On March 15 2007, my attention was drawn to a patent for a tobacco
smoking device, filed with the U.S. Patent and Trademark Office (USPTO)
for a "Hookah with simplified lighting" on June 9 2005. One of the authors
of the device being patented was Kamal Chaouachi, who on December 2 2004,
had a rapid response published in Tobacco Control [1] which was critical
of a paper by Masiak et al [2]. The submission process for rapid...
On March 15 2007, my attention was drawn to a patent for a tobacco
smoking device, filed with the U.S. Patent and Trademark Office (USPTO)
for a "Hookah with simplified lighting" on June 9 2005. One of the authors
of the device being patented was Kamal Chaouachi, who on December 2 2004,
had a rapid response published in Tobacco Control [1] which was critical
of a paper by Masiak et al [2]. The submission process for rapid responses
asks authors to “Please declare any competing interests”. I noted that Dr
Chaouachi’s letter contained no competing interest statement and so wrote
to him requesting that he submit a further rapid response which would
clarify his competing interest.
He duly submitted two rapid responses. The first, which I have not
published but retained, simply said “no competing interests”. I replied
that this brief response was unacceptable and that in the circumstances of
the revelation about his ostensible interest in the smoking
device, he should elaborate in a further rapid response.
In the second response Dr Chaouachi stated that he had signed away his rights “in
the presence of a State Attorney” to his tobacco smoking invention patent
on June 15 2005, some six days after the US patent was filed. Dr Chaouachi reiterated that “I had no competing interest at the time my Letter to the
Editor entitled 'Serious Effors in this Study" was sent to the Tobacco Control Journal.”
This last statement, in fact, is false. I am in possession of a report
from the French patent office (Bulletin Officiel De La Propriete
Industrielle Brevets D'Invention). At page 18 a patent in the names of
Billard, Chaouachi (Kamal), and De La Giraudiere is described. The patent
number is 04 06287, the company filing the patent is "Shishamania
International", the title of the patent is "NARGUILLE A ALLUMAGE
SIMPLIFIE". The date of filing is June 10 2004.
Thus, the US patent, filed at the US PTO on June 9, 2005, was first
filed in France on June 10, 2004. Dr Chaouachi’s e-letter was submitted
on December 2 2004. Therefore, the e-letter was submitted after the
French patent was filed, and before the date on which he reports
that he relinquished his rights to the patent.
In further correspondence during March 17, I confronted Dr Chaouachi
with the fact that his device had been registered with the French patent
authorities in June 2004 and that therefore he had made a false statement
in his declaration of no competing interests. He replied “This is not
"false statement" (!). … The French patent was filed at the date you
said. You are probably right as I cannot say myself so far when it was. I
have been informed of procedure. This is all.”
In summary, at the date Dr Chaouachi submitted his rapid response, he had a commercial interest in the subject of that submission. He did not declare this
interest. When later given the opportunity to do so, he maintained that he
had no competing interest at the time of writing his rapid response. He did not voluntarily declare that the patent had in fact been filed in France in June 2004.
In such circumstances, it is Tobacco Control’s policy to inform
offending authors’ institutions of such conduct. Dr Chaouachi would appear
to not be currently working for any institution. Tobacco Control is
unwilling to accept any further submissions from Dr Chaouachi.
Simon Chapman
Editor
1. Chaouachi K. Serious Errors in this Study.
http://tc.bmj.com/cgi/eletters/13/4/327 rapid response
2. Maziak W, Ward KD, Afifi Soweid RA, Eissenberg T. Tobacco smoking
using a waterpipe: a re-emerging strain in a global epidemic
Tob Control 2004; 13: 327-333
Foulds and Ramström raise important questions regarding a direct
comparison of mortality rates among smokers, smokeless tobacco (ST) users,
persons with mixed or former use, and non-users. They urge officials from
the Centers for Disease Control and Prevention (CDC) and from the American
Cancer Society (ACS) to make these comparisons and report the results, so
that Americans are fully informed about the health risks relate...
