The abstract's conclusion that persistent use of nicotine gum is "very rare" casts serious doubt upon the authors' objectivity. How can they here describe a 6.7% chronic nicotine gum use rate at six months as reflecting a 'very rare' condition while their March 2003 OTC NRT meta- analysis - published in this same journal - embraced a 7% six-month smoking abstinence rate finding as "effective?" [1]

I do hope the FDA will lay the authors' March 2003 meta-analysis beside this study's findings as the shocking news is that almost 100% of nicotine gum users who were declared to have quit smoking for six months (7%) appear to have still been hooked on the nicotine gum at six months (6.7%).

The big news is that one-quarter (24%) of nicotine patch users (1.7% of the 7%) who were previously reported to have successfully quit at six months were likely still using the nicotine patch.

If almost 100% of gum and 95% of patch users are still hooked on nicotine at six months and success is "very rare" then doesn't some rather serious life threatening NRT marketing deception need to be immediately addressed and corrected? The authors apparently want us to believe that those spending hundreds of dollars violating FDA use guidelines were not chemically dependent.

Yes, I'm clearly using Table 1 "one month gap"findings. But if this study is to be taken seriously, after the authors discarded all purchase data reflecting multiple same day scans on the assumption that they were scanning errors, some of which obviously evidenced purchases of multiple month supplies, I think we must. It also brings the authors selective data "estimates" closer to historical study findings.

What I find interesting is that there was zero analysis of any nicotine purchases except for NRT when every nicotine product sold has UPC codes and participants were required to scan all purchases. Why would their NRT scans be anymore reliable than other nicotine product scans? Wouldn't that have provided data on the number of smokers in each household, their brands, and whether or not they attempted cessation? In single smoker households the nicotine use picture should be amazingly clear.

It would be interesting to see this data analyzed by researchers who are not acknowledged NRT industry consultants and who do not feel compelled to disclose within the study that they have a personal financial stake in the development and marketing of new NRT products. The patterns of NRT use interlaced with cigarette and other nicotine purchases should produce some rather fascinating info on just how well "therapy" was actually going. I just don't know if it would be in the pharmaceutical industry's financial interests to share such details.

If the real agenda of this study - and reflecting back there seems to have been an overabundance of marketing objectives - is to get the FDA to double the OTC NRT use recommendation period from three to six months, thus substantially enhancing profits, the FDA would be well advised to attack the pharmaceutical industry's hiding of nicotine’s addictive properties with the same vigor it would if allowed to regulate tobacco product warnings and a failure to have any U.S. dependency disclosures.

The authors assert that "the literature has seldom examined dependence upon NRT." Is there any wonder why? Imagine having to put nicotine addiction warning labels on all nicotine weaning products. They are badly needed too. The 2003 Memphis youth NRT use survey finding that teens who have never taken a single puff off of any cigarette are now daily NRT users should have set off major alarms at the FDA.[2]

Is one of the objectives of this study to diminish growing concern that NRT products are the new gateway to a lifetime of nicotine dependency for tens of thousands of youth? If so, is it just possible that a bit of "real" dependency science may at some point be in order?

In reading this study it's almost as if the authors want us to believe that the brain's dopamine, adrenaline and serotonin neurons are somehow able to discriminate between nicotine from a cigarette and nicotine from NRT products. How are such shell games and nonsense any different from the tobacco industry's nonsense?

This study's intro and discussion read like decades of tobacco industry spin on the issues of addiction and safer cigarettes while again totally ignoring all nicotine dependency biochemistry or studies raising legitimate nicotine health risks.

Nicotine addiction isn't about getting high but about how the mind and body have redefined "normal." Our bodies rebelled against those first few puffs but quickly adjusted to inhaling thousands of chemicals. Amazingly, nicotine crossed the blood-brain barrier and was a chemical key that snugly fit the acetylcholine locks responsible for fine tuning a host of brain neurochemical pathways including select dopamine, adrenaline and serotonin circuits, and through cascading indirectly controlling more than 200 neurochemicals.

The mind's adjustments to being constantly bombarded with nicotine were gradual yet constant. But eventually the brain ran out of tricks as it could no longer keep up with the smoker smoking more nicotine in order to achieve remembered prior performance. It did everything possible to protect its reward, mood and anxiety circuits from overload and burnout. It some areas it reduced the number of receptors for nicotine, in others the number of transporters were diminished, while in some regions of the brain millions of additional neurons were grown.

Through disbursal and turning down the brain's receptiveness to nicotine, normal brain chemistry was altered as a new sense of normal emerged and an addiction was born. It was a sense of normal now completely dependent upon nicotine's two-hour chemical half-life.

Successful dependency recovery is being willing to allow the brain the time needed to readjust to again functioning without nicotine, and the quitter time to adjust to the brain's adjustments. It is impossible for the brain, body and consciousness to adjust to functioning and living without nicotine until its arrival stops.

If true, how can NRT claim responsibility for a 7% midyear nicotine cessation rate? It can't. As shown by superimposing this study upon the authors' March 2003 finding, within six months zero gum users and only five in one hundred patch users are nicotine free.

But what about the 5% who transdermal nicotine seemed able to help escape? I submit that they did not quit nicotine while engaged in using it but only after pulling off that last patch. There is a substantial body of non-NRT study evidence strongly suggesting that almost twice as many patch users (10%) would have succeeded if they had not toyed with months of nicotine weaning.[3]

An unsupported and uneducated quitter's core motivations and nicotine cessation desires appear unaffected by cessation method unless that method deprives them of some of their own natural recovery abilities. NRT appears to do just that by prolonging the up to 72 hours needed for 100% of nicotine and 90% of nicotine metabolites to be removed from the body and the brain to begin sensing the arrival of and adjusting to nicotine- free blood serum.

One of NRT's biggest fictions is that real world 'on-your-own' quitting rates are the same as those being generated in OTC NRT studies trying to cope with admitted blinding failures or even employing nicotine as a placebo device masking agent.[4] It's why the authors continue to take stabs at the 2002 Pierce JAMA survey conclusion that NRT is no longer effective, and ignore London and Minnesota surveys with similar findings.

Nicotine is the natural chemical defense that keeps the roots, leaves and seeds of the tobacco plant from being eaten by bugs. Drop for drop it's more deadly that strychnine and three times deadlier than arsenic. Amazingly, the FDA allowed the pharmaceutical industry to redefine and market an insecticide as medicine and label its use therapy.

It also stood by while new tortured definitions of quitting, cessation, and abstinence were created allowing NRT to hide nicotine and addictiveness concerns while making billions in profits by claiming meaningless odds ratio victories. It watched as researchers kept straight faces while pretending that those still using nicotine had accomplished some great feat that was then compared to those who truly had ended all nicotine use.

What FDA officials should not sweep under the rug or allow studies such as this to redefine, ignore or minimize is the growing awareness of the destructive potential of this amazing pesticide. The authors' assertion that "prolonged use of NRT is not thought to be harmful" is simply untrue as it flies in the face of a growing list of study concerns produced by real experts engaged in real science.

The U.S. National Cancer Institute has raised cancer concerns over the nicotine-derived nitrosamine NKK on normal lung epithelial cells. The Paris National Institute of Health recently found evidence that nicotine causes a major fall in production of PSA-NCAM, a protein with a vital role in the plasticity of the brain with apparent impairment of learning and memorization.

A 2001 Stanford study concluded that nicotine tremendously accelerates tumor growth rates and atherosclerosis through angiogenesis. And an October 2000 study in Pediatrics that followed 8,000 teenagers has depression experts rethinking why so many nicotine dependent Americans suffer from chronic depression and other mental health concerns.

But I want to mention one more risk that harm reduction oriented NRT experts just can't seem to grasp. I'm talking about an entire life being chemically dependent upon nicotine's two-hour chemical half-life. I'm referring to again sensing the full glory of our own reward pathway releases that flow from accomplishment, a big hug, or even a nice cool glass of water. About handling our own adrenaline releases, our own anxieties and anger, determining when it's time to eat, dealing with real hunger pains for the first time in decades, or even something as simple as the circumstances under which we'll feel our fingers grow cold.

Not only does the brain adapt to the chemical world of nicotine normal, the new addict quickly forgets who they really were and the amazing sense of calmness that existed inside their mind prior to climbing aboard the nicotine, dopamine/adrenaline/serotonin roller-coaster ride of endless highs and lows. Natural regulation of mood, flight or flight, and reward is life itself, something more nicotine cannot return.

Big brother health policy has unforgivably used nicotine cessation as a practice arena for someday going head-to-head with big tobacco in supplying the daily nicotine needs of a billion addicts. Smokers trusted us "science" to help arrest their dependency and it lied to them. It not only knew that "their" definition of quitting included nicotine, NRT marketing knowingly played upon it by constantly undermining their natural inclination to want to give up all nicotine by quitting cold.

The white-coat ceremony vow was to do no harm yet physician science remains silent while knowing that the dismal 5.3% six-month nicotine patch quitting rate (derived by subtracting persistent purchasers rate of 1.7% from the OTC NRT finding of 7%) drops to almost zero percent during a second or subsequent patch attempt.[5] If true, how can those calling themselves addiction scientists sleep at night knowing that there is no lesson to be learned from repeated NRT use but that relapse is 100% guaranteed as dependency, destruction, decay and disease continue bringing forth vastly increased odds of early demise.

John R. Polito Nicotine Cessation Educator

[1] Hughes JR, Shiffman S. et al, A meta-analysis of the efficacy of over-the-counter nicotine replacement, Tobacco Control. 2003 March;12(1):21-7. Full text link - http://tc.bmjjournals.com/cgi/content/full/12/1/21

[2] Klesges, L. et al, Use of Nicotine Replacement Therapy in Adolescent Smokers and Nonsmokers, Arch Pediatr Adolesc Med. 2003;157:517- 522. Abstract link - http://archpedi.ama- assn.org/cgi/content/abstract/157/6/517

[3] Polito, JR, Does the Over-the-counter Nicotine Patch Really Double Your Chances of Quitting? Link to online article - http://whyquit.com/whyquit/A_OTCPatch.html

[4] Polito, JR, Are nicotine weaning products a bad joke? Link to online press release - http://www.emediawire.com/releases/2003/10/prweb84809.htm

[5] Tonnesen P, et al., Recycling with nicotine patches in smoking cessation. Addiction. 1993 Apr;88(4):533. Link to abstract - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8485431&dopt=Abstract . Also note references to unpublished studies such as the Korberly nicotine patch study presented at the March 1999 Society for Research on Nicotine and Tobacco conference in New Orleans in which only 1 out of 149 OTC nicotine patch users was still not smoking at the six month mark.

