On Jan 19 2005, having been alerted to the extraordinary statement
shown on the cover of this issue of the journal (April 2005), I emailed
the letter below to Dr Chris Proctor at BAT in the UK. He replied the next
day asking when I would need the information sought. I replied immediately
that I would like it within a week. No further response has ever been
received from Dr Proctor.
On Jan 19 2005, having been alerted to the extraordinary statement
shown on the cover of this issue of the journal (April 2005), I emailed
the letter below to Dr Chris Proctor at BAT in the UK. He replied the next
day asking when I would need the information sought. I replied immediately
that I would like it within a week. No further response has ever been
received from Dr Proctor.
I invite him here publicly to now reply.
Simon Chapman
Editor
Dr C Proctor
BAT
UK
Dear Dr Proctor,
On January 16 2005, in an article in "This Day" (Lagos) headlined
'5.3m Nigerians Smoke Tobacco' a comment ("tobacco use is risky but
counterfeit cigarettes are lethal") was attributed to Mr Richard Hodgson,
Managing Director of British American Tobacco (BAT) Nigeria.
We intend commenting on this statement in a forthcoming issue of
Tobacco Control and would be grateful if you would answer the following
questions.
1. What is it that makes counterfeit cigarettes "lethal" but "tobacco
use" only "risky"?
2. Is Mr Hodgson's position consistent with official BAT global policy on
communicating with the public about the health consequences of smoking?
3. Do you believe that Mr Hodgson's statement would be interpreted by the
ordinary reader to mean that "use" of BAT's tobacco products in Nigeria
is less dangerous to health than the use of counterfeit cigarettes?
4. Do you agree that this statement is without foundation and so grossly
misleading and irresponsible?
5. What has BAT done to issue a public retraction of Mr Hodgson's highly
misleading statement and to discipline him?
My position in this debate, which has been a difficult one for the
tobacco control community, is that I neither condone nor condemn hiring
policies that favor non-smokers. However, I do support the employer's
right to adopt such a policy if the employer so chooses. I believe this
position—which is intermediate between the opposing views espoused by
Nigel Gray and Simon Chapman—is the most appropriate and defensible
po...
My position in this debate, which has been a difficult one for the
tobacco control community, is that I neither condone nor condemn hiring
policies that favor non-smokers. However, I do support the employer's
right to adopt such a policy if the employer so chooses. I believe this
position—which is intermediate between the opposing views espoused by
Nigel Gray and Simon Chapman—is the most appropriate and defensible
position for tobacco control advocates to articulate.
Many years ago the tobacco industry was lobbying forcefully in the
United States for passage of state laws banning employment discrimination
against smokers. From 1989 to 1993, 25 states enacted such "smokers'
rights" laws. Malouff et al published an analysis of those laws in TOBACCO
CONTROL in 1993,[1] and these authors provided a nice summary of reasons
why some employers might wish to hire only non-smokers:
"Why would anyone prefer to hire non-smokers? The answer may differ
from organisation to organisation and supervisor to supervisor. Some
possible reasons include evidence that smokers as a group have more job
accidents, suffer more work injuries, and create more disciplinary
problems at work than do non-smokers; a desire of some companies to avoid
worker compensation claims for lung damage that could be due to either
smoking or an occupational hazard, such as fighting fires; a desire for
physically fit employees, for jobs such as police officer and firefighter;
a desire to avoid the appearance of hypocrisy, when a smoker works in a
job to prevent or treat dependence on nicotine or some other addictive
substance; a need to maintain a super-clean workplace free of even the
tobacco on the breath of employees; the higher cost of employer-subsidised
life, health, disability, and worker compensation insurance when some
employees are smokers; the belief that smokers take more sick leave; the
fear that occupational toxins such as asbestos may interact with smoking
(even if limited to off-work time) to increase risks among employees; and
the desire of some religious organisations to hire employees who follow
off-work the non-smoking tenets of the religion. Also, the US tradition
has long been one of employment at will, meaning that employers can hire
and fire whomever they like for whatever reason they want. For instance,
employers might choose to hire employees who are relatives, who look or
act a certain way, or who seem to desperately need a job. A major
limitation on this employer freedom in modern times has been a series of
federal and state civil rights laws that prohibit employment
discrimination based on race, sex, age, and disability." (citations
omitted)
As noted by Malouff et al, the US Constitution and federal and state
civil rights legislation protect against discrimination based on race,
ethnicity, gender, age, and disability. To accord smokers (as a class) the
same level of protection against discrimination, as "smokers’ rights" laws
do, would be dangerous in my judgment.
