New Research Confirms that Tobacco Companies Use Menthol to Support Addiction, Especially Among Adolescents; Results Reveal Hypocrisy of TFK Actions

An article released today by the American Journal of Public Health concludes that tobacco companies use menthol to enhance addiction of smokers, especially adolescents and young adults. The study, which reviewed tobacco industry documents, examined data on menthol cigarette advertising and use, and tested cigarettes directly, was conducted by researchers at the Harvard School of Public Health (see: Kreslake JM, Wayne GF, Alpert HR, Koh HK, Connolly GN. Tobacco industry control of menthol in cigarettes and targeting of adolescents and young adults. American Journal of Public Health 2008).

The researchers found that tobacco companies use menthol to aid the addiction process of new, adolescent smokers. The menthol works through its anesthetic effects on the respiratory tract, which reduce the harshness of the initial smoking experience. Cigarette company research revealed that a low level of menthol can reduce the initial negative reaction to cigarette smoking. Since the initial negative reaction turns many adolescents off of cigarettes permanently, reducing this reaction can be the key to successfully addicting a youth.

For example, an R.J. Reynolds document notes that: "First-time smoker reaction is generally negative. . . . Initial negatives can be alleviated with a low level of menthol."

The memo also notes that: "Once a smoker adapts to smoking a menthol product, the desire for menthol increases over time. A brand which has a strategy of maximizing franchise acceptance will invariably increase its menthol level."

Thus, manipulation of menthol levels in cigarettes plays a substantial role in sustaining addiction to cigarettes as smokers become older and more experienced.

The article concludes: "Cigarettes are nicotine delivery devices. They are engineered to promote initiation and transition to addiction through design features that make the products more attractive and palatable. Although menthol is not addictive, it may contribute to tobacco addiction by promoting initiation and facilitating inhalation of smoke."

The Rest of the Story

First and foremost, this research exposes the hypocrisy of the Campaign for Tobacco-Free Kids, the American Medical Association, and other groups which are supporting the FDA tobacco legislation and actively opposing the Congressional effort to remove the menthol exemption.

These groups are arguing that we need to ban cigarette flavorings because these flavorings help induce young people to start smoking. They are supporting a ban on a wide range of flavors, including cherry, chocolate, strawberry, banana, mint, clove, raspberry, and even snozberry. Yet there is no scientific evidence that any of these flavorings are actually used to recruit and addict young smokers.

On the other hand, we now have solid evidence that menthol is actually being used by cigarette companies to recruit and support addiction among literally millions of young smokers. So what does the Campaign for Tobacco-Free Kids want to do with this flavoring? Ensure that it can remain in cigarettes, because smokers are actually using it!

This hypocrisy is just too absurd to be true. How can a public health group argue, on the one hand, that tons of flavorings that are not being used to any substantial extent to recruit young smokers need to be banned, but that the one flavoring that has now been conclusively shown to be contributing toward the addiction of millions of smokers needs to remain on the market?

I'm not arguing here that menthol products need to be removed from the market. I'm arguing that it is complete and utter hypocrisy to argue that chocolate needs to be banned from cigarettes, but that menthol needs to remain.

Second, I find it ironic that here we now have evidence of the one thing that the FDA legislation could potentially do that would actually make a dent in youth smoking, but the Campaign for Tobacco-Free Kids opposes it. All of the other measures in the legislation are not going to do a thing to prevent youth smoking. Now we have an evidence-base to support an action that we know will make a substantial difference, and the Campaign for Tobacco-Free Kids and its partners are opposing it!

Third, this story reveals just how apparent the lack of an evidence-base is in the national tobacco control movement. Where there is no evidence to support action, the health groups are demanding regulation. Where there is solid evidence to support action, the health groups are demanding that Congress not intervene. This is insanity!

Once again, I'm not calling on the regulation of the constituents of tobacco products. It should be well known to my readers that I am opposed to that concept and I don't think it is appropriate for the FDA to be entrusted with such a mission. However, it is ludicrous for those who are calling on the FDA to regulate cigarettes to give the Agency numerous tasks for which there is no evidence to suggest there will be any positive effect on the public's health, but to ban the Agency from taking the few actions for which there is evidence that there would be a positive effect on the public's health.

The loopholes in the bill, which preclude it from taking exactly those actions for which there is evidence that a dent in cigarette use would occur -- including the menthol exemption -- represent sellouts that occurred at the negotiating table with Philip Morris. To be holding on to these sellouts even after Congressional leaders themselves have demanded that the loopholes be removed and after research has been presented demonstrating why the loopholes are critical to the protection of cigarette sales is unconscionable.

