The Perils of Tobacco Teetotalism

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In a Washington Post op-ed piece, Hunter College epidemiologist Philip Alcabes takes aim at the public health idiocy encapsulated in the World Health Organization slogan "Tobacco: Deadly in Any Form or Disguise." The refusal to acknowledge that some forms of tobacco are less dangerous than others, says Alcabes, puts people's lives at risk by deterring them from replacing cigarettes with smokeless tobacco, some forms of which pose virtually no measurable health risks. "Tobacco is not deadly; the harm is in the smoke," he writes. "A policy that confuses innocuous tobacco with harmful smoke is responsible for millions of avoidable deaths each year worldwide." Alcabes argues that the all-or-nothing, Just Say No approach to tobacco (and nicotine) is inconsistent with the professed values of public health specialists, who in other areas promote harm reduction rather than insisting on abstinence. Academics such as Brad Rodu and various journalists (including me) have been making these points for years, but it's encouraging to see an epidemiologist making them in The Washington Post.

[Thanks to CEI's Christine Hall-Reis for the tip.]

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  1. Okay, maybe I’m just falling for the propoganda, but I recall seeing some pictures of lip cancer in tobacco chewers that sure convinced me that it was not what you’d call safe.

  2. i think you are getting nicotine and tobacco confused. tobacco causes cancer, nicotine does not.
    all tobacco products are dangerous when abused, including smokeless forms.
    nicotine gum is not smokeless tobacco, nicotine gum is nicotine gum.
    smokeless tobacco is dip and chew and cause cancer of the mouth.

  3. Clean Hands:

    American smokeless tobacco is associated with an increased risk of oral cancer (although it’s only half the oral cancer risk cigarette smokers face, and oral cancer is not a major cause of smoking-related deaths, which are mostly due to lung cancer, heart disease, and emphysema). Swedish-style smokeless tobacco (snus), however, does not seem to have a measurable impact on oral cancer rates, apparently because differences in production and storage methods result in lower levels of carcinogens. See, e.g., the 2001 National Academy of Sciences report Clearing the Smoke, which says snus “has generally not been associated with oral cavity cancer.”

  4. Cool, Jacob – thanks for the cite. I had not heard of snus previously.

    Of course, it probably doesn’t get rid of the nauseating smell of snuff spit. 😉 But that’s an aesthetic objection, rather than a health one.

    I guess at this point that I largely regard tobacco usage from a Darwinian standpoint — those who are bright enough to assess the risk and stay clear of it are ever so slightly more likely to reproduce successfully.

  5. Alternative nicotine delivery could be easy. Nicotine replacement therapy could work long-term. Gum and the patch are already available, but not to everyone. Also, they are still approved only for short-term use and can deliver only small doses — inadequate for heavy users.

    What the hell is he talking about? Who is nicorette not available to? Kids under 18, sure, and I would agree that there’s no sense in requiring ID for it but that’s a separate point.

    Also, how is the dose too small? A cigarette contains at most 2 mg of nicotine and you can buy 4 mg gum. And if that doesn’t work go crazy and pop em two at a time. Who’s gonna stop you?

  6. “Tobacco: Deadly in Any Form or Disguise.”

    You know, that slogan is just so ridiculous, I think I’m going to borrow it. My new nanny-slogan is thus:

    “Life: Deadly in Any Form of Disguise.”

    Anyone care to disagree? Name me one person who has survived life. Just one. Unless you’re a 100,000-year-old seaweed plant, I’d say that you’re on your way to your grave right now, no matter what you do. Every life inevitably ends in DEATH!!!

    So, anyway, since living is so dangerous, and is the leading cause of death, I propose a new program wherein we prohibit the nanny-statists from taking part in it.

    The best part is how none of these stupid slogans take into account the question of quantity. If I smoke 1 cigarette per month, is that “deadly”? In what context do you make this statement? I’d venture that, sure, smoking 1 cigarette per month is “deadly”, compared to sitting in a temperature-controlled, air-filtered bomb shelter drinking nothing but ultra-purified spring water and eating a diet tailored perfectly to your body. But everything we do carries at least a tiny amount of risk with it. Waking up every morning is dangerous as hell; most deaths undoubtedly stem from waking up and doing stuff.

    The idiocy of this whole debate is mind-numbing.

  7. I don’t know about the patch, but the gum seems ridiculously expensive, compared to smokeless tobaccy.

    “. . .all tobacco products are dangerous when abused, including smokeless forms.”