Simon Chapman dismisses Nigel Gray’s argument that smokers are less
productive (as a class) than non-smokers, because "many smokers do not
take extra sick leave or smoking breaks." However, "discrimination" based
on class averages may be justifiable when measurement of individual
behavior or risk is impractical or impossible. For example, I pay much
higher automobile insurance premiums because I have two teenage sons who
drive, even though they may (theoretically) be the best drivers around.
Installing alarm systems and smoke detectors in homes reduces premiums for
homeowners’ insurance, even though some people don’t use or maintain these
devices after installation. Insurance companies assess risk and develop
fees based, in large part, on actuarial data and aggregate experience.
Employers may wish to use the same approach. It is more practical for
employers to refuse to hire ALL smokers, than to refuse to hire only
smokers who have worse health or higher risk of disease.
In defense of his position, Simon offers the analogy that employers
might refuse to hire younger women because they might get pregnant and
take maternity leave, and more time off later to look after sick children.
In the US, that policy would constitute illegal discrimination based on
age and gender, and would violate the spirit (if not the letter) of the
federal Pregnancy Discrimination Act.[2] The analogy is further weakened
by the fact that age and gender are inborn and immutable characteristics
(except for transgender surgery), whereas smoking is neither. Yes, of
course, smoking is addictive; but effective treatments exist and millions
of smokers have been able to quit.
Simon also presents a "slippery slope" argument that "employers might
... draw up a check list and interrogate employees as to whether they
engaged in dangerous sports, rode motorcycles, or voted for conservative
politics." A philosophy professor has called this type of argument an
illegitimate application of reductio ad absurdum.[3] Yes, all manner of
discrimination in employment occurs today, and will occur tomorrow, but
most of that discrimination is sub rosa. A restaurateur may not hire
waiters with purple hair and pierced lips, even if those characteristics
aren’t mentioned in the company’s employment manual. The issue at hand,
though, is EXPLICIT "discrimination" spelled out in corporate policy.
Weyco, Inc, a health-benefits management company based in my home state of
Michigan, informed its employees about the company’s new "smoker-free"
workplace policy 15 months before implementation.[4] It’s hard to imagine
widespread adoption of similarly announced hiring policies based on
Simon’s example of political ideology. (A rare exception might occur when
such ideology is central to the job’s responsibilities—for example,
editorial writers for conservative newspapers.)
Another problem with this "slippery slope" argument is that it
implies—wrongly, in my judgment—that employers cannot be trusted to adopt
hiring policies based on a careful consideration of the merits and
demerits of each policy option. A health insurer may decide to
"discriminate" against smokers—and smokers only—for reasons outlined by
Malouff et al.[1] The National Basketball Association’s standard player
contract prohibits motorcycle riding, a recent violation of which caused
disastrous consequences.[5] Contracts with theatrical stars often
prohibit dangerous activities such as hang gliding and skydiving because
of the difficulty of hiring an acceptable substitute when injuries
occur.[6] In each case, the employer chooses hiring policies tailored to
its own needs and circumstances, and cascades of discriminatory practices
rarely (if ever) flow down that less-than-slippery slope.
