Lying About Snus and E-Cigarettes Is Like Blocking Access to Clean Heroin Needles

Two public health researchers condemn the "information quarantine" surrounding safer nicotine products.



In a blistering indictment of lying in the name of "public health," two prominent tobacco researchers slam medical organizations and government agencies for suppressing information about the huge difference in risk between cigarettes and other nicotine products. Writing in The International Journal of Drug Policy, Lynn Kozlowski, a public health professor at the State University of New York in Buffalo, and David Sweanor, an adjunct law professor at the University of Ottawa, argue that a quasi-official "information quarantine" surrounding smokeless tobacco and e-cigarettes endangers people's lives based on implausible utilitarian concerns coupled with "emotionally charged moral reactions" of "disgust and contempt." 

Back in 2003, Kozlowski and another co-author looked at what the Centers for Disease Control and Prevention (CDC) and the Substance Abuse and Mental Health Services Administration (SAMHSA) were saying about smokeless tobacco, which is at least 50 percent and may be more than 90 percent less hazardous than cigarettes (depending on the diseases considered and the type of smokeless tobacco, with low-nitrosamine, Swedish-style snus the least dangerous). The CDC and SAMHSA, ostensibly devoted to educating the public about health issues, not only overlooked the huge difference in risk; they falsely claimed smokeless tobacco is just as dangerous as cigarettes. 

Vapor Puffs

Last fall Kozlowski and Sweanor revisited the CDC and SAMHSA sites, and this time they also considered information presented by the Mayo Clinic, the National Cancer Institute (NCI), and the American Cancer Society (ACS). They found that the Mayo Clinic was still incorrectly telling people smokeless tobacco is no less dangerous than cigarettes, while SAMHSA and NCI provided "no cigarette-comparative risk information that might help correct public misunderstandings." The ACS site was the best of the lot, saying "smokeless tobacco products are less lethal than cigarettes," but it gave no indication of how big the difference is. 

This information quarantine seems to be pretty effective at keeping the public in the dark. Kozlowski and Sweanor cite an NCI survey that found just 13 percent of Americans know "some smokeless tobacco products, such as chewing tobacco, snus, and snuff, are less harmful to a person's health than cigarettes." Ignorance about the relative hazards of e-cigarettes, which are estimated to be something like 95 percent safer than the conventional kind, is also widespread, thanks largely to pronouncements from government agencies and anti-smoking groups that are unhelpful at best and downright false at worst. According to a 2015 Reuters poll, just 35 percent of Americans understand that "e-smoking is healthier than traditional cigarettes." The rest, nearly two-thirds, either disagree with that statement or don't know. 

"If science learned that one type of alcoholic beverage caused 3 in 5 regular users to die prematurely, losing 10 years of life, while another alcoholic beverage caused 95% or even 9.5% fewer premature deaths, consumers would want to know which legal product was which," Kozlowski and Sweanor write (citations omitted). "It would be scandalous, even criminal, to keep such facts from consumers. Yet such facts are being kept from adult consumers of legal tobacco/nicotine products either by not informing or actively misinforming consumers. It is as if tobacco consumers were blindfolded and not allowed to see dramatic differences in harm from different products."

The government not only refuses to tell people about the harm-reducing potential of smokeless tobacco and e-cigarettes. It will not let manufacturers of those products share this potentially lifesaving information. As Kozlowski and Sweanor note, the law that authorizes the Food and Drug Administration (FDA) to regulate tobacco products "forbids marketing by manufacturers of any reduced-harm product information unless it has been proven before marketing that such marketing will not have an adverse effect on population health, a near-impossible task, a barrier that no product has yet surmounted, and one not imposed on other FDA-regulated product categories."

That standard means the FDA can censor truthful information about less hazardous alternatives to cigarettes based on worries about how some consumers might respond to the information. Maybe some smokers who switch to snus would otherwise have given up tobacco entirely. Maybe some people who otherwise never would have tried tobacco will start using snus. Maybe some of those people will move on to cigarettes. "Even if some smokers who switch to SLT [smokeless tobacco] do reduce their individual risk," the CDC argued in 2003, "it is plausible that overall population health risk would increase if SLT were promoted as a potential reduced-exposure product."

It is in fact not at all plausible. Given the huge health advantage of snus, there would be a net reduction in tobacco-related disease even if the entire population started using it, unless they subsequently switched to smoking. As Kozlowski and Sweanor point out, there is little evidence of such a "gateway" effect. "Theoretical concerns are not enough…to justify information quarantine," they write. "Both a) evidence of a problem and b) evidence that the deception/evasion is important in dealing with the problem are needed."

From a libertarian perspective, of course, the CDC's concerns would not justify censorship and deception even if there were evidence to back them up. But the government's current policy is misguided even by the paternalistic standards of "public health," which allows withholding information when the benefits (including prevention of self-harm) are believed to outweigh the costs.

Kozlowski and Sweanor argue that "the demonization of tobacco/nicotine products and the tobacco industry may have distorted public health principles by acting as if all tobacco products should be banned." They note that "a moral outrage has characterized views on tobacco which has been much greater than for other unsafe, legal and even illicit consumer products." That emotional reaction explains why "harm reduction principles have been readily embraced for many decidedly unsafe commercial products (cars, pharmaceuticals, alcohol), and for behaviors often illicit or morally objectionable to others, yet cigarettes and tobacco have been treated quite differently." 

