Public Health

Does the Times Understand the Difference Between Safer and Safe?

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A study recently published in the journal Cancer Epidemiology Biomarkers & Prevention found "similar exposures to the potent tobacco-specific carcinogen NNK in smokeless tobacco users and smokers." This is how The New York Times interpreted that finding:

Smokeless tobacco, the kind users put between cheek and gum, is one way to satisfy a craving for nicotine without offensive smoke. But a new study has found that it may be almost as effective as cigarettes in delivering nicotine and carcinogens….

Countering suggestions that smokeless tobacco might be a less harmful alternative for people unable to give up tobacco, the researchers wrote that smokeless tobacco is very risky, and should be discouraged.

Ignore the part about nicotine, which is a red herring: Nicotine is not a carcinogen, and effective nicotine delivery is an advantage, not a drawback, for a cigarette substitute. But the Times is suggesting that smokeless tobacco poses nearly as big a cancer risk as cigarettes, which would be cause for concern. The headline is even scarier: "Hazards: Smokeless Tobacco on Par With Cigarettes." In other words, using smokeless tobacco is no safer than smoking cigarettes.

In reality, the study dealt with a single carcinogen, not with the overall risks posed by smokeless tobacco vs. cigarettes. The researchers note that "cigarette smoke contains, in addition to NNK, multiple carcinogenic combustion products which are not present, or present in only low amounts, in smokeless tobacco." (They also note that Swedish-style smokeless tobacco, which is increasingly available in the U.S., contains about half the NNK of the traditional American brands used by the subjects in the study.) They never say the hazards of smokeless tobacco are "on par" with the hazards of cigarettes, or anything like that. In fact, that assertion in the Times headline is contradicted by the article under the headline, which quotes the study's lead author, University of Minnesota researcher Stephen Hecht, as saying (emphasis added):

The main message of this study is that smokeless tobacco cannot be regarded as safe, because it delivers just as much of one of the carcinogens in cigarette smoke as cigarettes do. While it may be safer than cigarettes, it is not nearly safe enough.

No one who recommends smokeless tobacco as a harm-reducing alternative to cigarettes says it's completely safe—only that it's much safer, as you might surmise from the lack of combustion products. Hecht himself does not dispute this fact, which has been confirmed by studies comparing disease rates among cigarette smokers and smokeless tobacco users. When he asserts that smokeless tobacco "is not nearly safe enough," he is not stating a scientific fact; he is making a value judgment.

The journal article likewise mixes data with moralism. "NNK exposure in smokeless tobacco users as shown in this study presents an unacceptable risk and should not be encouraged," Hecht and his colleagues declare. Unacceptable to whom? This judgment should be left to individual consumers, with the scientist's role limited to researching and reporting the risks. In Hecht's view, perhaps, no risk is acceptable, but the people whose health is at stake may disagree.

[Thanks to Brad Rodu for the tip.]

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  1. But a cigarette looks much cooler that a wad of dip in your mouth. Please someone make a safe cigarette. I want to smoke again.

  2. that assertion in the Times headline is contradicted by the article under the headline

    It’s like magic!

  3. I work with journalists all the time. They have the average intelligence of a rock, and don’t care that the information you’re giving them does not support their desired story.

  4. Nicotine is a really interesting nootropic, with many potential beneficial uses. It helps concentration, alertness, and wakefulness among others.

    I would be interested in picking up a roll of snus, just to try it, but the damn stuff is really addictive, and I hate addictions.

  5. what’s the difference between snus and dip?

  6. The main benefit of chewing tobacco is that you get to use a spitoon [pppt. . .ding!]

  7. snus is uncured tobacco, dip or chew is smoked to cure it.

  8. Snus is the term used by Swedes for their smokeless tobacco, or dip, as it’s frequently called here in the states. There are big differences in the US versions of smokeless compared to Swedish though. In addition to a finer grind, Swedish snus has a more natural flavor (i.e. less minty or fruity, more tobacco-y, in general)and is cured differently resulting in the carcinigenic benefits mentioned briefly in the article.

  9. Can you free-base snus, and smoke it ?

  10. Mrs. Lunchstealer signed up for one of those things where the girls go around in bars offering free-zippos-for-your-address from Marlboro. They recently sent a flyer for “Marlboro Snus”.

  11. Interesting how similar the anti-tobacco people are to the anti-gun people. Simply stating facts is anathema to them. Got to mix in their values with only the facts they agree with.