Sugarman discussed many types of off-duty worker behavior that may
clash with employers’ interests, including personal (social/sexual)
relationships, civic and political activities, leisure activities,
moonlighting, characteristics of daily living (eg, health behaviors,
personal appearance), and illegal acts.[6] The rationale for addressing
these behaviors in corporate hiring policies may be strong in some cases
and weak in others. But as Seligman noted, "Employers are not always
right, but they are guaranteed to do better than regulators and judges in
deciding which employees will be the most productive."[7]
Currently 30 states in the US have "smokers’ rights" laws on the
books.[4] Nevertheless, an estimated 6,000 employers no longer hire
smokers, according to the National Workrights Institute.[8] That number
may seem large, but it’s only a small fraction of the 20.8 million
businesses in the country.[9] Smokers can still find jobs, and employers
can decide for themselves whether to employ them. Tobacco control
advocates should oppose laws that give smokers special protection similar
to the protections afforded to groups defined by race, ethnicity, gender,
age, and disability.
Ronald M. Davis, MD
Director
Center for Health Promotion and Disease Prevention
Henry Ford Health System
Detroit, Michigan, USA
1. Malouff J, Slade J, Nielsen C, Schutte N, Lawson E. US laws that
protect tobacco users from employment discrimination. Tobacco Control
1993; 2: 132-138. http://tc.bmjjournals.com/cgi/reprint/2/2/132.pdf
2. US Equal Employment Opportunity Commission. Facts about pregnancy
discrimination. http://www.eeoc.gov/facts/fs-preg.html (accessed 25 March
2005)
3. Thompson B. Bruce Thompson’s fallacy page: slippery slope.
http://www.cuyamaca.net/bruce.thompson/Fallacies/slippery.asp (accessed 25
March 2005)
4. Peters JW. Company’s smoking ban means off-hours, too. New York
Times, 8 February 2005: C5.
5. Dodd M. Bulls' Williams likely to miss season after accident. USA
Today, 24 June 2003.
http://www.usatoday.com/sports/basketball/nba/bulls/2003-06-23-williams-
injuries_x.htm (accessed 25 March 2005)
6. Sugarman SD. "Lifestyle" discrimination in employment. Earl Warren
Legal Institute, 27 June 2002. Paper 1.
http://repositories.cdlib.org/ewli/1 (accessed 25 March 2005)
7. Seligman D. The right to fire. Forbes, November 2003.
http://www.forbes.com/forbes/2003/1110/126.html (accessed 25 March 2005)
8. Ozols JB. A job or a cigarette? Newsweek, 24 February 2005.
http://msnbc.msn.com/id/7019590/site/newsweek (accessed 25 March 2005)
9. US Census Bureau. 1997 Economic census: minority- and women-owned
businesses, United States. http://www.census.gov/epcd/mwb97/us/us.html
(accessed 25 March 2005)
I had a question about your measure of recall, which in effect
requires the ability to think abstractly and verbalize to in fact 'prove'
to the interviewer that the ad and its message were seen, heard, and
'digested'.
Our organization in NY, the Advertising Research Foundation, which
may not be familiar to you, has embarked on a series of studies about the
role tha...
I had a question about your measure of recall, which in effect
requires the ability to think abstractly and verbalize to in fact 'prove'
to the interviewer that the ad and its message were seen, heard, and
'digested'.
Our organization in NY, the Advertising Research Foundation, which
may not be familiar to you, has embarked on a series of studies about the
role that emotion plays in advertising effectiveness. As such, we are
growing in confidence regarding the use of 'forced recognition' of ads to
tap into a non-verbal and emotional layer of impact that is, in essence,
stripped away by the more cognitive-based recall methods. In short, we
feel these two techniques are measuring two different things - one, a
perhaps mostly unconscious recognition that remains in memory, and does
affect behavior - and, of course, the more common recall method, which is
definately precise if one wants to 'force' the respondent to prove they
have seen an ad, and even understood the message.
This forced recognition is fairy easy to do now with the use of
online surveys - to show the ad in as close as possible to its natural
setting.