In your article you touch on the fact that the consumer would likely not report internet pruchases for fear of reprisal in taxation issues. The state does in fact over look the 1 or 2 carton of cigarette purchase issues when for instance a business man travels to Kentucky and buys a couple ther and brings them back with him to California.

I have also detected, in the industry of Internet Toabacco sales, where the new proposals for laws have only one true effect. 91% of the Internet sales are accpomplished by Soveriegn Tribal nations that pay for the most part no state or federal taxes and also from the international online sales points which also pay no state or federal taxes.

There is a movement a foot to set the Jenkins act more stringant and also prohibit the mailing of cigarettes thru the USPS via the S1177. The issue would eliminate only and I do say "only" the American online retailers that pay the federal and for the most part state taxes.

The retailer I web master for is a brick and mortar operatin in florida, pays Florida and Federal taxes on all cigarettes he sells, online and thru his store. He would be affected by the changes propsed and the ones that have already been made in effect in New York for example. Yet the 91 % that are exempt from following those proposed changes will not be affected. Not in the slightest bit. To assume that changing the laws to affect only those that actually pay some State taxes and all federal taxes would have an impact on internet sales is at the very least a sign of ignorance. Those who are legitimate would stop and the customers would go to the tribal nations or to foreign entities for the savings.

Tribal Nations avaoid taxes and ship vis the USPS in New York and the Universal Postal Union Convention ratified by the United States forbids the Federal and state governments from prohibition of foreign sales. I see the irony that a few politicians are seeking special interest money and support and ignoring the truth and only affecting American tax paying citizens.

I doubt if you as a liberal would even care but I felt the need to get it off my chest and tell yo just how wrong you really are in your views and reporting.

Joe McFarland St. Petersburg Florida

Bauld et al (2003) report a number of interesting results from the evaluation of the NHS smoking cessation services. One result in particular which warrants further investigation is the finding that 4 week success (quit) rates were higher for smokers treated in groups compared to those receiving individual support sessions. The authors briefly discuss possible explanations for this, including the possibility that the former treatment is likely to be offered by more experienced specialist staff. While this may well be true, I believe a far more likely explantion for the difference in success rates is due to selection bias as this was not a randomised study. Smokers with mental health ot other severe psycho-social problems, including drug or alcohol misuse, are usually deemed unsuitable for smoking cessation group programmes. Published research indicates that these smokers tend to be highly nicotine dependent and to have greater difficulty quitting whatever the treatment offered. The difference in success rates between groups and individual counselling might, therefore, simply reflect the two different populations being treated.

Personally, I prefer a description that tells something of the truth about tobacco smoke, "toxic tobacco smoke." Since the Tenth Report on Carcinogens indicates that tobacco smoke has 250 toxins in it, I don't see any reason not to refer to it as toxic tobacco smoke. This is better than dancing around the danger like many health agencies still do when they refer to the "health" effects of smoking, when they should be talking about disease and death.

Another quite direct acronym would be smoke harboring inhaleable toxins (SHIT). I know this would be offensive to most. How apropos.

Dear Editor,

I did some investigation comparing the current usage of the term "environmental tobacco smoke" and its acronym, ETS, and the usage of "secondhand smoke" and SHS. The results I obtained tend to support your editorial.

I went first to the WHO web site and typed ETS in the search box. The first page of results contain 10 entries. All 10 related to tobacco smoke. I then typed SHS, and out of the 10 first hits, only one dealt with tobacco smoke. I then typed "environmental+tobacco+smoke" in the search box. This returned 825 pages. Typing "secondhand+smoke" and then "second+hand+smoke", and I got in total 618 entries. So ETS seems to be the preferred term on an international basis.

I repeated the experiment on the JAMA site. The acronym "ETS" in the site's search box produced 27 hits, while "SHS" produced only 2. Looking at the exact term "environmental tobacco smoke" in the abstracts produced 36 hits, while "secondhand smoke" produced 10 hits, to which one is added when using the term "secondhand tobacco smoke" So the JAMA score is 36 to 11 in favor of ETS.

Using the search function on the Tobacco Control web site, the exact phrase "environmental tobacco smoke" in the abstract returns 36 articles, while "second hand smoke" returns 9 and "second-hand smoke" returns 5. So again here the score is 36 in favor of ETS vs 11 in favor of SHS.

It seems that the scientific community has pretty much made its choice already. Pushing SHS as a new standard might actually create more confusion than help.

On the other hand, my Collins-Robert English-French dictionary has an entry for "secondhand smoke", indicating that this is an informal term. This is confirmed by a world-wide search using Google. Searching for the exact term "environmental tobacco smoke" gives 47'700 hits, while searching for "secondhand smoke" gives 121'000 hits. But the acronym SHS is not well established, while ETS is. Searching for "ETS tobacco" on Google returns 47,500 entries, while typing "SHS tobacco" returns only 6,560.

The consequence is that, if you address the public at large, "secondhand smoke" in full is probably a preferable choice to "environmental tobacco smoke", but if you address the scientific community, there seems little reason to move away from the already well established "environmental tobacco smoke" and its abbreviation, "ETS".

Finally, there is another reason why I think one should stick to ETS and environmental tobacco smoke. This makes searching easier. The problem with "secondhand smoke" is that the spelling varies from country to country, British people often write secondhand in two words, with a hyphen or a space, and other people add the word "tobacco" between "secondhand" and "smoke", while there does not seem to be any variation of this type with "environmental tobacco smoke".

Over-the-counter nicotine replacement: Rhetoric vs. Reality

Mr. Polito has criticized our recent meta-analysis of over-the- counter (OTC) nicotine replacement (NRT) that appeared in Tobacco Control (Vol 12, p 21). Our brief response is below. Readers wishing to respond to us or obtain citations for our assertions can email john.hughes@uvm.edu or shiffman@pinneyassociates.com ).

The major assumption of Mr Polito’s comments appears to be that tobacco control is better off sticking solely with intensive behavioral therapy programs. Both of us helped develop such programs and agree that they can produce higher quit rates than OTC NRT. (Though Mr. Polito vastly overstates their efficacy: For example, he USPHS and Cochrane meta -analyses of such programs report a quit rate of about 15% - not the 50% cited by Mr. Polito.) Indeed, the highest rates of success are obtained when smokers combine both behavioral and pharmacological treatment.

The problem is that the vast majority of smokers does not want and will not use intensive behavioral treatment. Many surveys have shown that among smokers who try to quit, less than 5% of smokers will attend these programs. We, like Mr. Polito, would prefer that smokers get all the treatment they can, including behavioral treatment, but have come to recognize that smokers do not use intensive behavioral treatment, even in the developed countries, where it can be made available. In addition, these programs are costly, which will limit their feasibility in developing nations.

Thus, we believe a less effective treatment used by more smokers would do more good than a more effective treatment used by fewer smokers. For example, in the US, among 1000 smokers trying to quit, about 200 will use OTC NRT, resulting in about 14 quitters. However, at most 50 will use behavior therapy, resulting in 7 quitters. In summary, we believe it is irresponsible to hold out, as a sole remedy, a treatment that only 5% of smokers will use and assume that this fulfills responsibility to help smokers who want to quit.

Finally, we would point out that making OTC NRT available does not mean one should give up on group behavioral therapy. It simply gives smokers another option for dealing with life-threatening tobacco use.

Some other errors in Mr. Polito’s statements:

Neither of us has suggested that now that we have OTC we do not need "to explore more effective means of quitting." In fact we have authored articles urging the development of better behavioral techniques and critical of the current state of affairs.

Both our own audits and those of the National Cancer Institute indicate NRT research does not "consume the lions share of all cessation research dollars;" For example, we estimate less than 10% of US National Institutes of Health funding for smoking cessation research goes to testing NRT.

NRT ads are said to "bash… quitting via self-reliance," to convey that self-quitting is "hard and painful," that quitting with NRT is "painless" and that OTC NRT is "highly effective." In fact, our view is that the ads have emphasized the realistic difficulty and discomfort of quitting without overstating the relief provided by NRT, and have emphasized the importance of the smoker’s efforts in the quit process; .e.g, “only for those committed to quitting,” and “You can do it – Nicorette can help”

Mr. Polito also questions whether it has been getting harder to quit. Interested parties may want to review two recent meta-analyses by Irvin and colleagues, which show that success rates have been dropping, for both behavioral and pharmacological treatments. Many students of this issue believe that, as smokers who can quit easily do quit, the smokers remaining are those who have the hardest time achieving success.

Finally, we would note our response above does not a) use comparisons across studies differing in methods, timing, etc., which are notoriously misleading b) impugn the motives of the author or c) use ridicule or sarcasm.

John Hughes and Saul Shiffman

I am sorry to say that George Leslie and others who have long worked for the tobacco industry often end up moving their snake oil solutions to other areas, for example, Asia. Tobacco control advocates are few here and scientists who have any experience with research in air quality in the West are often consulted on problems of air pollution. It is then very easy for tobacco industry scientists to present themselves as secondhand smoke experts and "educate" unsuspecting researchers with workshop or symposium reports designed specifically to sell industry "solutions" on secondhand smoke exposure and risk. (His expertise appears even in a respected institutions' newsletter here in Thailand).

In one tobacco industry document, an industry employee reports on his role as educator of the Minister of Health, "I believe the present Minister offers us the opportunity to contribute our views and our success will depend on the degree to which we can educate him and his department on these issues, without overburdening him with details in which case he would probably seek clarifiction from our opponents." (Bates 2025593984/3989) And so it goes that tobacco industry scientists offer and find acceptance of their expertise where they and their so called "science" poison those struggling to promote meaningful health promotion. Out of sight for these industry propagandists is unfortunately not out of action.