  12. “No one who recommends smokeless tobacco as a harm-reducing alternative to cigarettes says it’s completely safe-only that it’s much safer”

    When discussing smokeless tobacco and cigarettes, the word safe should not enter the discussion for either product. “Slightly less dangerous” would be more appropriate. Claiming that smokeless tobacco has less carcinogens than cigarettes is rather pointless because pretty much everything has less carcinogens than cigarettes. As such, stating that smokeless tobacco is much safer doesn’t really mean anything. It is similar to saying it is much safer to jump off the Empire State Building than the Sears Tower.

    Oral cancer is the eighth leading cause of cancer death in this country. Tobacco is the primary factor of the terrible triad: a)tobacco usage, b)alcohol usage c)poor oral hygiene. Oral cancers caused by smokeless tobbaco are usually either verrucous carcinoma, which is RELATIVELY harmless or squamous cell carcinoma which poses a much greater risk. Unfortunately, oral squamous cell carcinoma is associated with a high degree of morbidity, many times requiring the radical resection of portions of one or both jaws, the tongue, portions of the palate, the neck, etc. Furthermore, radiation therapy and the associated xerostomia often times necessitate serial extractions to avoid complications from osteoradionecrosis, which, unfortunately, can be fatal in itself. And to make matters worse, oral cancers are notoriously difficult to detect, thus they are very often in the latter stages when finally discovered. This does not bode well for one’s prognosis.

    Smokeless tobacco is a major cause of these cancers and the associated complications, and while I agree it is “safer” than cigarettes, I think the above article insinuates a little too forcefully that it is safe for consumption.
    However, in a free society adults should be able to consume either product if they wish.

  13. 8th leading cause of cancer deaths…

    So, how many deaths are we talking about? That statistic is meaningless to me.

  14. According to the National Center for Health Statistics, there were about 2.4 million deaths in the U.S. in 2004. There were about 3,100 deaths from cancer of the oral cavity.
    Epidemiologic research from the past 50 years documents that smokeless tobacco use is 98% safer than smoking. Unlike cigarettes, smokeless is not an established cause of lung cancer, heart disease or emphysema.
    As noted above, oral cancer is not a pleasant disease. However, most cases of oral cancer in the U.S. result from smoking and/or heavy alcohol consumption. The risk for mouth cancer among smokeless users is, at most, about one-third of the mouth cancer risk among smokers. Recent studies, including one from the American Cancer Society, have *not* detected any oral cancer risk among smokeless users. However, even accommodating the higher risks claimed by anti-tobacco extremists, smokeless users have about the same risk of dying from mouth cancer as automobile users have of dying in a car wreck.
    In 1994 we published research documenting that lifetime smokeless users had an average loss of life expectancy of 0.04 years (15 days), compared with the average loss of 8 years among smokers. Jumping from a 100-story building is not a good analogy.
    Sullum’s occasional posts about smokeless tobacco are usually followed by comments referring to “spitting.” The posters are out of touch with smokeless product development. Modern products are about the size of small breath mints (think “Tic-Tac”), and can be used invisibly; several manufacturers offer products that can be used in any social situation. No tobacco juices are produced when these products are used, so spitting is as unnecessary as the derogatory terminology.
    Accurate information about tobacco use and consequential risks can be found at the University of Louisville-based research web site, http://www.smokersonly.org

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

  15. Accurate information about tobacco use and consequential risks can be found at the University of Louisville-based research web site, http://www.smokersonly.org

    Regardless, they are not a safe alternative ti cigarettes. Complete abstinance from tobacco is the only safe alternative.

  16. I must admit, I was not aware of the studies of which you speak. When I attended Dental School, at the University of Louisville, they were pretty aggressive in their suggestions of a major causative link between smokeless tobacco and oral cancer. However, if what you say is true, I will amend my arguments appropriately. Thank you for the information. Furthermore, it is a fairly widespread belief amongst many dentists and oral surgeons that smokeless tobacco causes a great deal of harm.

  17. Frank,
    That’s like saying “driving a car is not a safe alternative to riding a motorcycle; the only safe alternative is to not leave the house.”

    It seems you also do not understand the difference between safer and safe.

  18. That’s like saying “driving a car is not a safe alternative to riding a motorcycle; the only safe alternative is to not leave the house.”