American Medical Association Leadership Ignores Overwhelming Sentiment of Members; Refuses to Listen to Membership and Supports Current FDA Bill

Despite a vote by its members indicating support for the removal of all cigarette flavorings, the American Medical Association (AMA) leadership has refused to accept the opinions of its members and has instead opposed the removal of the menthol exemption from the FDA tobacco legislation.

On June 17, the American Medical Association voted to adopt the following policy regarding the removal of cigarette flavorings:

"In recent years tobacco products have been developed in a variety of flavors including chocolate, vanilla, mint and fruit. Surveys have shown that children are more likely to choose flavored tobacco products. Because these products appear to be specifically marketed toward children, today the AMA spoke out in support of state legislation that would prohibit the sale or distribution of flavored tobacco products."

According to an AMA press release supporting the removal of all cigarette flavorings: "Research shows that the earlier a person begins smoking the more likely he or she will become addicted to tobacco products and will continue to smoke throughout his or her lifetime," said AMA Board Member William Dolan, M.D. "We all know the dangers of smoking and by prohibiting the sale of flavored tobacco products targeted toward children, we may be able to keep the younger generation tobacco free."

Despite passage of this resolution, the AMA leadership continues to oppose the removal of the menthol exemption, and is thus supporting the continued use of menthol flavorings in cigarettes, which is at odds with the policy vote of the AMA members. According to an Associated Press article, AMA president Dr. Ron Davis said he was continuing to support the menthol exemption despite the sentiment and vote of AMA members because removing the exemption "might derail the legislation."

The Rest of the Story

So you mean to tell me that despite the vote of the AMA members, the AMA leadership is supporting the continued sale of menthol cigarettes and the continuing addiction of our nation's youth because it admits that it wants to protect Philip Morris profits from menthol sales and thus retain its political alliance with Philip Morris in support of the FDA legislation?

The rest of the story is that this may be one of the saddest chapters in the history of the AMA's support of the tobacco industry.

What surprises me, however, is that I thought this history had come to an end. Sure, the AMA has a long relationship with the tobacco industry and has been one of the strongest financial supporters of pro-tobacco legislators. But I thought that times had changed and that the chief organization representing America's physicians would relinquish its long-time role in protecting tobacco industry interests.

Well, I guess times haven't really changed after all. The AMA continues to ally itself with the tobacco industry, and in this case, to actively try to block efforts to protect the public's health by improving the FDA legislation in order to protect the financial interests of the leading cigarette company, whose Marlboro Menthol product is the 2nd leading menthol brand on the market.

My only regret is that I quit the AMA years ago. I would have loved to send in my AMA resignation in response to this gaffe.

Support for FDA Tobacco Legislation Continues to Crumble; Truth May Win Out in the End

Support for the proposed FDA tobacco legislation continues to crumble, as several more anti-smoking groups have announced their public opposition to the legislation.

Action on Smoking and Health (ASH) issued a statement in which it opposed the legislation unless it is amended to remove the menthol exemption. This is a provision in the legislation, included as a compromise to Philip Morris (whose Marlboro Menthol brand is the 2nd leading menthol brand in the country), exempts menthol from the list of cigarette flavorings that are banned by the legislation.

ASH wrote: "While the bill would ban the use of virtually all substances (e.g., clove, peppermint) used to flavor cigarettes, and to mask the harsh taste most young children experience when they first try smoking, the bill exempts menthol. But menthol is used overwhelmingly be African Americans, and makes it much harder for users to quit smoking once they get hooked. That's why this lethal "racist" loophole is being condemned by the Congressional Black Caucus, the National African American Tobacco Prevention Network, many former HHS Secretaries, and now by ASH."

ASH argues that the menthol exemption is racist, or at least racially insensitive, because it creates a systematic discrepancy in health protection that disproportionately affects African Americans: "the argument that the exception of menthol from the bill does not discriminate against African Americans seems inconsistent with clearly established American law which recognizes that actions or laws which have the “effect or consequence” of having a discriminatory impact on Blacks may violate civil rights laws prohibiting such discrimination." ...

"Thus the inescapable conclusion is that, at the very least, the menthol loophole would have a racially discriminatory impact, and debating the bill in its current form could well raise serious racial issue just prior to critical elections in which race is already playing a major factor. The fact that this lethal menthol loophole was apparently negotiated without a single representative from an African American organization [like the National African American Tobacco Prevention Network, which said 'our constituents across the country are just livid' at being excluded from any representation in negotiations on the menthol loophole”], or even of African Americans prominent in the antismoking and public health movements, only adds to that impression."