Stephen Hamann Thailand

Dear Mr Meyers, Thank you for your article about the name change of Philip Morris. It is appropriate that PM should wish to become invisible. In fact, they are simply backward, so I shall reverse their new name to airtla, meaning Aberrant Industry in Regular Touch with Legal Attorneys. I hope they shall hence forward remain named with this backward sign of wrong doing. Branding, after all, is one of their specialties that we too should appreciate.

Stephen Hamann Tobacco Control Policy Research Network Bangkok, Thailand

Upon reading the paper by Biener (Tobacco Control, June 2002), I couldn't help but be struck by the similarity between the reported effects of the Philip Morris anti-smoking campaign and the fictional campaign in Christopher Buckley's (1994) satirical novel "Thank You for Smoking."

In the fictional version, Nick Naylor, chief spokesperson for the Academy of Tobacco Studies (a.k.a. the tobacco industry), announces a $5 million industry-funded campaign designed to keep underage kids from smoking. The advertising creatives, despite being a little concerned at being asked to produce "an ineffective message that will have no impact on the people it is targeted at," come up with a new campaign titled "Everything Your Parents Told You About Smoking Is Right." The great strength of the campaign in Naylor's view is that "It is dull." In the agency's words "Kids are going to look at this and go, 'Puuke'."

In the factual version, Philip Morris spends a large amount of money developing and running a campaign titled "Think, Don't Smoke," which "featured an off camera adult asking teenagers…whether or not they smoked. The teens interviewed were all non-smokers who answered the interviewer by saying that they didn't need to smoke to be cool" (Biener, p.44). Not surprisingly, the study found that the Philip Morris ads are rated by the target audience (underage kids) as less effective than any of the other anti-smoking ads they recalled seeing.

You may wonder why it is that a company like Philip Morris, with many years of advertising experience, could develop such a spectacularly ineffective ad campaign. This is the same Philip Morris who won first place among Ad Age's Top 100 Ad Icons for the Marlboro Man: "The most powerful - and in some quarters, most hated - brand image of the century, the Marlboro Man stands worldwide as the ultimate American cowboy and masculine trademark, helping establish Marlboro as the best-selling cigarette in the world" (Ad Age, 2001).

You may wonder, indeed, unless you've read Buckley's book.

References: Biener L. Anti-tobacco advertisements by Massachusetts and Philip Morris: what teenagers think. Tobacco Control 2002;11(2):44-47. Advertising Age. The Advertising Century, 2001, http://www.adage.com/century Buckley, C. Thank You for Smoking, New York: Random House, 1994.

Notwithstanding evidence on the impact of advertising in sport, the powers that be in F1 have little interest in seeing tobacco sponsorship curtailed anytime in the near future.

Bernie Ecclestone, the man most responsible for F1's recent dramatic growth is on record as saying a ban on tobacco advertising isn't needed as it would have a negligible impact on the smoking habits of its millions of viewers.

'If tobacco was killing people it was doing so a long time ago. There has been no evidence, ever, that people who watch [F1] smoke. No one has ever proved that to me. Kids smoke because they think it's the right thing to do. It's more likely they do so because their parents or the people who surround them smoke. All the tobacco commercial says is, "If you are smoking, smoke our brand". It doesn't say "Smoke!"' (http://www.observer.co.uk/osm/story/0,6903,708327,00.html )

Since DiFranza's criticism of the editorial by Ling et al.(1) concentrates mostly on criticism of the paper by Fichtenberg and Glantz, published in Pediatrics,(2) we are writing to respond to these criticisms separately. We recognize that this is unusual, since the standard procedure would have been for DiFranza to write Pediatrics after the paper was published there. DiFranza, however, chose to write Tobacco Control (based on a preprint we provided him as a courtesy), so we are responding here.

The premise of youth access programs is that if merchant compliance reaches a high enough level, it will reduce youth access to cigarettes and, therefore, youth smoking. The goal of the first part of our analysis was to see if, based on the available literature, there was a relationship between merchant compliance and youth smoking. Whether or not the laws were being enforced at the time and if so, in what manner, is irrelevant to this analysis. If youth access programs work because high merchant compliance leads to lower smoking, there should be an association between high merchant compliance rates and low youth smoking rates, regardless of what led to those rates of compliance. If an intervention designed to increase merchant compliance was successful, we should see high compliance rates and low smoking. If the intervention was not successful, because they did not include enforcement as DiFranza suggests, there we should see low compliance and low smoking. (Whether there is prosecution of merchants or not (3) is irrelevant to testing whether making it difficult for teens to purchase cigarettes affects teen smoking prevalence.) Both of these cases would contribute to our test of the hypothesis that increased merchant compliance was associated with reduced smoking. The data to not exhibit such an association (Figure 1a of Fichtenberg and Glantz(2)).

All youth access program measure merchant compliance through undercover sales attempts by underage youth as was done in the Bagott(4) study. If merchant compliance measured in this was is not an accurate reflection of youth access, then none of the studies of youth access that base their effectiveness on merchant compliance are valid. The goal of our analysis was not to determine if compliance is a good measure of youth access but rather to relate the most commonly used metric for measuring the effectiveness of youth access programs, namely merchant compliance, and to youth smoking rates.

DiFranza says that we should not include studies from England because the legal age to purchase cigarettes is 16. We see no reason why youths aged 14-15 would not be affected by laws limiting purchase of cigarettes to those 16 and older.

DiFranza objects to including data from Australia, because 46% of the students lived outside the enforcement area.(10) As discussed above, whether or not active enforcement was involved is irrelevant to our analysis of the association between merchant compliance with youth access laws and youth smoking prevalence. All that is important is that compliance and smoking was assessed in the same community. In this case the authors point out that for the follow-up survey, 46% of students in the intervention community – which was defined based on school location – did not live in the intervention area. They conclude that this would be a problem if these children bought cigarettes closer to home rather than to school. Since there was no residence information from the baseline survey it was not possible to limit the analysis to student living in the intervention area. Nevertheless, we chose to include the study in our analysis despite this limitation. It is important to note that the results of this study were consistent with the others.

There is no problem with combining studies of different design in a quantitative meta-analysis as long as all studies are measuring the same endpoint. (11,12) As was reported in the methods section of our paper, the quantitative meta-analysis only included controlled studies. DiFranza objects to combining studies because the ages of the youths, and the methods used to test compliance, differed. (14) While we agree that factors such as age and gender of the youths may impact measured merchant compliance, we did not expect this variability to mask the effect of youth access programs, if they actually affected youth smoking rates. The small number, 5, of controlled studies of youth access programs which reported youth smoking made it impossible to stratify according to the age of the youths used in the compliance checks.

DiFranza objected to our evaluation of the change in youth smoking prevalence as a function of change in merchant compliance on the grounds that it is necessary to obtain compliance rates above 90% to have an effect on youth smoking prevalence. (15) In addition to the fact that the data shows no empirical evidence to support the hypothesis of such a threshold (Figure 1A in Fichtenberg and Glantz (2), reproduced as Figure 1 in Ling, et. al(1)), our basic premise is that if youth access programs actually reduced youth smoking, higher compliance rates would be associated with lower youth smoking rates. We examined this hypothesis in three ways. First we compared compliance and smoking rates in all communities for which both variables were measured at the same time. Since this is an ecological analysis which does not take into account trends over time, we then examined the relationship between changes in compliance and changes in smoking in case what mattered was whether there was a reduction in sales to youth rather than the absolute level of compliance at one time (Figure 1B in Fichtenberg and Glantz (2)) The data presented in Figure 1A demonstrate that there is no threshold of effectiveness at 90% compliance. Smoking rates for communities with compliance above 90% vary between 19.4%and 32.5%, with a mean of 25.9%. In communities with compliance rates below 90%, smoking rates vary between 15.6% and 37.7% with a mean of 25.7%. There is no evidence of a threshold of effectiveness.

DiFranza suggested that we control for a wide variety of socioeconomic and demographic factors. Because "When this type of analysis has been performed on a community and state level of analysis, reductions in youth smoking have been observed. (16,17)" Given the small number of studies available, it was not possible to explore the effects of potential confounders such as other tobacco control policies, price of cigarettes, socio-economic status. Nonetheless, in our discussion we report the results of population based studies, including but not limited to, those referred to by DiFranza. Chaloupka and Pacula (17) in the study cited by DiFranza do indeed find that statewide enactment and enforcement of youth access laws associated with reduced youth smoking. However in another analysis (18), the same authors found that this effect was restricted to black teens. The study by Siegel et al. (16) does indeed find that the presence of youth access laws was associated with decreased smoking initiation rates, however they conclude that this decrease was not mediated by decreased access because youths reported no decreased in perceived access.

In the first part of our analysis (Figure 1A), we compared compliance and smoking in all communities for which there was information. Since we were not trying to assess the effects of interventions but rather to see if there is a relationship between compliance and smoking, we did not make a distinction between control and intervention communities, or between baseline and follow-up data. As DiFranza points out, this type of analysis does not take into account temporal trends or other potential confounders. In order to take these into account we performed a quantitative meta- analysis using only controlled studies (n=5). This analysis yielded a pooled effect of a 1.5% decrease in youth prevalence (95%CI: 6% decrease to 3% increase).

Tutt cited a paper by his group (20) that was not included in our meta-analysis because it was not listed in Medline or cited in any of the other papers we located. Adding his results to those we report, however, does not affect the conclusions of our analysis. The correlation between merchant compliance and 30 day teen smoking prevalence including these data is .042 (P=.799) compared with .116 (P=.486) reported in Figure 1A of our paper. (2) Likewise the correlation between change in merchant compliance and change in youth smoking is -.163 (P=.504) compared with .294 (P=.237) without it. Thus, including Tutt, et. al's data actually strengthens the conclusions in our paper.