    They may be safer, but are not completely safe. Also, because we all pay for healthcare thru insurance and midicare, your unhealthy habits are all of our business, the government should make anything unsafe or unhealthy illegal to protect us.

  19. Remind me again what is “completely safe”. I’d say it isn’t “completely safe” to leave the house, but then I remember that most accidents occur in the home. Getting out of bed exposes one to all sorts of hazards, and not getting out of bed one to another set of hazards. WTF are we to do?

    The only truly unhealthy habit I see here is nosing into the business of other people and justifying it via shared healthcare costs. That sort of thing leads only to pain.

  20. The American Association for Cancer Research (AACR) is also partly responsible for the inaccurate NY Times headline and misleading article, as AACR issued the 8/9 press release
    http://www.aacr.org/home/about-us/news.aspx?d=808 with the inaccurate headline “Smokeless tobacco more effective than cigarettes for delivering dangerous carcinogens into the body,” which touted Hecht’s study and publicized Hecht’s misleading quotes.

    As such, the AACR is far more interested in generating sensationalized and misleading news stories that benefit the leading preventable cause of cancer deaths (i.e. cigarettes) than in reducing cancer morbidity and mortality among tobacco users.

    Bill Godshall
    Smokefree Pennsylvania
    Pittsburgh, PA

  21. As a counterpoint to the above post by Mr. Rodu, I suggest individuals visit the following sites:
    1. http://www.in.gov/isdh/programs/oral/s-tobacco.html
    The following quote seems to contradict the “car accident” analogy: “The risk of cancer in soft oral tissues is almost 50 times greater in long-term users than non-users. About 87 percent of these tumors are attributable to snuff.” My skyscraper analogy may have been too extreme to illustrate my point, but I believe your analogy is too extreme in the other direction.

    2.http://www.cancer.gov/cancertopics/factsheet/Tobacco/smokeless
    I found the particular passage to be quite interesting: “NCI also recognizes that nitrosamines, found in tobacco products, are not safe at any level. The accumulated scientific evidence does not support changing this position.”

    3. http://www.cancer.org/docroot/PED/content/PED_10_13X_Quitting_Smokeless_Tobacco.asp?sitearea=PED
    This is a link to the American Cancer Society website
    Mr. Rodu stated in his post that “recent studies, including one from the American Cancer Society, have *not* detected any oral cancer risk among smokeless users.”
    I found this assertion unusual because the ACS website directly states the following: “the most serious health effect of spit tobacco is an increased risk of cancer of the mouth and pharynx (throat). Perhaps I am misunderstanding the meaning of the word “increased” in the above quotation. Furthermore, this statement: “There is no evidence that spit tobacco or oral tobacco products are effective in helping smokers quit smoking” seems to contradict virtually everything discussed at http://www.smokersonly.org

    4.http://www.mayoclinic.com/health/chewing-tobacco/CA00019

    Again the following statements seem to directly contradict the assertion that the link between smokeless tobacco and oral cancer is tenuous: “Your risk of oral cancer is increased if you use smokeless tobacco. Oral cancer includes cancers of the mouth, throat, cheek, gums, lips and tongue. Surgery to remove cancer from any of these areas can leave your jaw, chin, neck or face disfigured”

    Mr. Rodu stated: “smokeless users have about the same risk of dying from mouth cancer as automobile users have of dying in a car wreck”
    The citations and websites I listed above seem to indicate that this assertion is true only if the drivers he mentions drive ten times the speed limit, without looking at the road while changing the radio station and talking on the cellphone while driving at night with the headlights off.

    Furthermore, the above quote makes no mention at all of morbidity associated with smokeless tobacco use. This is a huge omission, in my opinion. As I discussed in my previous post, oral cancer treatments are extremely invasive.
    I know this from my own personal experience. I have performed multiple mandibulo- and maxilloectomies, glossectomies, hemiglossectomies, serial extractions, etc. on individuals who had oral cancer as a result of prolonged smokeless tobacco use. The extensive work done by general practioners, periodontists, endodontists, etc., prior to treatment by an oral surgeon, can also be quite invasive, yet quite necessary to avoid the potentially fatal complications of osteoradionecrosis, as I also mentioned in my previous post. While these patients may not die, the reduction in quality of life is quite severe. I don’t quite understand why you didn’t mention the associated morbidity.