Our concern is, particularly at younger ages (12-18)where teens are
not necessarily fully cognitively developed, that there may be two things
happening to descrease the accuracy of findings, and subsequent linkage to
ad costs:
1. respondents, particularly younger ones, who cannot verbalize an ad
which may have affected them deeply from an image perspective, will be
terminated from the surveys. Or, if forced by an interviewer to elucidate,
they may drop out. This results in the stickly problem of completely
missing, non-randomly, as you know a horrible state we try and avoid. And
nearly impossible to back track and figure out.
2. For all respondents, the fact that the early level of processing -
which we call recognition - is in effect over ruled with the recall line
of questioning, we may be missing a substantial opportunity to capture the
effect of the image, emotional, and unconscious on the effect of the ad on
a respondent. If respondents are merely presented the ad in, for example,
an MPEG file, and asked if they have seen it, you recieve a purer and
broader measure of the potential effect of the ad. In short, with
recongition you will get accuracy, with recall, precision.
The ARF has a concern with using media weight (here called GRPs) as a
measure for predicition purposes. In our opinion, media weight represents
what was bought - it is better, in our opinion, to focuse on what you
'got' in the form of psychological GRPs - frequency and reach. Then the
link to and justification for relating the cost of media to the 'results'
of the advertising can be calculated with more confidence.
I am very curious to hear your response to this, for my own
edification, and to share with my colleagues here. As you could guess, we
all operate in 'silos of knowledge' and it would be terrifcally
fascinating to see how we can cross -educate each other.
The highest nicotine concentrations of this study have been found in
Austria. Some background for this is given by
http://tc.bmjjournals.com/cgi/content/full/14/1/3. Most amazing, however,
was that these results had been presented to the Austrian press without
causing a reaction. A study of Moshammer et al. (2004)
Int.J.Hyg.Environ.Health 207, 4, 337-343 even showed high correlations of
nicotine with active particle sur...
The highest nicotine concentrations of this study have been found in
Austria. Some background for this is given by
http://tc.bmjjournals.com/cgi/content/full/14/1/3. Most amazing, however,
was that these results had been presented to the Austrian press without
causing a reaction. A study of Moshammer et al. (2004)
Int.J.Hyg.Environ.Health 207, 4, 337-343 even showed high correlations of
nicotine with active particle surface, indicating not only chronic risk
for employees but also acute risk for customers
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=15471097>,
but at a press conference on the occasion of the annual meeting of the
Austrian Society for Occupational Medicine there was little interest in
these news and journalists continue to write on the dangers of fine
particulates without mentioning indoor pollution by cigarettes. This can
only partly be explained by a high proportion of smoking journalists and
the business of the editors with tobacco advertising (which largely will
come to an end in Europe in July). Another main reason is to be seen in
the joint distribution of cigarettes and newspapers by tobacconists in
Austria. This is another reason why we should attempt to restrict the sale
of tobacco to stores licensed to sell tobacco products only. Nobody would
have to enter these places to buy newspapers, no child would have to go
there for a pencil and see the tobacco ads, which could be restricted to
the interior of stores for the addicted.
I have been a smoker for many years and have never attempted or had
the desire to stop.
I will willingly compare my health care costs with any non-smoker.
I will challenge any non-smoker to match my absenteeism due to
illness work record for the past 40 years.
Editor's comment: I can introduce the writer to alcoholics who have never had a car crash; to 5 winners in every game of Russian roulette; and to a person who walked across a busy highway blindfolded and did not get hurt. By the writer's logic, all these activities are not dangerous.
Wasim Maziak has concerns about the small number of papers published in the journal from less developed nations (LDCs) and urges that we send more LDC papers out for review and not reject them without review. The editors share his wish to see more papers in the journal from LDCs, but there are two problems. First, we don’t get very many submissions from LDCs, and second, like those submitted from authors in wealthy nations, we...
Wasim Maziak has concerns about the small number of papers published in the journal from less developed nations (LDCs) and urges that we send more LDC papers out for review and not reject them without review. The editors share his wish to see more papers in the journal from LDCs, but there are two problems. First, we don’t get very many submissions from LDCs, and second, like those submitted from authors in wealthy nations, we receive many papers which we reject for a variety of reasons that I summarized in my editorial.