It is time for enthusiasts for youth access interventions to recognize that while these interventions may have seemed like a good idea, they do not achieve their primary goal of reducing youth smoking. All that happens is that youth obtain their cigarettes from other sources.(21)

Caroline Fichtenberg, MS, Department of Edidemiology, Johns Hopkins School of Public Health, Baltimore, MD Stanton A. Glantz, PhD, Center for Tobacco Control Research and Education, University of California, San Francisco

References:

1. Ling PM, Landman A, Glantz SA. It is time to abandon youth access tobacco programmes. Tobacco Control 2002;11:3-6. 2. Fichtenberg CM, Glantz SA. Youth access interventions do not affect youth smoking. Pediatrics (In press). 3. Altman DG, Wheelis AY, McFarlane M, et al. The relationship between tobacco access and use among adolescents: A four community study. Soc. Sci. Med. 1999;48;759-775. 4. Baggot M, Jordan C, Wright C, Jarvis S. How easy is it for young people to obtain cigarettes and do test sales by trading standards have any effect? A survey of two schools in Gateshead. Child: Care, Health and Development 1998;24:2007-216. 5. Staff M, March L, Brnabic A, Hort K, Alcock J, Coles S, Baxter R. Can non-prosecutory enforcement of public health legislation reduce smoking among high school students? Aust N Z J Public Health 1998;22:332-335. 6. Rigotti NA, DiFranza JR, Chang YC, Tisdale T, Kemp B, Singer DE. The effect of enforcing tobacco sales laws on youth's access to tobacco and smoking behavior: A controlled trial. New Engl J Med 1997;337:1044-51. 7. DiFranza JR, Rigotti NA. Impediments to the enforcement of youth access laws at the community level. Tobacco Control 1999;8:152-155. 8. Altman DG, Foster V, Rasenick-Douss L, Tye JB. Reducing the illegal sale of cigarettes to minors. JAMA 1989;261:80-83. 9. Altman DG, Rasenick-Douss L, Foster V, Tye JB. Sustained effects of an educational program to reduce dales of cigarettes to minors. American Journal of Public Health 1991;81:891-893. 10. Staff M, March L, Brnabic A, Hort K, Alcock J, Coles S, Baxter R. Can non-prosecutory enforcement of public health legislation reduce smoking among high school students? Aust N Z J Public Health 1998;22:332-335. 11. O’Grady B, Asbridge M, Abernathy T. Analysis of factors related to illegal tobacco sales to young people in Ontario. Tobacco Control 1999;8:301-305. 12. Pettiti D. Meta-Analysis, Decision Analysis, and Cost Effectiveness Analysis. 2nd ed. New York, NY: Oxford University Press; 2000. 13. Stroup DF, Berlin JA, Morton SC. Meta-analysis of observational studies in epidemiology. JAMA 2000;283:2008-2012. 14. Teall AM, Graham MC. Youth access to tobacco in two communities. Journal of Nursing Scholarship 2001;33:175-178. 15. Levy D, Chaloupka F, Slater S. Expert opinions on optimal enforcement of minimum purchase age laws for tobacco. J Public Health Management Practice 2000.6:107-114. 16. Siegel M, Biener L, Rigotti N. The effect of local tobacco sales laws on adolescent smoking initiation. Preventive Medicine. 1999;29:334-342. 17. Chaloupka F, Pacula R. Limiting youth access to tobacco: the early impact of the Synar Amendment on youth smoking. Working paper: Department of Economics, University of Illinois at Chicago; 1998. 18. Chaloupka F, Pacula R. Sex and race differences in young people’s responsiveness to price and tobacco control policies. Tobacco Control 1999;8:373-77. 19. Glantz SA. Preventing tobacco use-the youth access trap. Am J Public Health. 1996;86:221-4. 20. Tutt D, Bauer L, Edwards C, Cook D. Reducing adolescent smoking rates: Maintaining high retail compliance results in substantial improvements. Health Promotion Journal of Australia 2000;10:20-24. 21. Jones SE, Sharp DJ, Husten CG, et al. Cigarette acquisition and proof of age among U.S. high school students who smoke. Tobacco Control 2002;11:20–5.

May 8, 2002 To the editor,

In their editorial “It is time to abandon youth access tobacco programmes,” Ling, Landman and Glantz1 base their argument on an in press meta-analysis of youth access interventions by Fichtenberg and Glantz.2 These authors conclude that there is no proof that youth access interventions work to reduce youth smoking rates. Sadly, this analysis includes ten methodological flaws, each one of which individually renders the conclusions scientifically invalid.2 One of the invalid figures from the Fichtenberg analysis has been reprinted in Tobacco Control.1 1. Three of the eight studies included in the meta-analysis did not involve any actual enforcement of the law, and the authors of a fourth study concluded that enforcement was inadequate due to a political backlash from merchants.3-7 The inclusion of at least three of these studies is scientifically unjustifiable as it has been established for over a decade that merchant education programmes alone are ineffective at attaining the levels of merchant compliance that can be expected to reduce youth access to tobacco.8,9 Three out of the five studies included in the analysis of the effects of youth access restrictions on past 30-day smoking did not involve enforcement. The authors inappropriately list the Baggot study as including enforcement and fines when in actuality, the inspection method was so flawed that no merchant was ever caught and none were prosecuted.4 2. In the Baggot study, merchant compliance is reported as 100%.4 None of the stores sold to youths aged 13 or under during enforcement checks, yet 100% of smokers among the community youths surveyed reported that they regularly bought tobacco from stores and only rare subjects reported ever having been turned down. The study’s authors correctly concluded that the compliance inspections were an invalid measure of youth access. Yet Fichtenberg and Glantz included this invalid data in the analyses of a threshold effect and it is also included in the figure printed in Tobacco Control.2 3. It was improper to include a study from England where the legal age is 16 as the majority of secondary school students would be of legal age to purchase and no impact on youths ages 14-15 would be expected.4 4. It was improper to include the study from Australia. In addition to the fact that the study involved no enforcement, 46% of the students in the intervention group actually lived outside the intervention area!10 5. The meta-analysis improperly combined studies of different designs including cohort, cross-sectional, controlled interventions and non- controlled interventions. 6. Combining these studies is also inappropriate because the ages of the youths, and the methods used to test compliance, differed dramatically from study to study. For example, a compliance rate of 82% for a 14 year old is equivalent to a compliance rate of 62% for a 17 year old.11 A compliance rate of 42% for behind the counter sales is equivalent to a compliance rate of 58% for self-service sales.12 Differences in the techniques used to measure compliance render all of the computations and conclusions in this paper invalid. 7. The authors’ basic premise is that the percentage change in merchant compliance should correlate with the percentage change in the prevalence of youth smoking. The use of this measure represents a straw man. In my review of 176 articles concerning youth access, I cannot recall anybody in this field ever suggesting that the change in percentage of merchant compliance is an appropriate measure of youth access. To the contrary, there is wide agreement among experts in this field that absolute levels of merchant compliance above 90% as measured through realistic compliance checks using youths close to the legal limit will be necessary to effect a change in the prevalence of youth smoking.13 8. In the figure presented in the Tobacco Control editorial, intervention communities are being inappropriately compared to control communities from other continents and legal systems. If the authors wanted to compare smoking rates and youth access interventions across communities, a random sample should be used, uniform measures should be employed and other confounding factors such as socio-economic status and the cost of tobacco should be controlled for. When this type of analysis has been performed on a community and state level of analysis, reductions in youth smoking have been observed.14,15 9. It has been known for centuries that the prevalence of smoking increases during adolescence. This factor must be controlled for in cohort studies by the inclusion of a matched control group. During the period when most of these studies were conducted there was a secular trend of dramatically rising teen smoking rates observed in English speaking countries. Since merchant compliance would also be expected to increase over time in these intervention studies, it would be expected that a positive association between the intervention and smoking prevalence would be seen in both cohort and cross-sectional studies if enforcement were completely ineffective. The meta-analysis does not appropriately incorporate control communities for each intervention community. Only 3 control communities are included for 15 intervention communities across 7 studies. 10. In the same analysis, the few control communities are inappropriately included as additional “data points” in the mix. Baseline data rather than outcome data were used for one intervention community. These procedures indicate that the intention of this analysis was not to determine the impact of the interventions as the authors state.

The Fichtenberg and Glantz article is strongly reminiscent of the ‘scientific’ papers secretly commissioned by the now defunct Tobacco Institute. It is sad that the scientific literature continues to be poisoned for political ends. The Tobacco Control editorial which was based on this travesty of science also excludes and misinterprets data which contradict the authors’ long held biases.16

Joseph R DiFranza MD Professor of Family and Community Medicine Department of Family Medicine and Community Health University of Massachusetts Medical School 55 Lake Avenue Worcester, MA 01655 References 1. Ling PM, Landman A, Glantz SA. It is time to abandon youth access tobacco programmes. Tobacco Control. 2002;11:3-6. 2. Fichtenberg CM, Glantz SA. Youth access interventions do not affect youth smoking. Pediatrics (In press). 3. Altman DG, Wheelis AY, McFarlane M, et al. The relationship between tobacco access and use among adolescents: A four community study. Soc. Sci. Med. 1999;48;759-775. 4. Baggot M, Jordan C, Wright C, Jarvis S. How easy is it for young people to obtain cigarettes and do test sales by trading standards have any effect? A survey of two schools in Gateshead. Child: Care, Health and Development. 1998;24:2007-216. 5. Staff M, March L, Brnabic A, Hort K, Alcock J, Coles S, Baxter R. Can non-prosecutory enforcement of public health legislation reduce smoking among high school students? Aust N Z J Public Health. 1998;22:332-335. 6. Rigotti NA, DiFranza JR, Chang YC, Tisdale T, Kemp B, Singer DE. The effect of enforcing tobacco sales laws on youth's access to tobacco and smoking behavior: A controlled trial. New Engl J Med 1997;337:1044-51. 7. DiFranza JR, Rigotti NA. Impediments to the enforcement of youth access laws at the community level. Tobacco Control. 1999;8:152-155. 8. Altman DG, Foster V, Rasenick-Douss L, Tye JB. Reducing the illegal sale of cigarettes to minors. JAMA. 1989;261:80-83. 9. Altman DG, Rasenick-Douss L, Foster V, Tye JB. Sustained effects of an educational program to reduce dales of cigarettes to minors. American Journal of Public Health. 1991;81:891-893. 10. Staff M, March L, Brnabic A, Hort K, Alcock J, Coles S, Baxter R. Can non-prosecutory enforcement of public health legislation reduce smoking among high school students? Aust N Z J Public Health. 1998;22:332-335. 11. O’Grady B, Asbridge M, Abernathy T. Analysis of factors related to illegal tobacco sales to young people in Ontario. Tobacco Control 1999;8:301-305. 12. Teall AM, Graham MC. Youth access to tobacco in two communities. Journal of Nursing Scholarship. 2001;33:175-178. 13. Levy D, Chaloupka F, Slater S. Expert opinions on optimal enforcement of minimum purchase age laws for tobacco. J Public Health Management Practice. 2000.6:107-114. 14. Siegel M, Biener L, Rigotti N. The effect of local tobacco sales laws on adolescent smoking initiation. Preventive Medicine. 1999;29:334-342. 15. Chaloupka F, Pacula R. Limiting youth access to tobacco: the early impact of the Synar Amendment on youth smoking. Working paper: Department of Economics, University of Illinois at Chicago; 1998. 16. Glantz SA. Preventing tobacco use-the youth access trap. Am J Public Health. 1996;86:221-4.