    As I said above, I will definitely visit your site and better acquaint myself with the research you are doing, as I am a firm believer in increased research in this field.

  22. “The only truly unhealthy habit I see here is nosing into the business of other people and justifying it via shared healthcare costs. That sort of thing leads only to pain”

    While I feel strongly that smokeless tobacco poses grave health risks, I also feel very strongly that in a free society individuals should be able to use cigarettes and smokeless tobacco, or even illicit narcotics for that matter without government interference. I will never make the argument that unsafe products such as tobacco should be denied to an adult who chooses to use them.

  23. “the government should make anything unsafe or unhealthy illegal to protect us.”

    Because this comment made me ill, I expect Frank to be banned from the planet.

  24. I suggest that those who question or challenge the accuracy of Brad Rodu’s comment read the report that Rodu and I authored at:
    http://www.harmreductionjournal.com/content/pdf/1477-7517-3-37.pdf

    More recent analyses from New Zealand and Europe that reached similar conclusions are at http://nzhta.chmeds.ac.nz/publications.htm#review and http://ec.europa.eu/health/ph_risk/committees/04_scenihr/docs/scenihr_o_009.pdf

  25. “I suggest that those who question or challenge the accuracy of Brad Rodu’s comment read the report…”

    Are you trying to imply that those who question you are wrong, because frankly the bulk of the science is not in your favor.

  26. “I suggest that those who question or challenge the accuracy of Brad Rodu’s comment read the report that Rodu and I authored at:
    http://www.harmreductionjournal.com/content/pdf/1477-7517-3-37.pdf

    More recent analyses from New Zealand and Europe that reached similar conclusions are at http://nzhta.chmeds.ac.nz/publications.htm#review and http://ec.europa.eu/health/ph_risk/committees/04_scenihr/docs/scenihr_o_009.pdf

    Thank you for the links, Mr. Godshall. I will certainly examine those. As one who likes to consider himself a scientist, I always like to examine more data to determine if my position continues to be tenable.

    “because frankly the bulk of the science is not in your favor.”

    The great thing about science is the lack of sacred cows beyond examination. If the bulk of the evidence overwhelms that which was previously accepted, the old is thrown out.

  27. Chavez makes one excellent point with his 5:04 pm post: that most of what’s found on the internet about smokeless tobacco is inaccurate, even when the source is a “trusted” medical authority. The Mayo Clinic and the American Cancer Society are two of the worst offenders, as I pointed out in my article for the Capital Research Center, available at: http://www.capitalresearch.org/pubs/pdf/07_04_OT.pdf

    With regard to the American Cancer Society, it is important to emphasize the huge difference in the organization’s rhetoric on its website, and in this direct quote from a medical article authored by Cancer Society staff and published in Cancer Epidemiology, Biomarkers and Prevention (Volume 16, pages 347-358): “The death rate from cancers of the oral cavity and pharynx was not significantly associated with current use of spit tobacco.”

    Carl Phillips has also commented on the misinformation campaign in his wonderfully titled article, “You might as well smoke; the misleading and harmful public message about smokeless tobacco”, available at: http://www.biomedcentral.com/1471-2458/5/31

    The “50-Fold” Fallacy has been discussed in detail by the University of Alberta Tobacco Harm Reduction Research group at: http://www.tobaccoharmreduction.org/faq/glossary.htm (scroll down to “Fifty times the risk?”).

  28. “Chavez makes one excellent point with his 5:04 pm post”

    Ouch.

  29. The links you provided are quite interesting and I will have to read them, time-permitting.

    On a personal note, Mr. Rodu, I am curious as to how long you have been at the University of Louisville. When I attended Dental School there, quite a while ago, I was instructed in oral pathology by Drs. Richard Miller, Alan Gould and Mark Bernstein. I am quite certain they made use of the 50x statistic as well as other studies that heavily suggested a very strong causal relationship between smokeless tobacco and oral cancer. I am curious if you know these gentlemen and if they have modified their views on the subject.

  30. I must say, I am reading quite a bit of recent scholarship concerning smokeless tobacco and oral cancer on the internet, and there is a huge number of articles indicating a greatly increased risk for oral cancer . Brad Rodu’s research injects quite a bit of skepticism into the debate, but I will admit I am not yet swayed. The sheer bulk of articles taking the view opposite of his is overwhelming.