    Not really. The balance of evidence seems to suggest that snus tobacco has no consistent measurable impact on cancer, heart disease, or overall mortality. This is surprising to me, but that’s what the evidence seems to show. See Foulds et al (2003) for a recent review.

    Foulds et al, 2003. The effect of smokeless tobacco (snus) on smoking and public health in Sweden. Tobacco Control 12, 349-59.

  8. There is always this, for the desperate:

    http://www.wordspy.com/words/nicotini.asp

  9. The focus on the elimination of tobacco is not always productive. Just looking at smoking, it could be much more effective to get people to cut back than to get them to quit, but public policy focuses on getting people to quit.

  10. Tobacco is an anti-depressant.

  11. I guess at this point that I largely regard tobacco usage from a Darwinian standpoint– those who are bright enough to assess the risk and stay clear of it are ever so slightly more likely to reproduce successfully.

    But once you’ve generated offspring, smoke ’em if you’ve got ’em.

  12. “”Tobacco is not deadly; the harm is in the smoke,” he writes. “A policy that confuses innocuous tobacco with harmful smoke is responsible for millions of avoidable deaths each year worldwide.”

    I do find it odd that people who argue against claims that second-hand smoke can be dangerous (usually going into painful detail about how to interpret the effect sizes of the latest meta-analysis) just swallow the above sentence without analysis… is it because it falls on their side of the political debate? Or is it something else?

    Hmmm…
    Given that, I don’t imagine too many people see issues as black and white to the degree that they believe some forms of tobacco are less dangerous than others. Or that certain patterns of usage are more or less dangerous. Fairly young I figured out that my Grandfather’s health problems seemed linked to his two packs a day, and that his cutting down to one pack every two days was a good thing. Seemed to help my Grandmother’s chronic cough too.

  13. “”Tobacco is not deadly; the harm is in the smoke,” he writes. “A policy that confuses innocuous tobacco with harmful smoke is responsible for millions of avoidable deaths each year worldwide.”

    I do find it odd that people who argue against claims that second-hand smoke can be dangerous (usually going into painful detail about how to interpret the effect sizes of the latest meta-analysis) just swallow the above sentence without analysis… is it because it falls on their side of the political debate? Or is it something else?

    Hmmm…
    Given that, I don’t imagine too many people see issues as black and white to the degree that they don’t believe some forms of tobacco are less dangerous than others. Or that certain patterns of usage are more or less dangerous. Fairly young I figured out that my Grandfather’s health problems seemed linked to his two packs a day, and that his cutting down to one pack every two days was a good thing. Seemed to help my Grandmother’s chronic cough too.

  14. Double post. Second has important “don’t” added…oops.

  15. I quit smoking a couple years ago, and I doubt I could have done it as easily without smokeless tobacco (in my case, “Fresh Cope”). If you can stand the withering social approbation (at least twice as bad as with smoking), it really works. I’ve even recommended it to people trying to quit smoking!
    The fact that this approach gets brushed off by the authorities shows that they are ideologues with very little interest in reducing cancer rates.

  16. I quit smoking a couple years ago, and I doubt I could have done it as easily without smokeless tobacco (in my case, “Fresh Cope”). If you can stand the withering social approbation (at least twice as bad as with smoking), it really works. I’ve even recommended it to people trying to quit smoking!
    The fact that this approach gets brushed off by the authorities shows that they are ideologues with very little interest in reducing cancer rates.

  17. If I smoke 1 cigarette per month, is that “deadly”? In what context do you make this statement? I’d venture that, sure, smoking 1 cigarette per month is “deadly”, compared to sitting in a temperature-controlled, air-filtered bomb shelter drinking nothing but ultra-purified spring water and eating a diet tailored perfectly to your body. ,/i>

    I believe that if I’m given a large enough government grant, I can conclusively prove that people who smoke 1 cigarette per month will inevitably die. Eventually.

    Therefore, it is deadly. Correlation proves causation, when the grant is large enough.

  18. Sorry to be pedantic but shouldn’t it be “The Perils of Tobacco Teatotalism”?

    That is if it intends a parallel to those who abstain from alcohol consumption by drinking only tea .

  19. The zero tolerance of smoking has nothing to do with public health or cancer. Like all other zero tolerance policies, it is a control thing.

    Debating the health value of not smoking should be different than debating being allowed to smoke.