My name is Joseph Morris and I have been a dipper for the past 10 years. As I am writing this I am 3 days clean of dip.

I'll never forget my freshman year of high school. I was first introduced to dip outside at lunch. It gave me such a buzz and I even threw up. It soon became a lunch ritual. I would dip at lunch and be so buzzed for next periods class thatI would sleep right through it because I was so nautious. I threw up everytime I did it for the first week.

Why did I keep doing this? I guess I liked the buzz at first. The buzz soon turned into a fix to fill the physical craving.

This physical craving lasted 10 years. I am a 24 year old graduate student who is a dipper. All this education and I'm just asking to kill my self.

I 'm just beginning to get used to not dipping tobacco. Like so many of you who can relate, their isn't to many things I would do without a dip in.(Including kissing my girlfriend).

I had a real scare my freshman year of college. I had a lump on my gum which is still their today. First I was told it was a tumor and next I was told I was going to lose feeling in my lip. I could not believe this was happening to me. The doctor came back and told me it did not have to be removed and was not cancer. I vowed never to dip agian and that lasted a whole week. Now here I am five years later. I have been dipping five more years since a moment that should of taught me a lesson. I feel like I have woke up out of a little dream that has lasted ten years. Addiction blinds you from the truth. I finally came to a point where I have had enough being controlled by something that will eventually kill me. I have accepted the fact that I have been bad role model to the kids I coach, the kids I see at summer camp, and to one special kid my brother. My brother is a dipper and learned it from yours truly. He is a couple years younger then me and hopefully this letter will show him how stupid I've been. I love my brother just as some of you reading this love your brothers. You may be able to relate and should quit. If not for yourself do it for one of the reasons i've brought up. Honestly, how many 40-50 year old dippers do you no. I no one who has been doing it for about 20years. He has not listended to pleads from his dentist.QUIT NOW BEFORE YOU END UP LIKE SEAN MARSEE OR MR TUTTLE. Take a look at those pictures and you will pray to God it is not to late. I have one hanging up in every room at my apartment. I will never put a dip back in my mouth especially after reading those stories.

If I can help one little brother this unplanned letter is all worth it. If anyone can relate feel free to email me I feel great right now. Two days of miserable cravings is well worth the lifetime of having a jaw.

Thank You, Joseph Morris

Stan Shatenstein's review nicely summarised the essence of the drama, how the dramatis personae of tobacco control in the USA helped scuttle "the plausible, if arguable benefits of the McCain bill," which would have provided the greatest concessions to public health ever imagined, or indeed now imaginable. Worse, the incident fractured the anti-tobacco movement along severe earthquake fault-lines. In this telling, says Shatenstein, "the book is a rousing success."

The reviewer dwells on what he perceives as the book's "central failing": that the author Michael Pertschuk set about mainly to exculpate Matt Myers and his decision to go into secret negotiations with the tobacco industry pretty much on his own. (Actually, Pertschuk is harder on Myers, and so is Myers himself.)

But the book is far richer. It explains what was lost when the rejectionists vociferously opposed any concession to the industry. It tells how the "bad cops" Koop and Kessler helped the "good cops" extract the maximum conceivable in industry concessions -- a perfect inside- outside strategy until the "bad cops" forgot they were supposed to be acting. Pertschuk then provides a primer on "Thirteen Ways to Lead a Movement Backward" (echoing poet Wallace Stevens's "Thirteen Ways of Looking at a Blackbird"), whose obvious inverse is how to lead a movement to victory.

The most important lesson from the book, however, is that all the principals but one were willing to reconsider their roles in the debacle, to search deeply into their actions and motives, and to examine how they might have behaved differently. Pertschuk gives his own mea culpa. Even Ralph Nader learned something new, but Stan Glantz refused to be interviewed for the book (Pertschuk, personal communication).

When the next opportunity comes, as it surely will, I'd want all these reflective persons -- Myers, Nader, Pertschuk, Julia Carol -- to be out in front again.

The authors say:"The leaf is from a broad leafed plant (Diospyrus melanoxylon or Diospyrus ebemum) native to India" I feel there is an error here.Diospyrus ebenum (Ebony,black) is not a source for Tendu leaves, as far as I know.(The authors write 'ebemum'-probably a typing error.For a list of plants from which bidi leaves are obtained, see the following paragraph, from J.K. MAHESHWARI National Botanical Research Institute, Lucknow - 226 001, India http://www.fao.org/docrep/T0115E/T0115E0g.htm

"1.11 Tendu leaves

The leaves of tendu (Diospyros melanoxylon) are most widely used as bidi (country cigarettes) wrapper. The collection of bidi leaves and making bidis is a labour-intensive cottage-scale industry. The leaves of the following species are also used locally: D. exsculpta, Bauhinia racemosa, Holarrhena pubescens, Artocarpus heterophyllus, Careya arborea and Cordia dichotoma.

I read your recent apt editorial with great interest. The views presented represent some of the more seminal in contemporary ethics vis-a-vis the ivory tower. As you are well aware, it is unfortunate to note that many academic institutions in developing countries collaborate (in the literal sense of the word!) with the major domos mentioned in your five scenarios. Less than 5% of academic research are carried out citizens of developing countries. Money, or lack of it, is the usual obstacle. Thus, 'fortunate' African academics like myself, with two dozen peer-reviewed publications, are rare in the developing world. Your editorial raises three issues, which I would like to address from the lenses of a developing country academic:

1) The editorial starts on the premise that the five senarios are totally unacceptable to any university. Not quite. Mariam Babangida and Maryam Abacha were wives of two dictators who collectively ruled Nigeria for 14 years. Mariam established a Better life for Rural Women Program while Maryam established the Family Support Program. Both programs were affiliated to Nigerian universities, and funded from Nigeria's petrol dollars. It is on record that Maryam Abacha, who with her late husband plundered about $US5 billion from Nigeria's treasury, was awarded a PhD from The University of Maiduguri, Nigeria. As an 'academic' she joined Idi Amin, Uganda's former dictator, who was awarded a PhD from Uganda's Makerere University. The military-dictator husbands of these powerful women collectively damaged the very fabric that would facilitate improved quality of life for Nigerian women and Nigerian families. On another note, the atrocities perpetrated by Cecil Rhodes in Southern Africa are well known to students of African history. Yet, many brilliant students world-wide (but excluding Southern African countries, where the ill-gotten wealth was obtained) continue to benefit from Rhodes scholarship. I suspect that Sydney University offers its students Rhodes scholarships. Furthermore, Shell Nigeria provides funding to six Nigerian universities, part of which is allocated to ecological research. Thus, although I agree that these suggestions are in poor taste, but when poor States have to deal with such ethical dillemas, I am pretty certain they would not adopt your moral high ground - the recent acceptance of a space tourist by the cash-strapped Russian space mission is a case in point. The point I'm making is that it is difficult to discuss ethics and morality on an empty stomach.

2) You suggested that the funding of universities by the tobacco industry merits greater condemnation than their funding of other agencies such as sports and schools. I disagree. Such a perspective is akin to the front-page headlines the fall of the Australian dollar below the 50 US cents 'psychological barrier' made in Australian newspapers about six weeks ago. The fact, as you rightly pointed out, is that the tobacco industry has been poaching venal and naive academics, and using them to sow doubt among the public. With funding going directly to a university, ethical approval processes should reduce the propensity for a few academics to become the tobacco industries' mouthpiece after taking the proverbial thirty pieces of silver. If properly managed, the tobacco industry could end up funding their nemesis. Should the tobacco industry withdraw funding from universities that dare speak the truth, editorials such as yours would take on a superior ethical flavour.

3) Is the tobacco industry alone in influence peddling in universities? Not quite. The adverse effects of the atrocities of the pharmaceutical and information technology industries on the quality of research in our universities, and indeed on the quality of health care is currently a subject of intense intrest, attracting a recent editorial in the New England Journal of Medicine. I was particularly exasperated by their antics at the 14 International AIDS conference in Durban, South Africa, in July 2000[1]. It is tempting to excuse their lobbying on the premise that pharmaceuticals potentially save lives while tobacco certainly costs lives. However, in the final analysis, the primary concern of pharmaceutical industries is the bottom line. Their recently withdrawn court case, apparently to compel the South African government to buy their more expensive drugs is a case in point.

In conclusion, the ethics of tobacco funding need to be placed in context. While it is ridiculous the the tobacco industry should continue to exist at all, given the plethora of evidence on the adverse effects of their products, we have all had to contend with the reality that it would continue to exists for many more decades in spite of our best efforts. A consensus also apparently exists that the fight against the tobacco industry would have to be conducted at many points, to be successful. Rejecting, outright, tobacco industries' funding for research in universities is a rational approach to isolating them. Accepting the funding, and subjecting the projects undertaken with such funds to utmost ethical approval is another. While the former is the more appropriate response in wealthy nations, it would be unfair to blame poor nations for adopting the latter strategy.

