(UAB Cancer Epidemiology and Control Seminar Series, September 16, 1998)
I’d like to start by talking a bit about Brad’s work with smokeless tobacco. Some of you may already be familiar with his research and his book, but I think the response to them nicely illustrates my theme.
Brad’s position, which he sets forth in his 1995 book For Smokers Only, is straightforward. He thinks smokers ought to give up tobacco completely. But if they choose not to, he says, they are much better off using smokeless tobacco than smoking cigarettes.
In his book, Brad notes that oral cancer is the only life-threatening risk associated with the use of smokeless tobacco, and even that disease is twice as common among smokers. He estimates that "if all 46 million smokers used smokeless tobacco instead, the United States would see, at worst, 6,000 deaths from oral cancer [a year], versus the current 419,000 deaths from smoking-related cancers, heart problems, and lung disease."
By this measure, Brad says, smokeless tobacco is 98 percent safer than smoking. He and Philip Cole estimate that life expectancy for a 35-year-old smokeless tobacco user is 80.9, virtually the same as for nonusers.
Brad’s pitch to smokers goes like this: You can enjoy tobacco flavor and nicotine at a fraction of the risk, without the pesky smoke. But he emphasizes that "smokeless tobacco should only provide a viable and comparatively safe damage control measure for the current and last generation of nicotine addicts. Forty years or so from now I hope there are no tobacco users left on the planet."
Brad has been condemned by other opponents of tobacco not because what he says is inaccurate but because they consider it detrimental to the cause. "To say that one form of tobacco is safer than the other at this point in the debate is just irresponsible," said Gregory Connolly, director of the Massachusetts Tobacco Control Program. "Tobacco is tobacco.…It’s like telling someone to jump from the fifth floor instead of the 10th floor."
The American Association of Oral and Maxillofacial Surgeons preferred a different analogy: "Suggesting this switch is like telling someone to use a rifle instead of an Uzi." The president of the American Dental Association called Brad’s proposal "naive at best and irresponsible at worst." The National Cancer Institute said recommending a switch to smokeless tobacco "sends the wrong message."
Harm Reduction vs. Prohibitionism
This criticism reflects a shift in the anti-smoking movement from harm reduction toward prohibitionism. The shift can be seen by comparing two reports from Consumers Union that were published two decades apart. The 1972 report Licit and Illicit Drugs said "efforts should be made to popularize ways of delivering frequent doses of nicotine to addicts without filling their lungs with smoke." Accordingly, one of its suggestions was to "popularize chewing tobacco and snuff."
That recommendation was conspicuously absent from The Facts About Drug Use, a 1991 Consumers Union report. Instead, the authors expressed concern about the rising popularity of smokeless tobacco, especially among adolescents. "The evidence is compelling that smokeless tobacco produces nicotine levels in the body comparable to those produced by smoking and carries additional risk of cancer of the mouth," they said, giving no indication that snuff and chewing tobacco might pose less of a health hazard than cigarettes.
Public health officials give the topic the same one-sided treatment. In 1986 Surgeon General C. Everett Koop issued a report that condemned smokeless tobacco as carcinogenic and addictive. He warned against "the tragic mistake of replacing the ashtray with the spittoon." That same year, Congress banned broadcast ads for smokeless tobacco and required warning labels.
One of those labels sums up the prevailing view, echoed by public health officials, anti-smoking activists, self-help books, and newspaper columnists: Smokeless tobacco "is not a safe alternative to cigarettes." That message is true enough, but it’s hardly helpful to anyone interested in assessing the relative risks of different tobacco products. In particular, it’s of no use to cigarette smokers considering a switch.
This insistence on abstinence, coupled with a refusal to acknowledge that different forms of a drug pose different levels of risk, should be familiar to anyone who’s been following the drug policy debate in this country. It’s the sort of attitude I’ve come to expect from supporters of the war on drugs. It’s also the sort of attitude I’ve come to expect from tobacco’s opponents, including those who say they are motivated by a desire to promote "the public health." This has to be a disturbing phenomenon for anyone who believes that the public health model offers a more rational and compassionate alternative to the war on drugs.