Foulds and Ramström raise important questions regarding a direct
comparison of mortality rates among smokers, smokeless tobacco (ST) users,
persons with mixed or former use, and non-users. They urge officials from
the Centers for Disease Control and Prevention (CDC) and from the American
Cancer Society (ACS) to make these comparisons and report the results, so
that Americans are fully informed about the health risks related to
tobacco use. But there is a simpler and more compelling solution: The
CDC must release publicly all data it uses to estimate the relative risks
and mortality rates among tobacco users.
Every year the CDC publishes statistics concerning how many Americans
smoke, and how many Americans die as a consequence (1,2). These
statistics form the raison d’être for current tobacco policies at all
levels of American government – and for the massive regulatory scheme
currently under consideration by the U.S. Congress.
The data from which the CDC estimates prevalence of tobacco use are
publicly available from the National Health Interview Surveys. In stark
contrast, the data from which the CDC estimates deaths from tobacco use
are not available to researchers outside the agency or its collaborator,
the ACS. Instead, the CDC takes a black-box approach of filtering
information on mortality through its online program called Smoking-
Attributable Mortality, Morbidity, and Economic Costs (SAMMEC) (3).
But SAMMEC is marginally informative, and utterly unsatisfactory. It
does not provide any information comparing the mortality experience of
smokers and ST users. It cannot even provide simple statistics like the
number of deaths among current and former smokers. In 2006 I submitted a
request for these data through the SAMMEC web site. I received this
unsigned response from the CDC Office on Smoking and Health: “Data are not
available for current or former smokers separately.”
The public release by the CDC of data relating to tobacco-related
mortality will also place the agency in compliance with the intention of
the NIH Data Sharing Policy (4), which states that “data sharing is
essential for expedited translation of research results into knowledge,
products, and procedures to improve human health.”
Brad Rodu
Professor of Medicine
Endowed Chair, Tobacco Harm Reduction Research
University of Louisville
Competing Interests: Dr. Rodu's research is supported by
unrestricted grants from two smokeless tobacco manufacturers to the
University of Louisville. More information is available at
www.smokersonly.org
References
1. Centers for Disease Control and Prevention 2005: Cigarette
smoking among adults – United States, 2004. MMWR 54:1121-1124.
2. Centers for Disease Control and Prevention, 2005: Annual smoking-
attributable mortality and years of potential life lost, and productivity
losses – United States. MMWR 54:625-628. 1997–2001.
3. Smoking-Attributable Mortality, Morbidity, and Economic Costs
(SAMMEC). Available at: http://apps.nccd.cdc.gov/sammec/login.asp
4. NIH Data Sharing Policy. Available at:
http://grants.nih.gov/grants/policy/data_sharing/
Henley et al’s paper (1) showing worse health outcomes in men
switching from cigarettes to smokeless tobacco, compared with men ceasing
tobacco use completely, adds to our understanding of the potential risks
from smokeless tobacco use. However, it also raises some additional
questions:
1. Like the authors’ earlier paper comparing health outcomes in
exclusive smokers with those of exclusive smokeless users in C...
Henley et al’s paper (1) showing worse health outcomes in men
switching from cigarettes to smokeless tobacco, compared with men ceasing
tobacco use completely, adds to our understanding of the potential risks
from smokeless tobacco use. However, it also raises some additional
questions:
1. Like the authors’ earlier paper comparing health outcomes in
exclusive smokers with those of exclusive smokeless users in CPS-II (2),
this paper did not report a comparison with those people who continued to
smoke. Papers by other groups examining the health outcomes from potential
harm-reducing behavior changes (3,4) have presented the whole picture,
comparing the outcomes for continuing smokers, never smokers and those
making the potentially less harmful change (e.g. reducing cigarette
consumption). Occasionally clinicians are asked by smokers who don’t want
to quit tobacco, whether their health risks would be reduced by switching
to smokeless tobacco. This question may come up more frequently with some
of the major cigarette manufacturers now test-marketing smokeless
products. The CPS studies have the data to help answer that question. The
public should be informed just how much their chances of premature death
from lung cancer, COPD etc are likely to be reduced by using smokeless
tobacco rather than smoking. The authors should be encouraged to analyze
and publish those data as well. A survival curve comparing never tobacco
users, smokers and smokeless tobacco users would be helpful, as would the
adjusted risks of each tobacco-related disease for each group.