1. Awofeso N, Degeling P, Ritchie J, Winters M. Thabo Mbeki and the AIDS 'jury'. School of Health Services Management, Faculty of Medicine, University of New South Wales, Sydney 2052, Australia.

The authors have written an excellent article. Readers may also be interested in knowing that the website for the British Columbia Ministry of Health also contains copies of industry documents retrived from the Guildford depository in England.

Approximately 40,000 pages of documents on the Canadian operations of BAT and Imperial Tobacco Limited are posted at: www.hlth.gov.bc.ca/guildford/index.html

Thank you.

Readers may be interested to know that the Virginia Slims ad shown in this article was changed after the head of Philip Morris was asked pointed questions about it in a recent deposition. The deposition was taken as part of the "Engle" class action lawsuit in Florida, which is heading towards a large punitive damages award (the jury has already handed out two positive verdicts for the plaintiffs).

Here is an excerpt from the Wall Street Journal, which provides some details.

---------------------------

Wall Steet Journal June 13, 2000

Philip Morris Removes Slogan From Ads In Second Attempt Responding to Critics

By GORDON FAIRCLOUGH

Michael E. Szymanczyk, head of Philip Morris Cos.' U.S. tobacco operations, said he ordered changes last month to an advertising campaign for Virginia Slims cigarettes after a lawyer suing the cigarette maker asked him pointed questions in a deposition.

Mr. Szymanczyk, testifying in the trial of a class-action suit filed by Florida residents with smoking-related illnesses, said he removed the slogan "Find your voice" from the ads after being deposed by plaintiffs' attorney Stanley M. Rosenblatt, who had suggested it might be offensive to smokers with throat cancer. ...

Mr. Szymanczyk testified that during a deposition in May, Mr. Rosenblatt asked him if he thought the Virginia Slims ad slogan "Find your voice" would be offensive to people who had developed throat cancer from smoking and lost their ability to talk. The next day, Mr. Szymanczyk testified, he ordered the slogan removed from the ads. "He made a good point," Mr. Szymanczyk said, adding that using the slogan in the first place "was my mistake."

During the deposition, Mr. Rosenblatt also questioned Mr. Szymanczyk about the use of the line "Don't let the goody-two-shoes get you down" in some Virginia Slims ads. Mr. Rosenblatt suggested it encouraged people to disregard health warnings about cigarettes.

In his testimony Monday, Mr. Szymanczyk said that slogan was set to "expire anyway" and be discontinued at the end of June. If it had been scheduled to continue, however, Mr. Szymanczyk said he would have ordered it pulled, too. He said he has told managers in charge of the Virginia Slims brand to make sure "there isn't any hint of rebelliousness" in future advertising. "We don't want controversial advertising," he said. "I don't want people to look at our advertising and say that we're trying to do something wrong."

A Philip Morris spokesman said that the Virginia Slims ad campaign, which also has been criticized by antismoking activists for targeting minority women, would continue to run, but with the changes ordered by Mr. Szymanczyk. ...

Dear Editor

As the person who posed four of the seven arguments, used in the March volume of Tobacco Control, supporting banning smoking in outdoor areas I would like to expand on the four points I raised. The arguments put by me apply to an Area Health Service which will shortly become totally smoke-free, this will include outside areas. Until now hospitals have regarded smoking as a special case, as a cultural habit, by going smoke-free we will put smoking where it belongs, in the drug/health category. The measures, which will apply to smoking, apply to many other practices common in the community but not tolerated in hospital.

1. Outdoor bans send an important message to the community.

I believe this is the most important reason for an Area Health Service to ban smoking on all its campuses. The first statement in the Charter of Central Coast Health is To promote, protect, and maintain public health and for that purpose to provide health services for the residents of its areas. By condoning smoking on Health Service grounds we sending the community the message that smoking is a cultural issue when in fact it is a major public health issue. The fact that many people still believe that smoking is cultural issue should not deter us from our charter. It is our duty to try to change community perception and put tobacco use firmly in the drugs/health arena. It will take time and yes some people will be unhappy. In a recent focus group an employee said, "I wonder if we do take away their right to smoke, the next thing is their right to food" The evidence of harm caused by tobacco use is overwhelming but still in many people's minds there is doubt. "If tobacco is so bad why does the Government not ban it?" is a common response to tobacco control measures. State and Federal Governments consistently give conflicting messages how they view smoking. A Health service must send a strong message that smoking is a major cause of ill health.

2. Other freedoms are curtailed in hospitals why not smoking too?

It's true other freedoms are curtailed in hospital to protect the health of patients. Alcohol is given to patients but not in doses that would be deemed harmful. It is unlikely that a patient in hospital with a condition caused or exacerbated by Alcohol would be allowed to drink. They would be supported with other medications to reduce the withdrawal. Narcotic dependant people are not allowed to have heroin but are given methadone. In both of these cases the patient is provided with a safer substitute. Nicotine addicted patients are offered NRT, also a safer substutute. Some patients with cardiac conditions are restricted to complete bed rest or on fluid restrictions. We make a decision based on medical ground what is good for them.

Patients who do not wish to follow rules may and do discharge themselves. Many patients discharge themselves from hospitals every day because there is some rule or condition of being in hospital they do not like. Should we allow poker machines in hospital because some people are addicted to gambling? A condition already in the contract of the leases of the coffee shops on hospital grounds forbids gaming machines, not because we are worried about side-stream gambling.

3. An enforced ban will be good for peoples health

Again it's true. Prior to surgery patients are strongly discouraged from smoking for very good health reasons. In fact many surgeons refuse to operate unless the patients stops smoking. Many medical conditions may improve by having a rest from smoking. We already say to people you may want to do something, but we so disapprove that we will not lift a finger to help you. A cardiac patient, on fluid restrictions, wants to go outside and drink an unlimited amount. As a nurse, I can tell you very few nurses would assist a patient outside in those circumstances. If caught a nurse acting like that would be in serious strife. We would not take narcotic or alcohol addicted patients outside for a fix. We would not assist patients on bed rest to walk. We would not wheel a diabetic patient outside to feast on chips and chocolate. Nurses do take patients outside but, with the current exception of smoking, it is always because it will do them some benefit. Introducing a policy that stops staff taking patients outside to smoke will put smoking in the category of health not culture. Like it or not health services make decisions on who will get treated and who will not. People in hospital are not prisoners they are there by choice. An expectation of patients in hospital is that they in some way support the treatment they are given. We expect them to take the proscribed medication, to stay on bed rest, or assist in the physiotherapy.

4. Escorting patients outside can cause staff shortages leading to patient neglect.

" Yes your honour we took Mrs. Smith outside for a cigarette, left her there and returned to the ward. Unfortunately she dropped her cigarette on her nightie and in the fire that followed she died." I can see the headlines now. Or " Yes your honour I took Mrs. Smith outside for a cigarette and stayed with her. Unfortunately Mrs. Jones on the unattended ward and in dire need of a bedpan and unable to find anybody decided to make her way to the toilet, forgetting that she was a double amputee" Another good headline I rest my case

I believe that many, now standard, tobacco control measures pushed the envelope at the time. The only people you alienate by pushing tobacco control are the manufactures. I would be horrified if they ever approved of any measure I support.

Don Cook RN Health Promotion Unit Central Coast Health, Gosford NSW Australia

In researching passive smoking issues for a suggested 'best practice' model in Australia, I was asked -- no, urged -- by normally sedate and conservative tobacco control bureaucrats a number of jurisdictions (which had no legislation to limit smoking in indoor areas) to consider the issue of smoking in outdoor places of public assembly. This was clearly an Issue of Public Importance.

My own experience in the Australian Capital Territory -- where smokefree indoor air legislation has been in effect since 1994 -- was also that the public is unhappy about ETS exposure when they attend events at outdoor venues. I was aware of moves in the USA to prohibit smoking at such venues, promoted by statement such as, 'We wanted to make this the best family venue in California.' But in the 'evidence-based policy' environment of Australia, did this mean that prohibiting or restricting smoking at these venues is justified on health grounds?

I believe that there is evidence to support the view that, although people's ETS exposure in venues which are substantially or entirely unenclosed will normally be less than in enclosed spaces, tobacco smoke exposure in these circumstances can product symptoms of ill health. These can be a particular concern for vulnerable individuals such as young children, pregnant women and people who suffer from allergies and pre- existing respiratory or cardiovascular conditions.

Particularly in places where smoking in indoor environments is subject to legislative control, the community accepts (and expects) that they have a right to be protected from ETS exposure in confined areas. If this is protection is not provided as a matter of venue policy, there is no reason that it should not be included in smokefree public places legislation. Such a provision could refer to restricting or prohibiting smoking in a place or part of a place where, during an event to which members of the public are invited or permitted to attend, persons sit or stand in immediate proximity to each other.

If such legislation also has provisions which require reasonable steps to be taken to prevent tobacco smoke from penetrating non-smoking areas, then this should motivate building managers to ensure that outdoor smoking areas are located well away from building entrances and air intakes.

Margo Goodin Director, Tobacco Control Program ACT Department of Health and Community Care Canberra

The views expressed are the views of the author and should not be taken as representatives of the Department or of the ACT Government.

Dear Bill,

Thanks so much for an excellent article!! We can't be pro-active enough against the smoking cartel deceivers!!

The MSA volume adjustment provision makes me sick!! How our government and people have been duped and diced!

I recently read some facts about smoking in China and it said over 300 million in China now living will die prematurely from smoking!! Truly we have a challenge on our hands as activists and health educators to help the young, the gullible, the innocent!

God bless you in your work and may your pen and voice be even more active in the days and weeks ahead as you seek to be a blessing and help to others!!

Sincerely,

Wes Lombard; RN

Dear Prof. Chaloupka,

I read with interest your article in Tobacco Control "Curbing the epidemic: governments and the economics of tobacco control".