  31. “Unacceptable risk.” That’s sweet! I just love it when other people decide that risks I want to take are acceptable or un. When I told me Dentist I didn’t want my head to be bombarded with x-rays every year, and I was only willing to get xrays every 3 years, she told me that it was “worth the risk.” Cancer is worth the risk of maybe missing a cavity?

  32. On a continuum of mortality risk from 1 to 100, with NRT products (gum, lozenges, skin patches, inhalers) at 1 and cigarettes at 100, smokeless tobacco products are less than 2.

    Although 2 may be twice the risk of 1, it is only 1/50th the risk of 100.

    Quit-or-die abstinence-only anti-tobacco moralists are obsessed with focussing only on comparing the risks of using smokeless tobacco with the never using any tobacco product, which is an inaccurate and intentionally deceptive analogy when comparing the risks of smoking cigarettes to the risks of using smokeless tobacco.

    Claiming that smokeless tobacco is not a safe alternative to cigarettes is analagous to the following intentionally deceptive (but technically accurate) claims:

    “Surgery, chemotherapy and radiation are not safe alternatives to praying for cancer patients” (as those medical procedures pose risks for cancer patients).

    “Drinking water is not a safe alternative to drinking a lots of vodka every day” (as rapidly drinking five gallons of water can kill a person).

    “Driving an automobile down a highway is not a safe alternative to walking down a highway” (as people are injured and die and auto crashes).

    “Using condoms is not a safe alternative to having unprotected sex with lots of partners who have HIV” (as condoms sometimes break).

    “Methadone is not a safe alternative to injecting street heroin with dirty needles” (as methadone also poses risks).

    “Solar and wind power are not safe alternatives to coal burning power plants” (as solar and wind energy also pose risks).

  33. The statement “nicotine is not a carcinogen” is simply false. Nicotine has been known to be a carcinogen for some time. It does not directly cause the changes that make cells cancerous, so its mechanism of action was not understood for some time. It is now known that it interferes with the body’s vascular growth processes in a fashion which helps cancerous mutations progress into actual cancers, and makes it harder for the immune system to deal with them before such progress has occurred. This was only worked out in the last few years.

    Bottom line: nicotine, by itself, does cause cancer, albeit by a rather complex mechanism.

  34. “Quit-or-die abstinence-only anti-tobacco moralists are obsessed with focussing only on comparing the risks of using smokeless tobacco with the never using any tobacco product, which is an inaccurate and intentionally deceptive analogy when comparing the risks of smoking cigarettes to the risks of using smokeless tobacco.’

    My posts dealt entirely with the risks of smokeless tobacco in and of itself, not comparative risks when put up against one of the most toxic products on earth. By using the cigarette comparison, you are minimizing the risk of smokeless tobacco. As I have said in my previous posts, there is a multitude of science that disagrees with your position. Excuse me if I choose not to ignore it entirely.

  35. “Quit-or-die abstinence-only anti-tobacco moralists are obsessed with focussing only on comparing the risks of using smokeless tobacco with the never using”

    I cannot even remotely be considered a “quit-or-die abstinence-only anti-tobacco moralist”, yet I have seen and understand the very real health risks of smokeless tobacco. Is this contradiction evidence I am profoundly wrong, or does it perhaps indicate such hyperbole is a mechanism to smear those with which you disagree?

  36. While I feel strongly that smokeless tobacco poses grave health risks,

    I for one try to base my beliefs about the risks of various behaviors on facts, rather than feelings.

    YMMV, of course.

  37. Nicotine has been known to be a carcinogen for some time. It does not directly cause the changes that make cells cancerous,

    Come again? Its a carcinogen, but doesn’t cause cancer?

  38. Don’t you hate it when you make a nuanced argument about a complex topic, and somebody with an agenda comes along and deliberately misstates your point?

    You’ve got to wonder if people who do that sort of thing are blinded by their simplistic narrow-mindedness and can’t see what they’re missing, or they’ve just convinced themselves that winning the fight they’ve picked is important enough to justify jettisoning even the slightest pretense of honesty, objectivity, and thoughtfullness.

    Oh, hi Chavez.

  39. Those who suggest that NICOTINE is essentially harmless should read the follwing paper:
    Critical Review. Nicotine for the Fetus, the Infant and the Adolescent?
    Journal of Health Psychology 12(2), 215-224, 2007. DOI: 10.1177/1359105307074240
    _ Ginzel_et al_12_2-1.pdf

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