2. Also like the previous paper (2), this study found raised risks of
death from lung cancer and COPD among those who switched to smokeless
tobacco. For example, among snuff users (27% of switchers), the adjusted
hazard ratios for all cause mortality (1.11, 95% CI=0.94-1.3), coronary
heart disease (1.12: 0.82-1.53) and stroke (0.89: 0.49-1.62) were not
significantly elevated, and were lower than those for lung cancer (1.75:
1.2-2.5) and COPD (1.68: 0.9-3.3). The authors have pointed out the
possibility that the increased lung cancer risk could be caused by
circulating carcinogens from the tobacco. However, the authors did not
speculate on the possible cause of increased risk of death from COPD among
those switching to smokeless tobacco compared with those quitting
completely. It is hard to think of mechanisms that do not involve
increased exposure to smoke, either from secondhand smoke, or increased
smoking (including smoking other substances) before or after recruitment
to the study. It would be useful to hear the authors’ thoughts on what
caused the smokeless users’ raised COPD risks, and also how that might
affect interpretation of the other raised risks found in these studies
(i.e. are these effects likely due to confounding with smoke exposure,
rather than smokeless use per se?).
3. This excellent study by the American Cancer Society reported
increased risks of cancer of the oral cavity and pharynx (HR=2.5, CI=1.2-
5.7), based on 7 deaths in switchers, and the previous paper comparing
exclusive smokeless users with never tobacco users in CPS-II found an
adjusted hazard ratio for oropharynx cancer of 0.90 (0.12-6.71). The US
American Cancer Society website currently states that:
“Smokeless tobacco ("snuff" or chewing tobacco) is associated with
cancers of the cheek, gums, and inner surface of the lips. Smokeless
tobacco increases the risk of these cancers by about 50 times.” (5)
The authors have previously stated that, “We do believe that there
has been inadequate concern about potential adverse risks of spit tobacco
use”(6). In fact the available evidence suggests that the public
drastically overestimates the relative risks from smokeless tobacco. For
example, only 11% of smokers believe that smokeless is less harmful than
cigarettes (7). Perhaps the information on the ACS website should be
updated to be more consistent with the results of these two ACS studies so
as not to add to the public’s biased perception?
Lastly, this paper is important to informing the harm reduction
debate as it pertains to smokeless tobacco, but it only contributes to
part of the story. It fails to point out that the largest difference in
risk is likely to be the one between switchers and continuing smokers,
while the difference between switchers and complete quitters is relatively
small. It is not surprising that those that switch to another form of
tobacco may have elevated health risks compared to those who quit tobacco
entirely. But what is sorely needed is analysis of the risks of switching
to a potentially less harmful tobacco product (smokeless) versus
continuing to smoke the most deadly form of tobacco, the manufactured
cigarette.
1. Henley SJ, Connell CJ, Richter P, Husten C, Pechacek T, Calle EE,
Thun MJ. Tobacco-related disease mortality among men who switched from
cigarette to spit tobacco. Tobacco Control 2007;16:22-28
2. Henley SJ, Thun MJ, Connell C, Calle EE. (2005) Two large
prospective studies of mortality among men who use snuff or chewing
tobacco (United States). Cancer Causes and Control 16:347-358
3. Godtfredsen NS, Holst C, Prescott E, Vestbo J, Osler M. Smoking
reduction, smoking cessation, and mortality: a 16-year follow-up of 19,732
men and women from The Copenhagen Centre for Prospective Population
Studies. Am J Epidemiol. 2002 Dec 1;156(11):994-1001.
4. Tverdal A, Bjartveit K. Health consequences of reduced daily
cigarette consumption. Tob Control. 2006 Dec;15(6):472-80.