Within the context of a hedonic pricing model a colleague and I recently ran a set of regressions relating cigarette prices to their characteristics (nicotine content, carbon monoxide content, tar level etc). Primarily the intent was to establish were all smokers the "same" or did sub-groups exist that differed from each other. We have written this up as a working paper.

We found (not surprisingly) that at least 2 sub-groups existed.

May I ask two questions

1. has anyone considered the possibility of taxing the constituents of cigarettes - e.g. tar content, carbon monoxide content etc. - as a way of targeting tobacco effects rather than tobacco per se?

2. ignoring the industry and probable collusion within it - in theory, does the potential exist to proliferate the variety of cigarettes available to consumers - in terms of characteristic combinations - and thereby allow consumers to select bundles that may have less harmful effects than those they currently smoke?

By inference I am suggesting that these approaches may offer two further weapons to the arsenal of tobacco control.

I accept of course that there is no such thing as a safe cigarette and that the preferred option will always be abstinence.

I look forward to hearing your thoughts in due course,

yours sincerely,

Ciaran O'Neill

Ciaran O'Neill (PhD) Reader in Health Economics and Policy School of Public Policy, Law and Economics University of Ulster at Jordanstown Newtownabbey Northern Ireland

Comprehensive Tobacco Control Strategies Impact Youth and Adults

by Rick Kropp Tobacco Prevention and Policy Resources Santa Rosa, CA May 1, 1998

Efforts to Prevent and Reduce Youth Smoking Also Help Reduce Adult Smoking, And Vice Versa

As someone who has been falsely accused for many years of “just” being a youth access specialist and “just” focusing on youth tobacco prevention, I have devoted a great deal of time and thought to those tobacco advocates who claim that a “youth-focused” tobacco control strategy is ineffective, neglects larger tobacco issues such as ETS exposure and adult smoking, and is counter- productive in achieving a smoke-free society.

I have come to the conclusion these claims really missing the point. Their proponents fail to see the forest before the trees.

The reality is that these so-called “youth-focused” strategies support and enhance efforts to reduce adult smoking and nonsmokers’ exposure to ETS, and vice versa.

When someone looks at the wide array of tobacco control policies and programs in our public health and political arsenal, it becomes quite clear (at least to me) that all these approaches are interrelated and mutually supporting of each other.

For sure, many tobacco advocates and elected officials use the “youth” focus to achieve political and policy goals. And while this may appear to be an effective strategy, it surely does play into the hands of the tobacco industry over the long term.

National comprehensive tobacco control strategies include tobacco tax increases; the regulation of nicotine and tobacco products; eliminating nonsmokers exposure to ETS; youth tobacco prevention policies such as youth access laws and their enforcement; youth tobacco prevention education programs in the schools, home and community; restrictions on tobacco advertising, promotion and sponsorship; and cessation programs for current tobacco users.

In its most basic form, this national strategy addresses three public health problems: 1) a prevention problem where the goal is stopping children, teens and young adults from initiating regular tobacco use and becoming addicted to nicotine through the use of various prevention, media, education and policy strategies; 2) an addiction problem where the goal is getting adults and teen tobacco users to quit on their own or through cessation and relapse prevention programs; and 3) an ETS exposure problem in the home, family vehicles, all workplaces, enclosed public places, and public buildings. This national tobacco strategy impacts youth and adults. Tobacco prevention strategies such as youth access reduction efforts impact youth, but also effect adults such as merchants, parents and other adult family members who are sources of tobacco for minors.

Tobacco prevention strategies such as advertising restrictions impact youth and adults. The objectives of tobacco advertising and promotion are: 1) market expansion, attracting nonusers to begin smoking and chewing tobacco, almost entirely minors; but also 2) to encourage tobacco consumption in three ways: by supporting continuation of smoking by adult and youth smokers who would otherwise quit; by encouraging adult and youth quitters to relapse; and by increasing adult and youth smokers’ daily consumption of cigarettes.

Many other tobacco control strategies and approaches impact youth and adults. For example, creating and promoting positive parental and family influences in the home to prevent youth smoking impacts adults as well. Interventions that promote positive role models for young people in the community also impact adults. Restricting youth exposure to tobacco advertising and promotion also impacts adults exposure. Efforts to counter pro-tobacco influences in the community impact youth and adults. Anti- tobacco media advertising campaigns can and should impact both youth and adults.

Eliminating exposure to ETS in the home and family vehicles impacts both youth and adults. School smoking restrictions apply to and impact both students and adults. Local and state clean indoor air laws impact adults and youth. Regulating the labeling, packaging and contents of tobacco products impacts youth and adults. Increasing tobacco excise taxes effects the consumption of both youth and adults.

The “youth” versus “adult” tobacco control issue is an inaccurate and misleading distinction. Broad-based tobacco control programs, for example our California Prop 99 program, impact youth and adults through interrelated and mutually supportive activities.

Tobacco smoking and periodontitis. DAVID A. SCOTT1, MARK IDE2,3, RON F. WILSON1 AND RICHARD M. PALMER2 Dental Clinical Research1, Department of Periodontology and Preventive Dentistry2 and School of Dental Hygiene3, Guy's, King's and St. Thomas' Schools of Medicine, Dentistry and Biomedical Sciences, King's College London, UK.

Chronic inflammatory periodontal disease (gum disease) is a major cause of tooth loss in humans. Periodontitis can be painful, emotionally disturbing, and expensive to treat. Perhaps the greatest single controllable risk factor for periodontitis, other than poor oral hygiene, is tobacco smoking, and smoking remains a major risk factor for the development and progression of periodontitis even when adjusting for oral hygiene status, gender, socioeconomic status and age 1,2.

Smokers are significantly more likely to develop inflammatory periodontal disease at a younger age (early onset periodontitis), to develop more severe disease, to have more aggressive rapidly progressing disease, and to respond poorly to periodontal treatment on comparison with non-smokers 3-7. The influence of smoking on periodontal health is so profound that it has even been suggested that smoking-related periodontitis should be considered as a distinct disease category 4,7.

Smoking is known to effect many aspects of periodontal health, having been reported to influence gingival bleeding and to be associated with increased recession of the gingivae, increased attachment loss, increased alveolar bone loss around the teeth, increased tooth mobility, increased incidence of tooth loss, increased staining of the enamel, thickened and fibrotic gingiva, and halitosis (oral malodour) 1-9. There is evidence to suggest that the risk of periodontitis in smokers may be dose-dependent 2,4,5,8.

It is well known and almost universally acknowledged that smoking contributes to the pathogenesis of heart disease, stroke, cancer, and many other smoking-related diseases. Despite a barrage of anti-tobacco public health campaigns and the increased availability of nicotine replacement therapies and other interventions to aid cessation, nicotine users and addicts are continuing to smoke and others continue to take up a smoking a habit. An appeal to vanity may therefore be helpful, particularly among young persons, as recognised in the yellowing fingers, wrinkled skin, psoriasis, and stained teeth described in the recent advertising campaign in British Columbia, Canada, detailed in the cover essay of a recent edition of Tobacco Control (1999;8:128-31).

Dentists and oral health professionals have long been aware of their responsibility to educate patients on the dangers of tobacco use and to advise on the benefits of stopping smoking. We suggest that the association between smoking and chronic inflammatory periodontal disease should be recognised as an important weapon to be used in the armoury of those involved in the battle against smoking. Smoking-related periodontitis is a disease that can be much more severe and unpleasant than may be generally appreciated. There is also evidence to suggest periodontitis may also be a risk factor for the development of systemic problems such as cardiovascular disease and low birth weight 10. In addition to a recognition and appreciation of periodontitis as a smoking- related health problem, aesthetic concerns such as early tooth loss, halitosis and the adverse effects on periodontal tissues, as well as the financial burden of periodontal treatment, may be considered in the planning and implementation of tobacco control strategies.

References: 1. Ismail AI, Burt BA, Eklund SA. Epidemiologic patterns of smoking and periodontal disease in the United states. J Am Dent Assoc 1983;106:617-23. 2. Martinez-Canut P, Lorca A, Magán R. Smoking and periodontal disease severity. J Clin Periodontol 1995;22:743-9. 3. Ah MK, Johnson GK, Kaldahl WB, Patil KD, Kalkwarf KL. The effect of smoking on the response to periodontal therapy. J Clin Periodontol 1994;21:91-7. 4. Haber J. Cigarette smoking: a major risk factor for periodontitis. Compend Contin Educ Dent 1994;15:1002-8. 5. Kaldahl WB, Johnson GK, Patil K, Kalkwarf KL. Levels of cigarette consumption and response to periodontal therapy. J Periodontol 1996;67:675 -81. 6. Burgan SW. The role of tobacco use in periodontal diseases: a literature review. Gen Dent 1997;45:449-60. 7. González YM, de Nardin A, Grossi SG, Machtei EE, Genco RJ, De Nardin E. Serum cotinine levels, smoking and periodontal atachment loss. J Dent Res 1996;75:796-802. 8. Grossi SG, Genco RJ, Machtei EE, Ho AW, Koch G, Dunford RG, Zambon JJ Hausmann E. Assessment of risk for periodontal disease II. Risk indicators for alveolar bone loss. J Periodontol 1995;66:23-9. 9. Miyazaki H, Sakao S, Katoh Y, Tekehara T. Correlation between volatile sulphur compounds and certain oral health measurements in the general population. J Periodontol 1995;66:679-84. 10. Beck JD, Offenbacher S, Williams R, Gibbs P, Garcia R. Periodontitis: a risk factor for coronary heart disease? Ann Periodontol 1998;3:127-41.

I believe we have come a long way when we are at the point that we are trying to define just what this toxic pollution really is. When I first started writing, about 15 years ago, I saw the need to define tobacco smoke polluted air which had been air conditioned and filtered but which still contained the gaseous elements which are in tobacco smoke in copious amounts. When the air is not entirely smokefree, filtering it through an air conditioning system will not make it safe for us who are hyper-sensitive to second hand tobacco smoke, hence the need for nomenclature which would essentially describe air with the smoke smell filtered out, but which still contains the gaseous elements. These are exceedingly dangerous to us as a component of ETS. This kind of air has a characteristic stuffy odor, which can cause me illness that can require weeks or months to recover to the previous state of well being which I had previously enjoyed.