Underlining that inconsistency, Kozlowski and Sweanor offer some provocative comparisons. "Telling consumers that all product options are as bad as cigarettes is untrue and almost certainly as deadly for users as telling at-risk populations that condom use affords no protection," they write. Regarding the prohibitive requirements for marketing reduced-risk tobacco products, they say, "It is as if needle-exchange programs had to prove no negative public health effects before being implemented—while heroin given via dirty syringes was sold over the counter."

It may seem hyperbolic to charge people like CDC Director Tom Frieden and celebrity physician Margaret Cuomo with the public health equivalent of discouraging condom use and blocking access to clean hypodermic needles. But the analogies are apt. If you want to curtail the spread of communicable diseases, easy availability of condoms and clean needles is a no-brainer. But if you want to discourage sex and heroin use, you may decide that making those activities safer is counterproductive. Public health officials and medical authorities who misrepresent the hazards of smokeless tobacco and e-cigarettes have made a similar judgment, and it is just as reprehensible.

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  1. These ‘public health experts’ are the same sort that pushed carbs over fats.Evidence be damned .It’s about control and stopping people from doing things of which they disapprove.

  2. Dammit Reason, I just quit dipping last year.

    1. October 15th, 1999. After 16 years of use. I still dream about having a dip.

      1. Wow, me too. I stopped after 10 years in January 2011. About once per month or every two months I’ll have dreams where I’m dipping and I’ll wake up, afraid I picked it up again.

        Haven’t had one since and I don’t miss it, no cravings or anything.

        1. I don’t miss it, no cravings or anything

          I’m the opposite. I’d dip again in a heartbeat.

  3. It is all about control. And perhsps the sin tax “revenue” generated during tobacco sales. It is like “gosh, darn, and crud” would require donations into the swear jar when uttered.

    1. Government = baptists
      Tobacco companies = bootleggers

      1. So this.

        If it’s all bad, why not just use cigarettes? They are readily available everywhere, and sell a lot more tobacco than snus.

        Also, autocorrect just turned snus into “anus.”

    2. It’s absolutely about both the sin tax revenue and government anti-smoking bureaucrats protecting their status. This disinformation campaign is all preparation for eventually applying the same regs and taxes to eCigs as tobacco (while using scare tactics to keep smokers from making the switch in the meantime). If giving a whole lot of people cancer is the price to pay for protecting bureaucratic turf and preserving government revenue streams, well, I have no doubt all those a$$holes can live with that.

      1. I think it is more basic than that. They have a puritanical need to be “holier than thou”. They have spent the last 50 years crusading against the evils of tobacco. Everything against them has been evil. Evil companies that spouted evil disinformation and put forth evil advertisements all designed to lure the innocent to their destruction. These are foundational truths.

        So there is no room in their psychology for anything involving the recreational use of tobacco. In every possible event, it is evil. The kind of evil that puts your soul at risk. There is no epidemiological study that can quantify the risk to your immortal soul. There never will be any evidence that can sway them.

        If you have a hard time with this, just imagine Ed Meese reviewing data on the availability of pornography in the internet age and sexual assault rates. Even with a complete disappearance of all sex crimes, can you ever imagine Meese admitting that porn is anything less than pure evil?

        Deeply held core beliefs very rarely change. In fact, we rarely challenge them. So no, the tobacco warriors are not going to go quietly into that good night. You are a sinner, and must be saved.

        1. So tobacco was evil because it got people to smoke. Then smokeless tobacco was evil because tobacco?

          So why hasn’t the condemnation spread to nicotine gum? Is it path dependent? Like because of the time in which nicotine gum came onto the market?

          1. Probably, although I have heard a bit of derision pointed in that direction.

            It is an astute observation though. Most of today’s decision makers at the CDC were in their teens or younger when nicotine gum and patches became a common thing. They were also originally prescription-only, therefore medical in nature.

            I suppose context is everything. Vaping is pretty much identical to nicotine gum, so you’d think the response would be the same.

          2. “So why hasn’t the condemnation spread to nicotine gum?”

            At what point will people realize that Big Pharma IS a major player in the condemnation of anything nicotine, tobacco-related or stop smoking related that they don’t have market share in?

            It is truly amazing that people in general don’t see the absurdity – pharmaceutical grade nicotine sold by big pharma is okay, but pharmaceutical grade nicotine sold by anyone else is bad.

    3. “gosh, darn, and crud”

      Nice law firm name.

  4. It doesn’t seem hyperbolic in the least. Cigarettes kill far more people than dirty needles ever have. Like orders of magnitude more.

    In fact on might argue that it would be hyperbolic to claim that blocking needle exchange programs is as bad as preventing marketing of e-cigarettes. The CDC claims that 6 million Americans die each year from cigarettes.

    They list 658,507 total deaths from HIV in the USA Ever. According to the world health organization, a half million die worldwide each year from Hepatitis C.

    So if we make the silly assumption that every one of those is from IV drug users without access to needle exchange programs and is in the US, we are still short of cigarette harm by about an order of magnitude. And that’s a huge leap to even get it within a single order of magnitude.

    No, it is not hyperbolic to cite these examples. Quite the opposite, in fact.

    1. Great observation.

  5. Nannies gonna nanny.

  6. Are these guys part of the “reality based community” and the party of science I keep hearing about?

  7. The good (harm reduction) is the enemy of the best (abstinence).

  8. Its gotta be galling to the CDC that a device so cheap it can be considered disposable is doing a better job at reducing smoking than all the time and money they’ve spent.

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