokers of
Cigarette Mentholation: A Review of the Evidence Relating to Key Research
Questions. Regul Toxicol Pharmacol. 2007 Mar;47(2):189-203.
12. Hong MK, Bero LA. How the Tobacco Industry Responded to an
Influential Study of the Health Effects of Secondhand Smoke. BMJ. 2002 Dec
14;325(7377):1413-6.
13. Yano E. Japanese Spousal Smoking Study Revisited: How a Tobacco
Industry Funded Paper Reached Erroneous Conclusions. Tob Control. 2005
Aug;14(4):227-33; discussion 33-5.
14. Levy DT, Mumford EA, Cummings KM, Gilpin EA, Giovino G, Hyland A,
et al. The Relative Risks of a Low-Nitrosamine Smokeless Tobacco Product
Compared with Smoking Cigarettes: Estimates of a Panel of Experts. Cancer
Epidemiol Biomarkers Prev. 2004 Dec;13(12):2035-42.
15. Piano MR, Benowitz NL, Fitzgerald GA, Corbridge S, Heath J, Hahn
E, et al. Impact of Smokeless Tobacco Products on Cardiovascular Disease:
Implications for Policy, Prevention, and Treatment: A Policy Statement
from the American Heart Association. Circulation. 2010 Oct 12;122(15):1520
-44.
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.
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.
ASH Ireland very much welcomes the comprehensive article on cigarette waste by Smith and McDaniel. This is an issue ASH Ireland has been actively engaged with. In November 2009 ASH Ireland met with the Minister for the Environment, Heritage and Local Government (Leader of the Green Party in Ireland) and outlined the scale of the problem to him and his department. Cigarette waste accounts for nearly half of all the litter...
NOT PEER REVIEWED We welcome the timely review published by Hill et al. [1], and agree that more research is needed to assess the equity impacts of tobacco control interventions. The results of the review indicated that "increases in tobacco price have a pro-equity effect on socioeconomic disparities in smoking", but that "evidence on the equity impact of other interventions was inconclusive [...]". The inconclusiveness o...
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...
INTRODUCTION Mejia et al1 argue that a harm reduction strategy based on promoting snus, the form of smokeless tobacco widely used in Sweden, is unlikely to result in any substantial health benefit to the US population. They divide the population into five tobacco groups (never tobacco users, former tobacco users, current cigarette smokers, current snus users, and current dual users), attaching to each group an estimate of...
NOT PEER REVIEWED I commend the authors on a significant effort involved in conducting this rather insightful research.
Having conducted qualitative research on FCTC implementation in the Pacific, I can provide comment in relation to the Cook Islands which may explain why MPOWER measures mentioned here did not achieve decreases in prevalence (at least in the figures obtained in this study).
Firstly, th...
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...
NOT PEER REVIEWED
We refer to the article, "Did the tobacco industry inflate estimates of illicit cigarette consumption in Asia? An empirical analysis" Chen J, et al. published in Tobacco Control on November 25, 2014 (Tob Control 2015;0:1-7) and concur with the important points raised in this article. While the article focuses on Hong Kong, other countries in South East Asia also faced a similar experience. The...
We are mildly flattered that Philip Morris found it worthwhile to have Peter Lee criticize our framework [1] for assessing the likely population effects of aggressive promotion of smokeless tobacco as a harm reduction strategy in the USA. Peter Lee is a longtime tobacco industry consultant who has a history spanning decades criticizing important studies demonstrating the harms of tobacco and secondhand smoke [2], inclu...
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...
Pages