5. www.cancer.org “Detailed Guide: Oral Cavity and Oropharyngeal
Cancer What Are The Risk Factors for Oral Cavity and Oropharyngeal
Cancer?” (accessed Feb 14, 2007)
6. Henley SJ, Thun MJ. Response to: Foulds J and Ramstrom L letter
regarding "Causal effects of smokeless tobacco on mortality in CPS-I and
CPS-II". Cancer Causes Control. 2006 Aug;17(6):857-8.
7. O'Connor RJ, Hyland A, Giovino GA, Fong GT, Cummings KM. Smoker
awareness of and beliefs about supposedly less-harmful tobacco products.Am
J Prev Med. 2005 Aug;29(2):85-90.
The longstanding tradition of the U.S. military and tobacco industry
leaders 'smoking in the good ol' boys room' is well documented by the
Smith, Blackmon, Malone "Death at a Discount" research paper!
It is time that the military and other federal politicos become
concerned about the health of our military, and drop the montra of tobacco
use being a 'right'. Obviously, the lobby of the tobacco industry even
infi...
The longstanding tradition of the U.S. military and tobacco industry
leaders 'smoking in the good ol' boys room' is well documented by the
Smith, Blackmon, Malone "Death at a Discount" research paper!
It is time that the military and other federal politicos become
concerned about the health of our military, and drop the montra of tobacco
use being a 'right'. Obviously, the lobby of the tobacco industry even
infiltrates the Department of Defense offices, too.
While military personnel can buy tobacco products cheaply in base
commissaries, they also are readily hooked on snuff and cigarettes whil
deployed overseas (a known tactic of the industry since WWI). This
acciction to tobacco products spells profits to the industry when our
soldiers return, plus significant future health care costs to all.
West Virginia has a documented high prevalence of tobacco addiction
in our reserve and active military families.
We have made tobacco cessation quitline services available free-of-charge
to resident military personnel and their immediate family members through
a statewide program called AboutFace. The Federal government and
Department of Defense need to do an 'about face' on their view of tobacco
use and the military.
This death-at-a-discount study has excellent timing; it may be that
the 110th Congress will approve an increase in commissary tobacco prices!
I suggest the pricing of tobacco products available to our soldiers be
added to the criteria for grading the federal government on tobacco
control [1].
[1] American Lung Association. State of Tobacco Control: 2006.
[cited 2/13/07]; Available from: http://lungaction.org/...
This death-at-a-discount study has excellent timing; it may be that
the 110th Congress will approve an increase in commissary tobacco prices!
I suggest the pricing of tobacco products available to our soldiers be
added to the criteria for grading the federal government on tobacco
control [1].
[1] American Lung Association. State of Tobacco Control: 2006.
[cited 2/13/07]; Available from: http://lungaction.org/reports/tobacco-
control06.html
Dr Gupta’s letter suggests that the reduction in lung cancer in both
Sweden and Connecticut is highly likely to be due to a reduction in
smoking in both places. This is entirely unsurprising, and as far as
Sweden is concerned is precisely what we suggested in the original paper
he referred to:
“There has been a larger drop in male daily smoking (from 40% in 1976
to 15% in 2002) than female daily smoking (34% in...
Dr Gupta’s letter suggests that the reduction in lung cancer in both
Sweden and Connecticut is highly likely to be due to a reduction in
smoking in both places. This is entirely unsurprising, and as far as
Sweden is concerned is precisely what we suggested in the original paper
he referred to:
“There has been a larger drop in male daily smoking (from 40% in 1976
to 15% in 2002) than female daily smoking (34% in 1976 to 20% in 2002) in
Sweden, with a substantial proportion (around 30%) of male ex-smokers
using snus when quitting smoking. Over the same time period, rates of lung
cancer and myocardial infarction have dropped significantly faster among
Swedish men than women and remain at low levels as compared with other
developed countries with a long history of tobacco use.” (p349,
abstract)1.