The most common reason we reject papers without review is that they are describe very local populations and don’t take readers into any original areas that have obvious implications for others. A typical such paper might be a smoking prevalence or knowledge/attitudes/correlates of smoking study undertaken on the staff of a hospital, a group of medical students from one university or a population sample. We reject such papers all the time no matter where they come from, but unfortunately they mostly come from LDCs.
Often these papers are well done, but they rarely say anything different other than reporting on another population in another place. Dr Maziak suggests that such papers “are likely to have implications on a wide sphere of health and economic research, usually transcending the country in focus.” I’m sorry to say that they rarely do. If we were to run such papers, we would clog up the journal with them very quickly which would mean we would be able to publish less of the papers that our judgement is increasingly showing to be of relevance to others, give our upwardly spiraling impact factor.
We do not send them out for review because we do not want to waste reviewers’ valuable time if we have no interest in publishing such papers.
Journals are not the only place that such data can be published. Websites and WHO collections allow people who are interested in such studies to gain access to such data.
The table below shows the distribution of all submissions to the journal since January 1992. The data has been adjusted to take into account papers which have been submitted as part of specially commissioned supplements, and so the third column shows the acceptance rate by country of origin of corresponding author for all papers submitted for routine consideration by the journal. These data do not of course reflect papers which are still under review and they do not take account of papers written by authors registered in countries whose papers concern another country. This often happens in cases where an author from (say) Nigeria, is working in the USA or where there are multiple authors from different countries.
The great majority of our submissions come from researchers in wealthy nations, particularly the USA, Australia, Canada, Great Britain, Scandanavian nations, and New Zealand. This undoubtedly reflects the extent of research support available in those nations and so the “health” of the research enterprise on tobacco control in those nations.
Interestingly, we have received 25 submissions from Turkey. Nearly all of these have been rejected as they were either very small, parochial studies (typically smoking prevalence in special, local populations) or had other problems.
All authors submit their paper with the hope that it will be published. The unavoidable fact of life about all (good) journals is that they receive far more papers than they can ever publish. So culling must occur. Rejection does not occur only on the basis of study quality. Competent but dull papers fare worse than competent but interesting papers. Papers that cause the editorial group to say "we already know this" do worse that those where we say "this is something new and interesting."
I reiterate that we would love to publish more papers from LDCs, but as Dr Maziak agrees, we should not do this at the expense of quality.
Country or region
Submissions
Acceptances
Adjusted acceptance rate
USA
364
150 (41.2)
28.6
Europe incl Turkey
135
22 (16.3)
16.3
Australia & New Zealand
119
85** (48.7)
37.8
Asia
89
22*** (24.7)
12.4
UK
78
24**** (30.8)
24.3
Canada
44
14 (31.8)
31.8
Middle East
19
0 (0)
0
Latin America
9
2 (22.2)
22.2
Africa
8
3 (37.5)
37.5
Total
865
322 (37.2)
25.4
Notes:
* includes 46 papers accepted for commissioned supplements
** includes 40 papers accepted for commissioned supplements
*** includes 11 papers accepted for commissioned supplements
***** includes 5 papers accepted for commissioned supplements
I start by expressing my earnest pride of Tobacco Control and the
status it acquired in a record time. I am certainly grateful for making it
access-free for developing countries. However, I have some reservation
regarding TC editorial policy that I have mentioned before, and for which
I want to provide my motivations, speaking only about research articles.
Obviously the quest for quality cannot be debated and...
I start by expressing my earnest pride of Tobacco Control and the
status it acquired in a record time. I am certainly grateful for making it
access-free for developing countries. However, I have some reservation
regarding TC editorial policy that I have mentioned before, and for which
I want to provide my motivations, speaking only about research articles.