  20. Every few months or so, when I have the money, I treat myself to a stogy or two at the local cigar lounge. That’s all I usually smoke, and you would think that even that small amount of exposure would not pose a serious, life-threatening risk to my health… yet I sure that there a sizable number of puritanical assholes out there who think that this one small tobacco-related indulgence will shave decades off my life and cause health care prices to sky rocket. (BTW, when did insurance companies have more power than the Bill Of Rights in determining what my personal freedoms are?)

    The thought of it makes me sicker than anything that tobacco smoke (first, or second-hand) can do to me.

  21. Seig Health!

    It’s only a matter of time before the next wave of
    quacks and meddlers declare there is no safe red meat, or alcohol, or non-organic broccoli, or….

  22. “I guess at this point that I largely regard tobacco usage from a Darwinian standpoint– those who are bright enough to assess the risk and stay clear of it are ever so slightly more likely to reproduce successfully.”

    As far as I can tell, there would be very little selection against tobacco smokers. Premature mortality in tobacco smokers isn’t very significant until 45+ years, at which point most people have had all of the children they will ever have.

  23. For anyone interested in more details than were contained in Dr. Alcabes’s op-ed, we launched http://www.TobaccoHarmReduction.org yesterday (to coincide with No Tobacco Day) to make the same points about reduced-harm substitutes for smoking. Our FAQ addresses some of what has been written here, and we would like to hear your views on our forums.

    Carl V Phillips, Associate Professor, University of Alberta School of Public Health

  24. A brief clarification of the scientific and practical rationale for tobacco harm reduction:
    1. Nicotine is addictive, but it causes none of the diseases associated with smoking. It can be used as safely as caffeine.
    2. Smokeless tobacco provides nicotine and tobacco satisfaction that are similar to those from smoking.
    3. Smokeless tobacco does not cause lung cancer, emphysema or cardiovascular diseases, so it’s use is 98% safer than smoking.
    4. Long-term (40+ years) use of smokeless tobacco confers mouth cancer risk, but it is one-third to one-half that of smoking.
    5. Modern smokeless tobacco products are invisible in use. Details can be found on the University of Louisville research website at http://www.smokersonly.org

    Brad Rodu
    Professor of Medicine
    Endowed Chair, Tobacco Harm Reduction Research
    University of Louisville

  25. Breathing smoke into lungs that were designed for clean air seems a strange way to achieve enjoyment, but like most kids at my school I was encouraged to smoke by clever marketing and product placement in movies etc that made our impressionable young minds think that smoking a ‘cool’ thing to do. I started smoking and despite many failed efforts at quitting I continued to smoke for more than 10 years.

    Yes we all die sometime… but usually our actions and lifestyle determine WHEN and HOW we will die. As a smoker I realised my health was in decline and I was only in my late 20’s. It confronted me, to realise that I was maximising the likelihood of spending my last years breathing through a hole in my neck, having parts of me progressively surgically removed, talking with a little electronic voicebox… before finally ending my life by choking on my own mucous in an emphysemia ward. That was a realistic scenario which Im sad to say is very common, Ive worked in hospitals and every day I see people in that sad situation, often wheeling themselves into the cold to puff a cigarette through the hole in their neck.

    To all smokers who are writing that ugly little scenario into the last years of their life please take some advice from someone who finally quit after 10 years. Ive now been 5 years without a cigarette (Thank God) I didnt replace it with gum but I did replace it with light exercise and I feel great. The first year was a constant temptation but being a non-smoker becomes much, much, much easier after that. I feel so healthy, I never cough anymore, my immune system is better than ever, I look and smell better, and now I dont avoid thinking about the future.

    Im sure some smokers out there will find a way to denigrate my position but I hope my message helps someone as its a genuine testimonial.

  26. Regarding the government’s policy of promoting abstinence. Its the only sensible option which considers the needs of the broader community and future generations of potential smokers. Harm reduction for existing addicts is an appropriate secondary strategy.

    The price of any form of tobacco addiction is not justifiable. Even a reduced prospect of face cancer is absolutely no justification to smoke. I know cigarettes seem SOOOOO great when you?re addicted but frankly they?re simply a very effective method of dosing an addiction. The pleasure or satisfaction associated with smoking is simply a satsifaction of the addiction that the cigarettes initially created, so there is no true benefit to smoking, only relief from detriment.

    For that reason I consider that all governments have a duty to protect against this poisonous substance which has demonstrated such widespread and profound harm with absolutely no benefits.