The idea that smoking and lung cancer rates may fall to a similar or
greater degree in other places is entirely irrelevant to whether or not
snus played a role in smoking reduction in Swedish men. Indeed, in the
original paper we stated clearly that:
“Both within and outside Sweden, smoking is primarily influenced by
factors other than availability of smokeless tobacco (for example, real
price of cigarettes, health education, smoke-free air policies, industry
marketing, etc).” (p357)1
It is therefore entirely unsurprising that these types of factors
will have influenced smoking and lung cancer rates in the United States
and every other country, regardless of whether or not snus is available. A
key point in our original paper that distinguished Sweden from other
countries was that smoking rates WITHIN that country have fallen
significantly faster in men than women, and that this appeared to be
related to the fact that men in Sweden use snus much more than women. So
although these comparisons between one country in Europe and a state in
the US are almost entirely irrelevant to the question of the effect of
snus use on lung cancer rates in Sweden, the more appropriate comparison
(if one wanted to make one) would be of the difference in decline of lung
cancer rates between men and women in Sweden as compared to changes in
that difference in the US. It is not clear whether the data presented in
Dr Gupta’s letter was for men, women or both.
Since the publication of our original paper there have been
subsequent publications that have confirmed that in Sweden, men who start
using snus are less likely to become daily smokers, that men who smoke and
then start using snus are more likely to stop smoking, and that a higher
proportion of men than women in Sweden have quit smoking, with the
difference largely attributable to snus use2,3. It had previously been
suggested that the men who quit smoking in Sweden are not the same ones
who start using snus (and that snus use is therefore not involved in men
quitting smoking)4. However, studies have now verified that in fact a
sizeable proportion (26-29%) of Swedish men who quit smoking use snus as a
smoking cessation aid2,5.
It is now crystal clear that their transfer of nicotine dependence
onto snus has accelerated the rate of decline of smoking among Swedish men
in substantial numbers. That transfer from an extremely harmful form of
tobacco use (cigarette smoking) to a much less harmful form (snus) has
contributed to a reduction in the rate of smoking-caused diseases in
Swedish men.
1. Foulds J, Ramstrom L, Burke M, Fagerstrom K. The effect of
smokeless tobacco (snus) on public health in Sweden. Tobacco Control 2003;
12:349-59.
2. Ramström LM, Foulds J. The role of snus (smokeless tobacco) in
initiation and cessation of tobacco smoking in Sweden. Tobacco Control
2006 Jun;15(3):210-4.Pdf available at:
http://www.tobaccoprogram.org/staffarticles.htm
3. Furberg Furberg H, Bulik C, Lerman C, et al. Is Swedish snus associated
with smoking initiation or smoking cessation? Tob Control.2005; 14:422-
424.
4. Tomar SL, Connolly GN, Wilkenfeld J, Henningfield JE. Declining smoking
in Sweden: Is Swedish Match getting the credit for Swedish tobacco
control’s efforts? Tobacco Control2003; 12:368-59
5. Gilljam H, Galanti MR. Role of snus (oral moist snuff) in smoking
cessation and smoking reduction in Sweden. Addiction 2003;98:1183-9.
Dr Gupta’s comparison of trends in lung cancer mortality and smoking
prevalence in Sweden and Connecticut purports to undermine the claim that
increasing snus use in Sweden has contributed to declining lung cancer
rates there.
Dr Gupta argues that some factor other than snus must have been at
work because the ratio of lung cancers between Sweden and Connecticut has
remained constant despite the large differenc...
Dr Gupta’s comparison of trends in lung cancer mortality and smoking
prevalence in Sweden and Connecticut purports to undermine the claim that
increasing snus use in Sweden has contributed to declining lung cancer
rates there.
Dr Gupta argues that some factor other than snus must have been at
work because the ratio of lung cancers between Sweden and Connecticut has
remained constant despite the large difference in snus use between the two
places. He identifies this “other factor” as a declining cigarette smoking
prevalence that he attributes to tobacco control policies.
We agree that a decline in cigarette smoking in both countries
explains the lung cancer trends but we don’t see how this rules out a role
for snus. This is exactly the mechanism by which proponents of snus would
claim that snus use reduces smoking prevalence, namely, that population
smoking prevalence declines because existing smokers switch to snus and
new tobacco users use snus rather than cigarettes (Ramström and Foulds
2006).