I believe it is not enough to just use ETS since it is too brief. People new to this problem may not get the picture. I use 'second hand tobacco smoke/ETS' as the defining description since it describes second hand tobacco smoke pollution as a factor added to ETS, but which might require a dialogue about ETS since it is a seperate complex problem.

I think it is necessary that we spell it out for them, what 'second hand tobacco smoke/ETS' actually is. I also believe that since this has been used for so many years, we should not change it because it does work. Some legislators pretend to ignore this but they know what we are talking about. It is more important to keep talking about it until they do the right thing. They need to know that we are knowledgeable and have the resources to back us up.

Sincerely, Albert Benson

I wonder if we are being a bit too condescending to the general public in this discussion about what to call passive smoking. I agree that this proliferation of terms is probably somewhat confusing. All of the terms currently in use by scientists and laypeople have their drawbacks. However, my experience in conversation with the wo/man in the street is that we are all fairly good at decoding our imprecise language.

For instance, several times I have heard people, even activists in the tobacco-control movement, call passive smoking "secondary smoking." A few times I have also seen this "incorrect" use of the term in letters to the editor of newspapers. Now in the scientific literature this term means smoking a tobacco product other than the one a smoker usually smokes. For instance, a person who usually smokes cigarettes, but very occasionally smokes a pipe or a cigar, is said to be engaging in secondary smoking when indulging in that pipe or cigar instead of smoking a cigarette. But when ordinary people use the term to mean "secondhand smoking" I suspect that everyone (or practically everyone) decodes "secondary smoking" correctly. (There is of course the wider issue of imprecise language being read and spoken by people whose native language is not English and who are still at a stage of comprehension that is not sophisticated enough to have to deal comfortably with several ambiguous terms all supposedly "meaning" the same thing.)

One point not already raised by previous correspondents is that even highly educated writers, such as scientists, sometimes make the mistake of using the phrase "exposure to passive smoking." Presumably what they are trying to say is something like, "exposure to another person's or other people's tobacco smoke in the air." Of course, I concede that, again, most of us manage to decode correctly the incorrect expression, "exposure to passive smoking."

It is true that the term "passive smoking" may cause some people subliminally to become passive about having to put up with tobacco smoke in their air. On the other hand, it is probably just as true to say that those who are not passive about this forced exposure to a poisonous pollution are angered by the term "passive" and thus are motivated to become active in their opposition to so many people being passive about it. Incidentally, I know of no scientific evidence about how the term "passive smoking" affects people, their attitudes or their actions.

The term "involuntary smoking" seems unnecessarily clumsy. Besides, for those who believe that active smoking is addictive, those addicted to it could be said to be doing "involuntary smoking."

Forgive me, but I just can't imagine normal people talking about "Environmental Tobacco Smoke" or "ETS" at parties, on picnics and in pubs, nevermind whether or not it is the pet term of the tobacco industry. I can't recall any person outside the tobacco-control movement using the term anywhere, not even in the more formal forum of letters to the editor of newpapers and magazines. Do we really want to create yet another unnecessary a gap between the terms being used by the scientific community and those outside it?

When I use the term "secondhand smoke" I have always assumed that everyone knew I meant the tobacco smoke in the air that surrounds me, smoke created firsthand by someone other than me lighting up a cigarette, pipe or cigar. It doesn't matter to me one whit whether those listening to me know that only a small fraction of that is exhaled smoke and that most of it is sidestream smoke. The point is that I am being exposed to other people's dirty, sticky and poisonous pollution and I am certain that when I'm on a TV or radio programme everyone knows that that is what I am unhappy about.

As much as some may regret it, passive smokers are smokers. They are doing a type of smoking which is causing many of the sorts of disease outcomes linked to active smoking. Indeed there are some disease outcomes now associated with passive smoking that are not linked to active smoking, such as tooth problems in children and Legg Perthes disease. To avoid the obvious fact that passive smoking is a type of smoking and has unsurprising smoking-related disease outcomes is to undermine the power of the message we want to get across. If you are a passive smoker and don't like being called a smoker, you shouldn't object to being called a smoker; you should object to being forced to be a smoker. Since well over 90% of the population in the U.S.A. are either active smokers or passive smokers, we have to face the fact that smoking is the norm in America and presumably in all Westernized, industrial nations. Once we accept that fact, angrily, we will be better motivated to take effective action.

Incidentally, I suspect that some disease outcomes from "passive smoking" are not at all from inhaling smoke. For example, various eye problems resulting from exposure to smoke are probably due to the surface of the eye being exposed directly to the pollution and not to the eye receiving irritant ingredients of the smoke delivered to it via the bloodstream. The link between second-hand smoking and cervical cancer may be due to sticky tobacco smoke adhering to the fingers of the smoking sexual partners and being applied directly to the female sexual organs during digital stimulation as in foreplay. I also hypothesize that certain rare skin disorders apparently brought on by exposure to tobacco smoke in the air may be reactions of the skin to the smoke adhering to the skin and then being absorbed directly into it. (See, for instance, the various publications in the scientific literature by B. J. L. Sudan on the disease suffered by him and the immediate members of his family when exposed to tobacco-smoke pollution.) If these instances of exposure other than through inhalation are considered important, then perhaps a term such as "tobacco-smoke pollution" (please note the hyphenated, grammatically correct form of that phrase)would be better than any term involving the word "smoking." The problem with Allyn Taylor's suggested "environmental tobacco pollution" is that what we are discussing is the pollution of the environment by smoke, not by tobacco. It is of course true that tobacco products pollute the environment (as in dropped cigarette butts being left in their billions as litter practically everywhere and specifically in places where toddlers pick them up and ingest them and also lit butts being discarded and causing major forest fires) but this is a matter distinct from what we are trying to discuss when coming up with a term for exposure to tobacco-smoke pollution.

On balance, I think I agree with John Slade that we are probably going to be wisest if we choose "tobacco-smoke pollution" as our term. However, because of the various reasons already put forward in favour of "secondhand smoking," I would be very pleased with it as well.

As described, there are problems with both the term "passive smoking" and "ETS", but on balance I think ETS has advantages.

To be difficult, I'd propose a different term altogether, Tobacco Smoke Pollution. The problem is, basically, one of pollution, and its most useful comparisons are to other pollution problems. Persons exposed to tobacco smoke pollution can have their exposures described using the same syntax as exposure to other airborne pollutants. An advantage of this approach is that it places the arcane world of tobacco smoke in the mainstream of pollution and environmental concerns and breaks down the artificial barriers of the specialized jargon we in tobacco control so often saddle ourselves with.

If Tobacco Control is looking for input as to what name to use, I urge "Secondhand Smoke". ETS is a great term for those that don't like to type, but it's a very neutral term. People hate secondhand smoke, they don't care much about ETS.

Passive Smoking and Involuntary Smoking are good terms, but I don't think they'll catch on.

Congrats to Tobacco Control for a great launch into Cyberspace!

Tac

Simon:

In your note, you appear to use "secondhand smoke" to refer to exhaled smoke. However, it seems as if many people use secondhand smoke synonymously with ETS, and that's how I use it. People talk about nonsmokers' exposure to secondhand smoke, but nonsmokers' exposure is typically to ETS, which is made up of exhaled smoke PLUS sidestream smoke. It would be difficult for someone to be exposed to pure exhaled smoke -- unless you go back in history to the old Chesterfield advertisement (c. 1928) in which the woman tells her man to "blow some my way." Our different usage of "secondhand smoke" is a good example of the ambiguity of these terms.

Ron

I work at a radiostation in Amsterdam - The Netherlands, in the on-air studio directing the show, doing editing and mixing and so on. I have to work together with 1 other in the same room. This is usually a smoker.

I will simply get fired if I would even ask my co-workers to stop smoking. You have to get this through to the LAW a.s.a.p. maybe then I stand a chance...

I sure as hell have felt these consequences many-a-time already. I get head-aches etc. I tend to be very hateful towards life, and have become very pessimistic all because of those stupid smokers.

In his letter, Neil Francey points out that the definition of "crimes against humanity" includes "inhumane acts... intentionally causing great suffering".

On July 7, 1999 a jury in the Engle class action case in Florida answered the question: "Have Plaintiffs proven that one or more of the Defendant Tobacco Companies engaged in extreme and outrageous conduct or with reckless disregard to cigarettes sold or supplied to Florida smokers with the intent to inflict severe emotional distress?" with a yes as to all the manufacturing defendants. These included Philip Morris, R.J.Reynolds, Brown & Williamson, Lorillard, and Liggett.

Though the failure of the U.S. to ratify the Rome statute establishing the international criminal court may provide the loophole through which the companies may escape, we have moved measurably closer to the day when the tobacco companies are treated as they deserve.

Congratulations on the excellent new on-line Tobacco Control and hats off to RWJ and BMJ Publishing. The cross referencing and interactive features represent a step change in the value of the publication and a new front in the efforts to contain the tobacco epidemic. If Philip Morris was worried before, then it will be more worried now.

Perhaps now is the time to rethink our relationship with the house journal of the tobacco control community. The 'real' Tobacco Control will soon become the one that is on-line - it is simply too good, too useful, too far ahead of the hardcopy. The other one - lovingly printed and illustrated on paper you could wrap the crown jewels in - will become a sublime souvenir, a beautiful material reminder of the virtual reality.

I hope the low marginal cost of adding internet-only subscribers will stimulate imaginitive pricing for those that need the information but do not have the money. That way, the eTC will have increased both the usefulness and the reach of the excellent material presented.

Dear editor:

I'm not sure if this electronic letter meets your guideline that it "contribute substantially to the topic under discussion," but I do want to congratulate you for moving "Tobacco Control" into cyberspace. eTC looks great, and will be an invaluable service to tobacco reseachers and tobacco control advocates throughout the world.

Ron Davis Henry Ford Health System Detroit, Michigan, USA rdavis1@hfhs.org

disclosure of "competing interest": I was editor of "Tobacco Control" from 1992 to 1998, and I'm now North American editor of the BMJ.