    In other contexts we expect and demand that the government to protect us from other poisons through FDA guidelines and regulations. We don?t want our neighbours using DDT in their back yard. We don?t want our kids being exposed to lead in the tap water at school. Why not protect future generations of humanity from being sold an addictive poison which has no benefit and phenomenal detriment?

    Opposing arguments re “nanny state” (with sympathy to the afflicted) are clearly hollow justifications which can only arise from those with some form of vested interest in the perpetuation of this curse on humanity, if only for the base satisfaction of their own addiction. When considering the cost there?s simply no sufficient reason to expose future generations to this addictive poison.

  27. The data on cancer from smokeless tobacco (SLT) is VERY sketchy. Most of the early epi studies from the 60’s and 70’s indicated that smokeless causes oral cancer. More recent studies are much more sophisticated at controlling for age, sex, smoking, occupation, etc (things that affect cancer rates). Most of these newer studies show very weak or no association with cancer. SLT does cause local gum problems and leukoplakia, both of which usually resolve shortly after quitting.

    Aside from nicotine, there is nothing in tobacco that isn’t found in other food-type plants. Nitrosamines, formaldehyde, Polonium 210, arsenic, you name it, are all found in higher levels in broccoli, nuts, and other foods. Tobacco is nothing special in that regard. We’ve never studied what would happen if someone held crushed almonds in their gums for hours a day, but my guess would be leukoplakia and gum recession.

    There is also very little good research on whether smokeless is a gateway to (or from) smoking. Many of the statements on this are based on conjecture. SLT may lead people to cigarettes; on the other hand it may allow cigarette smokers to more easily quit. It is an EXCELLENT nicotine delivery device, much more satisfying to a smoker than a nicotine patch or gum. I worked as an airline mechanic’s helper during college, and there were lots of guys who used smokeless during the day because smoking was prohibited around the planes. They didn’t smoke all day, and only lit up after work. Probably cut their smoking by half.

    Let’s be real: the tobacco industry has a lot at stake and will mislead us in one direction. But realize that the CDC and other gov’t health agencies also have years invested in selling tobacco fears to the public; they can’t back off on SLT without appearing “soft” on smoking.

    But if we just stick to the data, this is the Bottom Line: IF smokeless tobacco is harmful, it is very much less harmful than smoking. Its harm is so slight that the best, largest studies barely register it.

    In my opinion, if it keeps someone comfortable by providing nicotine when they need it, and thereby prevents or reduces their smoking, it is a net gain to the health of the smoker and those around him/her. By the way, in some areas of the country there are many women who use smokeless.

  28. The data on cancer from smokeless tobacco (SLT) is VERY sketchy. Most of the early epi studies from the 60’s and 70’s indicated that smokeless causes oral cancer. More recent studies are much more sophisticated at controlling for age, sex, smoking, occupation, etc (things that affect cancer rates). Most of these newer studies show very weak or no association with cancer. SLT does cause local gum problems and leukoplakia, both of which usually resolve shortly after quitting.

    Aside from nicotine, there is nothing in tobacco that isn’t found in other food-type plants. Nitrosamines, formaldehyde, Polonium 210, arsenic, you name it, are all found in higher levels in broccoli, nuts, and other foods. Tobacco is nothing special in that regard. We’ve never studied what would happen if someone held crushed almonds in their gums for hours a day, but my guess would be leukoplakia and gum recession.

    There is also very little good research on whether smokeless is a gateway to (or from) smoking. Many of the statements on this are based on conjecture. SLT may lead people to cigarettes; on the other hand it may allow cigarette smokers to more easily quit. It is an EXCELLENT nicotine delivery device, much more satisfying to a smoker than a nicotine patch or gum. I worked as an airline mechanic’s helper during college, and there were lots of guys who used smokeless during the day because smoking was prohibited around the planes. They didn’t smoke all day, and only lit up after work. Probably cut their smoking by half.

    Let’s be real: the tobacco industry has a lot at stake and will mislead us in one direction. But realize that the CDC and other gov’t health agencies also have years invested in selling tobacco fears to the public; they can’t back off on SLT without appearing “soft” on smoking.

    But if we just stick to the data, this is the Bottom Line: IF smokeless tobacco is harmful, it is very much less harmful than smoking. Its harm is so slight that the best, largest studies barely register it.

    In my opinion, if it keeps someone comfortable by providing nicotine when they need it, and thereby prevents or reduces their smoking, it is a net gain to the health of the smoker and those around him/her. By the way, in some areas of the country there are many women who use smokeless.

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