The fact that smoking prevalence declined in Connecticut as a result
of more traditional tobacco control policies simply shows that there is
more than one way to reduce smoking prevalence. The fact that the decline
in cigarette smoking over the time period examined was greater in Sweden (
-13%) than in Connecticut (-8%) supports the hypothesis that the addition
of snus to more conventional tobacco control policies has increased the
decline in smoking prevalence.
We concede that the comparison does not prove that snus was
responsible for the decline in lung cancer rates in Sweden, but it is much
more supportive of the claims for snus than Dr Gupta allows.
Yours sincerely
Coral Gartner and Wayne Hall
References
Ramström, L. M. and J. Foulds (2006). "Role of snus in initiation and
cessation of tobacco smoking in Sweden." Tobacco Control 15(3): 210-214.
Some tobacco control community members believe that advocating the
use of snus, a form of Swedish smokeless tobacco said to be less harmful
than cigarettes, would prove an effective harm reduction strategy against
tobacco related diseases. One important basis for such a claim is the
fact that snus is widely used in Sweden (23% men used snus daily in 2002),
where the incidence of cancer caused by tob...
Some tobacco control community members believe that advocating the
use of snus, a form of Swedish smokeless tobacco said to be less harmful
than cigarettes, would prove an effective harm reduction strategy against
tobacco related diseases. One important basis for such a claim is the
fact that snus is widely used in Sweden (23% men used snus daily in 2002),
where the incidence of cancer caused by tobacco is relatively low, and the
observation that the Swedish are switching from smoked tobacco to snus.
One way of looking at this claim of harm reduction through the use of snus
is to compare tobacco related cancer rates in Sweden to those in the state
of Connecticut, where use of any kind of smokeless tobacco including snus
has been consistently rare.
The table below provides a comparison of age adjusted incidence rates
for Sweden and Connecticut. As the data show, the incidence of tobacco
related cancer is much lower in Sweden, about one half that of
Connecticut. Trend data for Sweden seemingly provide further supportive
evidence to the harm reduction hypothesis, as a dramatic increase in snus
use in Sweden (0.4 kg/person in 1970 to 0.9kg/person in 2000) coincides
with a decreasing cigarette consumption (1.1kg/person in 1970 to
0.6kg/person in 2000) resulting in a decrease of tobacco related cancer
from 97.8 per 100,000 in 1966-1970 to 56.7 per 100,000 in 1993-1997.1,
However, if snus has a harm reduction effect, the incidence of
tobacco related cancers should not only decline in Sweden as snus use
increases, but it should decrease more in Sweden than in Connecticut,
where the consumption of smokeless tobacco has remained <1% over 1990s.
However, the data below demonstrate that the ratio of the incidence of
tobacco related cancer in Sweden and Connecticut has remained constant at
about 0.5 since 1973, and the same ratio for lung cancer has been stable
at about 0.4 since1960. Rather than snus causing the decrease in tobacco
related cancer in Sweden, these data suggest that another factor was
responsible in reducing cancer incidence in both Sweden and Connecticut.
That factor is likely to be the decline in cigarette use, which fell in
men from about 28% to 15% (Sweden) and 26.7% to 18.7% (Connecticut) from
1985-2003.1,3 During the period of 1970s to 1990s, both populations were
exposed to smoking reduction strategies such as increased awareness of
health risks, increased prices, a change in social norms regarding tobacco
use, etc but both places did not have an increase in snus use. Thus, the
data do not seem to support the hypothesis that the decrease in tobacco
related cancers in Sweden is due to increasing use of snus.
References
1. Foulds, J., Ramstrom, L., Burke, M., Fogerstrom K. Effect of
Smokeless tobacco (snus) on smoking and public health in Sweden. Tobacco
Control, 2003; 12:349–359.
2. Cancer Incidence in Five Continents. Vol. I-VIII. Lyon:
International Agency for Research on Cancer.
3. CDC. State System: State Tobacco Activities tracking and
evaluation system. Tobacco Use Supplement to the Current Population
Survey. 2006. Available at http://apps.nccd.cdc.gov/statesystem/. Accessed
January 17, 2007.