Obviously the quest for quality cannot be debated and editors should
aim to include only high quality articles in their journals. Other
criteria for paper consideration however, such as interest, relevance, and
impact can be subjective and indeed debatable. We have to remember that
the biggest share of the smoking burden falls on developing countries and
that this situation is projected to worsen considerably in the coming
years. A quick look at published research articles in TC gives the
opposite impression, as they mostly pertain to developed countries. Of
course simple epidemiological studies are not interesting to the editors
as well as readers outside the relevant country, but the impact of such
research should be equally considered. For example, reliable simple
epidemiologic figures on health risks from a certain country are likely to
have implications on a wide sphere of health and economic research,
usually transcending the country in focus. Lessons from studying the
global burden of disease and risk factors, as well as understanding the
impact of certain risk factors (ETS) globally have stated time after time
that a major limitation of our today's knowledge lies in the lack of
reliable information from most of the world, the developing world. How
about the other side of the coin? I claim that a significant proportion of
high profile research currently published in TC concerns tobacco control
issues relevant only to functioning law-abiding democracies (policy,
advocacy, advertisement, litigation), while probably the most defining
feature of developing countries is being dysfunctional dictatorships. Do
the editors of TC consider how such high profile research is perceived by
those bearing most of the burden of the tobacco epidemic?
Understandably many published research from developed countries
provide a model for other countries, but one can equally argue that the
path of evolution of tobacco control may not be similar in different
societies. The tobacco epidemic currently exists at variable stages in
different parts of the world, and when most editors of TC are from
countries that have gone a long way in their tobacco control campaigns, it
is natural that their own perspective will influence what they judge as
relevant or interesting in research.
I don't think that TC should sacrifice quality, or be more relaxed in
accepting studies from developing countries, or stop considering papers'
interest for the readers, but I urge the editors to consider a broader
perspective and long term impact of research, when deciding what is
interesting or relevant. After all, for high quality papers that fill an
information gap, external peer review can balance the review process for
studies from developing countries. This is a time tested mechanism that
should not be much weakened by strong editorial preferences. I reiterate
my support to TC and would be happy to learn that my concerns are
exaggerated. Otherwise, the main scientific publication of the tobacco
control community should at least aim to reflect the global tobacco
epidemic.
Sincerely
If you wish me to answer questions, it would seem more appropriate to
write to me directly than to ask the questions in a journal without even
drawing the existence of such a letter to my attention. However, I will
explain the situation.
I met Enstrom for the first time in 2000 at a meeting which Philip
Morris organised in Richmond, Virginia. We both gave talks. One of his
talks...
If you wish me to answer questions, it would seem more appropriate to
write to me directly than to ask the questions in a journal without even
drawing the existence of such a letter to my attention. However, I will
explain the situation.
I met Enstrom for the first time in 2000 at a meeting which Philip
Morris organised in Richmond, Virginia. We both gave talks. One of his
talks concerned an analysis based on very long term follow up of the
California CPS-I dataset, but was not to do with ETS. I may have said
that it would be a good idea to study risk associated with ETS in this
dataset – I cannot remember now – but I certainly was not involved in the
actual analyses leading to the paper he published with Kabat in the BMJ in
2003. Indeed the first I ever knew of such a paper was when it appeared.
I have, as you say, commented on Enstrom’s publications before. This
was as part of a routine series of reviews of relevant epidemiological
papers I have conducted for the industry over many years. The fact that I
may have criticised one publication does not necessarily imply weaknesses
of other publications. The methodological issue with the Enstrom/Kabat
paper cited by Bero et al (in the paper to which your letter replies) is
that there was no real “unexposed” group in the CPS-I dataset. Surely
this is true of virtually all ETS studies? Enstrom and Kabat showed that,
among those never smoking men and women in their studies who survived to
1999, those who in 1959 reported they had a spouse who currently smoked
were very much more likely to report at home or at work ETS exposure in
1999 than did those who in 1959 reported they had a spouse who had never
smoked. Clearly their exposure index did indicate higher ETS exposure in
the exposed group and their finding of a lack of relationship with lung
cancer, CHD or COPD risk should not be dismissed – it should be taken into
consideration along with the evidence from all the other studies.
Your letter suggests that I may "develop" analyses to my "liking",
implying that I may give a deliberately biased interpretation of the data.