Reduction as a permanent solution may give people false expectations
Thanks to Dr. John R Hughes for his interesting remarks of 20 January 2007
to our article (TC 15:472-480). We have the following comments:
1. Dr. Hughes states that our main finding (no health benefit from
reducing cigarettes) has not been found in the few prior prospective
studies of this topic. This is not correct. Based on a large study
population in C...
Reduction as a permanent solution may give people false expectations
Thanks to Dr. John R Hughes for his interesting remarks of 20 January 2007
to our article (TC 15:472-480). We have the following comments:
1. Dr. Hughes states that our main finding (no health benefit from
reducing cigarettes) has not been found in the few prior prospective
studies of this topic. This is not correct. Based on a large study
population in Copenhagen, Dr. Nina S Godtfredsen and co-workers have
reported the same results in a series of publications, references given in
our article. Dr Hughes’ remarks imply that there may be other prospective
studies that give other results. We have not been able to find other
prospective studies that take up this problem.
2. Our article reports on results from three examinations; for the
majority of participants the interval between the examinations was five
years. A subgroup of the study population was nominated ‘sustained
reducers’. They were heavy cigarette smokers at the first examination, had
reduced their daily cigarette consumption by at least 50 % at the second
examination, and had remained as ‘reducers’ at the third examination.
Their mean consumption at the three examinations was 23.6 – 10.0 – 10.4
cigarettes per day (table 6 in our article).
Dr Hughes states that “the question at each follow-up did not ask about
smoking since the last follow-up”. This is correct, and we agree with Dr
Hughes that it is unknown what the rate of smoking really was between
follow-ups in sustained reducers. The sustained reducers had, however, a
mean daily consumption that was almost the same at the second and third
examination, and in our opinion, the most reasonable explanation is that
their daily cigarette consumption had stabilised at a consumption level
which actually was at least 50% lower than at the first examination. We
also underline that at the second examination, reducers had a serum
thiocyanate level that was lower than in heavy smokers, and close to the
serum thiocyanate level in moderate smokers (table 3 in our article).
3. Dr Hughes states that reduction actually increases motivation to quit.
In our paper, we state explicitly:”Undoubtedly, reduction in consumption
may have a place as a temporary measure in systematic smoking cessation”.
Our conclusion that advising reduction may give people false expectations,
refer to reduction as a permanent solution. We think that the results of
our study and of those of the Copenhagen Study, with study populations of
more than 70 000 persons together, give a sound basis for this conclusion.
Age Tverdal,
Professor
Norwegian Institute of Public Health,
Oslo
Kjell Bjartveit
Director Emeritus
National Health Screening Service
Oslo
The recent study by Tverdal and Bjartveit (TC 15:472-480, 2006) that
found no health benefit from reducing cigarettes had several assets not
found in the few prior prospective studies of this topic; e.g. the
reducers had reduced by over 50% and several outcomes were measured.
I would, however, like to make two comments. First, one asset of the
study was the examination of "sustained reducers;" i.e., those who...
The recent study by Tverdal and Bjartveit (TC 15:472-480, 2006) that
found no health benefit from reducing cigarettes had several assets not
found in the few prior prospective studies of this topic; e.g. the
reducers had reduced by over 50% and several outcomes were measured.
I would, however, like to make two comments. First, one asset of the
study was the examination of "sustained reducers;" i.e., those who
reported reduction at two consecutive examination. Although this
estimation of sustained reduction is superior to that in prior studies,
the question at each follow-up did not appear to ask about smoking since
the last follow-up but rather asked about smoking at the current time;
thus, in actuality, it is unknown what the rate of smoking really was
between follow-ups in "sustained reducers." As a result, there is still
the possibility that these results are false positives. Having said that,
I do believe the burden of proof is on those who believe reduction is
helpful to provide more rigorous tests.
Second, the concluding sentence of the abstract states advising
reduction may "give people false expectations." While this may be true to
some extent, advising reduction does not appear to undermine motivation to
quit but actually increases motivation to quit. Dr Carpenter and I
published a review paper of 19 studies (that did not come out until after
this current study was submitted). None of these studies suggested
reduction undermined motivation to stop smoking. Instead, 16 of the 19
found smoking reduction increased the probability of future cessation.
(NTR 8:739-749, 2006). Thus, I believe smoking reduction can be beneficial
to smokers if they see reduction not as an end itself but as way to
quitting. In fact, surveys suggest this is exactly how the large majority
of smokers see reduction (Hughes et al, NTR, in press)
On March 15 2007, my attention was drawn to a patent for a tobacco smoking device, filed with the U.S. Patent and Trademark Office (USPTO) for a "Hookah with simplified lighting" on June 9 2005. One of the authors of the device being patented was Kamal Chaouachi, who on December 2 2004, had a rapid response published in Tobacco Control [1] which was critical of a paper by Masiak et al [2]. The submission process for rapid...
Foulds and Ramström raise important questions regarding a direct comparison of mortality rates among smokers, smokeless tobacco (ST) users, persons with mixed or former use, and non-users. They urge officials from the Centers for Disease Control and Prevention (CDC) and from the American Cancer Society (ACS) to make these comparisons and report the results, so that Americans are fully informed about the health risks relate...
Henley et al’s paper (1) showing worse health outcomes in men switching from cigarettes to smokeless tobacco, compared with men ceasing tobacco use completely, adds to our understanding of the potential risks from smokeless tobacco use. However, it also raises some additional questions:
1. Like the authors’ earlier paper comparing health outcomes in exclusive smokers with those of exclusive smokeless users in C...
The longstanding tradition of the U.S. military and tobacco industry leaders 'smoking in the good ol' boys room' is well documented by the Smith, Blackmon, Malone "Death at a Discount" research paper!
It is time that the military and other federal politicos become concerned about the health of our military, and drop the montra of tobacco use being a 'right'. Obviously, the lobby of the tobacco industry even infi...
This death-at-a-discount study has excellent timing; it may be that the 110th Congress will approve an increase in commissary tobacco prices! I suggest the pricing of tobacco products available to our soldiers be added to the criteria for grading the federal government on tobacco control [1].
[1] American Lung Association. State of Tobacco Control: 2006. [cited 2/13/07]; Available from: http://lungaction.org/...
Dr Gupta’s letter suggests that the reduction in lung cancer in both Sweden and Connecticut is highly likely to be due to a reduction in smoking in both places. This is entirely unsurprising, and as far as Sweden is concerned is precisely what we suggested in the original paper he referred to:
“There has been a larger drop in male daily smoking (from 40% in 1976 to 15% in 2002) than female daily smoking (34% in...
Dr Gupta’s comparison of trends in lung cancer mortality and smoking prevalence in Sweden and Connecticut purports to undermine the claim that increasing snus use in Sweden has contributed to declining lung cancer rates there.
Dr Gupta argues that some factor other than snus must have been at work because the ratio of lung cancers between Sweden and Connecticut has remained constant despite the large differenc...
Dear Editor
Some tobacco control community members believe that advocating the use of snus, a form of Swedish smokeless tobacco said to be less harmful than cigarettes, would prove an effective harm reduction strategy against tobacco related diseases. One important basis for such a claim is the fact that snus is widely used in Sweden (23% men used snus daily in 2002), where the incidence of cancer caused by tob...
Reduction as a permanent solution may give people false expectations Thanks to Dr. John R Hughes for his interesting remarks of 20 January 2007 to our article (TC 15:472-480). We have the following comments: 1. Dr. Hughes states that our main finding (no health benefit from reducing cigarettes) has not been found in the few prior prospective studies of this topic. This is not correct. Based on a large study population in C...
The recent study by Tverdal and Bjartveit (TC 15:472-480, 2006) that found no health benefit from reducing cigarettes had several assets not found in the few prior prospective studies of this topic; e.g. the reducers had reduced by over 50% and several outcomes were measured.
I would, however, like to make two comments. First, one asset of the study was the examination of "sustained reducers;" i.e., those who...
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