I find this insulting in that I always take great pains to try to give an
unbiased scientific view of evidence. I note the massive attempt by the
anti-smoking industry to rubbish the Enstrom/Kabat study. Could this
reflect the fact that its results were not to their "liking"?
I have analysed the US-funded review and I want to share some of my findings. I am afraid there are serious errors in this document and I will quote only two of them to give an idea of their scope.
ERRORS. “Waterpipe use likely increases the risk of bronchogenic carcinoma [68] as well as lung [16,20,69] oral,[8] and bladder [21,70] cancers.”
I will not discuss each of all the cited references bec...
I have analysed the US-funded review and I want to share some of my findings. I am afraid there are serious errors in this document and I will quote only two of them to give an idea of their scope.
ERRORS. “Waterpipe use likely increases the risk of bronchogenic carcinoma [68] as well as lung [16,20,69] oral,[8] and bladder [21,70] cancers.”
I will not discuss each of all the cited references because most of the volunteers were simultaneous or ex-users of different (tobacco) products. I will only focus on references 69 and 16.
Ref 69 is : Rakower J, Fatal B. Study of Narghile Smoking in Relation to Cancer of the Lung. Br J Cancer. 1962 Mar; 16:1-6.
In blatant opposition to the above interpretation, the two cited researchers clearly said from the outset how they surprisingly noticed that “there [was] an eightfold difference between the lowest lung cancer mortality rate for the immigrants [Jews] from Yemen [a majority of them being hookah smokers] and the highest for the immigrants from Europe [50% were smokers and most of them were cigarette users].” This strange fact led them to analyse the tar filtering properties of narghile (results: 84mg for 10g of tobacco ; 161mg without water in the vase). As it was not enough to explain the low rates they observed, they discussed, among other matters, the influence of inhalation patterns and the question of temperature.
Many other references not cited in this review tend to show that hookah actually reduces the risk of lung cancer. Should we also add that Rakower and his colleague were talking about was “tumbâk” which contains much more nicotine than the one (tobamel) which is gradually swamping the world? Or that the same hookah used by Yemenis (mada’a) is usually topped with tons of charcoal?
The other cited reference (#16) is Lubin JH et al. (Quantitative evaluation of the radon and lung cancer association in a case control study of Chinese tin miners. Cancer Res 1990; 50:174–80). But we are not told that the same Lubin, only two years later, concluded another study by : [water] “pipe smoking may be less deleterious than cigarette smoking. The reasons for this are unclear, but may be due to the filtration action of the water bath or to less vigorous inhalation of pipe smoke”. (Lubin JH, Li JY, Xuan XZ, Cai SK, Luo; Yang QS, Wang JZ, Yang L; Blot WJ. Risk of lung cancer among cigarette and pipe smokers in southern China. Int. J. of Cancer 1992; 51 (3)3: 390-5.)
Strangely enough, neither the last reference nor another chief one, Hazelton (*), are cited.
METHODOLOGY. A fair number of the cited references relies on a previous, also US-funded, Egypt-based review (**) which is actually a mix of Medline abstracts and summaries of local documents. The authors of the last report pretend that “many of the studies on these subjects [i.e. hookah use] are merely anecdotal or lack the necessary rigorous study design or the power needed to be certain of the results.” (Radwan)
Rigour, that’s the word. This new “review” tells us about its one-year “precursor” that it “focused on Egyptian waterpipe research”. I am sorry to say that this is a wrong statement because the scope of the latter was going far beyond Egypt and was as wide as the new one. This has to be said from an ethical point of view: the modest researchers of the American-Egyptian team (ESPRI Centre) should deserve our respect for their work and its scope. Besides, it must be clear that both their document and the new one, we are talking about now, contain errors, the latter however to a greater extent.
This new review also emphasises the fact that it is “comprehensive” and “critical”. However, let’s point out that key references (*) are strangely absent in this document not to mention the best introduction to the issue : a 420 page multi-disciplinary doctoral thesis the abstract of which has been widely advertised over the past years among the tobacco control community and Globalink members. This work contains the 4 first reviews in sociology, anthropology, history and tobaccology (health and pharmacological aspects) concerning hookah/narghile use.
Indeed, was Wolfram the relevant reference (number 3) to support the given figure of people using hookah in the world or the other fact that its use is multi-century ? Wolfram is the right specialist for the platelet function but did the authors really know where he got that data from ? Let us tell them: indirectly from the a.m. thesis.
Consequently, it would have been more respectful and relevant to quote the existence of that document.
As for the “criticical” side, the reader of that document will be informed of what happened to an unlucky fellow who used a hookah: aspergillosis… without knowing that the poor man did not change the water of his hookah for weeks…
Effectively, the authors did not deem it necessary to bring out such a “detail”. For those who don’t know how a hookah is served, let us make it clear here that the water inside the vase is changed at the end of each session.
PREVENTION. This is, in my opinion, the most important and pressing issue and I regret that no practical orientation is given whereas so many ideas could be put forward instead of untiringly awaiting sound scientific evidence-based results from humans or from God.
CONCLUSION. Finally, since this document has been advertised and will probably be “indexed” under Mother Medline, the loop is looped and the boucle est bouclée, as French would say. Consequently, I urge everybody interested in this topic to access that document and personally check what I have been saying through these lines. I am ready to provide any colleague with a commented list of all other serious errors (about nitrosamines, lead, etc.) I have picked up in the document and I am ready to defend my position in any public debate.
Unlike before, I now sometimes ask myself : what is the reason behind such a stakhanovist production of papers on hookah the outcome of which only leads to more and more confusion (“bizid ettin bellé”, would we say in Arabic) ?
- Do we need quantity or elementary common sense-based quality ?
- Do we need ideology (we regret that the authors also attack smokeless tobacco…), boycott and blind unprofitable competition or international multidisciplinary co-operation to face the new challenge the worldwide spread of hookah use represents?
I only hope all this hubble-bubble-toil-and-trouble is not a race for funds in this merchant world ? You see, I am very perplexed these days.
Thank you for your attention.
Kamal Chaouachi, author of:
- DOCTORAL THESIS: « Le narguilé : analyse socio-anthropologique. Culture, convivialité, histoire et tabacologie d’un mode d’usage populaire du tabac », Université Paris X, 2000, 420 pages.
(English free translation): “Narghile (hookah): a Socio-Anthropological Analysis. Culture, Conviviality, History and Tobaccology of a Popular Tobacco Use Mode”, 420 pages. This reference document can be ordered through www.anrtheses.com.fr (use capital letters to fill in the boxes).
- BOOK: “Le narguilé. Anthropologie d’un mode d’usage de drogues douces”, Ed. L'Harmattan, 1997, 262 pages. (English free translation): An Anthropology of Hookah. its Use and Soft Drugs, 262 pages.
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Notes:
(*) For example, Hazelton’ s excellent study based on the use of a 2-stage clonal expansion model (incl. nested dose-response models for the parameters): “Smoking a bamboo waterpipe or a Chinese long-stem pipe appears to confer less risk than cigarette use, given equivalent tobacco consumption”. Why ? because “The arsenic-tobacco interaction also appears to be very important”, a point that previous studies (cited Lubin’s for instance), in the same country did not take into due consideration.
(Hazelton, W. D., Luebeck, E. G., Heidenreich, W. F. and Moolgavkar, S. H. Analysis of a Historical Cohort of Chinese Tin Miners with Arsenic, Radon, Cigarette Smoke, and Pipe Smoke Exposures Using the Biologically Based Two-Stage Clonal Expansion Model. Radiat. Res. 2001, 156: 78-94)
(**) Radwan GN et alii. Review on Waterpipe Smoking. J. Egypt. Soc. Parasitol. 2003 Dec;33 (3 Suppl):1051-71. Also note that this document is often referred to, in the related bibliography, as “cited in Israel” when it should be, if we mistake not, “cited in Radwan”.
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