In a press release, ASH argued that by agreeing to this compromise, the Campaign for Tobacco-Free Kids has sold out the health of African Americans in order to appease the financial concerns of Philip Morris: "sacrificing African American children to mollify the largest killer of Blacks in the U.S. is nothing short of grotesque and obscene, and may well be counterproductive and totally unnecessary. . . . passing the bill with the menthol loophole is racist (or at least racially insensitive)."

ASH also condemned the Campaign for Tobacco-Free Kids for negotiating this bill with Philip Morris, for doing so in secret, and for failing to open the process up to any other tobacco control groups, especially those representing communities of color: "ASH also objected that such an exemption was apparently negotiated in secret with a tobacco company to gain its support, and with virtually no input from individuals and organizations with both a special interest and a unique perspective on African Americans, public health, and cigarettes."

Maryland GASP has also come out against the legislation. A column in the Maryland Gazette by its president - John O'Hara - condemns the legislation for its numerous loopholes which O'Hara says give the tobacco industry virtual control over the FDA. He also points out that the legislation sells out the health of African Americans to protect tobacco industry profits. The column argues that this legislation should be abandoned and that groups need to go back to the drawing board and develop a true piece of tobacco control legislation for the next Congressional session.

The Daily Voice, described as "Black America's Daily News Source," featured an article about the menthol exemption in the legislation. The piece argues that: "It is believed that Philip Morris actively lobbied Congress to include the menthol exemption, which is financially critical to the American tobacco industry's profit margin." The article goes on to assert that this compromise in the legislation is inappropriate because it an institutional example of how the "tobacco industry continues, after nearly a century, to enslave our community in many creative ways."

The Rest of the Story

There are two important implications of this story.

First, from a practical perspective, I believe that the FDA tobacco legislation is dead for this legislative session. I don't see any way that the bill can overcome the dual devastating blows of the widespread media coverage of the menthol exemption and its being framed as a sell-out to Philip Morris, as well as the crumbling of the coalition of support and internal misgivings of groups about being on board with the tainted process that led to the legislation in the first place.

If nothing else, the menthol guffaw gives bill opponents a perfect way to defeat the bill on the Senate floor: simply introduce an amendment to remove the menthol exemption. Doing so will tie the hands of bill supporters. If they vote against the amendment, they are exposing themselves as tobacco industry protectionists who are willing to sell out the health of African Americans to protect cigarette company sales. If they vote for the amendment, they are unlikely to be able to garner enough votes to break any filibuster and move the legislation forward.

Most likely, the effect of the menthol guffaw will be to convince Senate leaders not to bring the bill to the floor in the first place. They will probably want to avoid the embarrassment of a showdown over the menthol issue.

From a political standpoint, bringing the bill to the floor under these conditions will take the focus off the public health aspects of the bill and displace it over to the menthol exemption and to the appeasement of tobacco industry interests. The potential political gains to be garnered from support for the legislation have been greatly obscured.

The second important aspect of this story is that it shows the power of the truth. As the truth is gradually (albeit slowly) revealed and digested by the tobacco control community, groups are beginning to line up in droves against the legislation. The coalition of support is crumbling because no one wants to be seen as standing up for the financial profits of Big Tobacco, which is what the Campaign for Tobacco-Free Kids is doing by negotiating this deal with Philip Morris, supporting it in Congress, and opposing any amendments to strengthen the bill.

People are willing to stay on a sinking ship only so long. Once they can actually see the water pouring into the ship, they head for the lifeboats.

It's time for the tobacco control movement to abandon this sinking FDA legislation ship before it capsizes. We need to regroup on shore and build, together, in an open and inclusive process, a new ship. Hopefully, the ship we build in the next legislative session won't be called - like its predecessor - the S.S. Philip Morris.

New York County Legislator Seeking to Ban Smoking Outdoors Because It Sets a Bad Example

According to an article in the Daily Freeman (Kingston, NY), a Dutchess County legislative leader is promoting a smoking ban for all county parks and their parking lots because smoking sets a bad example for children. A similar law being considered in neighboring Ulster County would ban smoking on all county-owned property.

According to the article: "With smoking now banned in all indoor public spaces in New York state, some county officials in Ulster and Dutchess hope to join a growing number of municipalities to snuff out smoking in outdoor areas as well. The Ulster County Legislature last week set a public hearing for 6 p.m. Aug. 6 on a proposed local law that would ban smoking on all county-owned or county-controlled property. Members of the Dutchess County Legislature's Public Works Committee, meanwhile, are expected on Monday to discuss a proposal to ban the use of tobacco in county parks. ..."

"'I just feel there shouldn't be tobacco use in county parks,' said Dutchess County Legislature Majority Leader Sandra Goldberg, who led the Dutchess initiative. Goldberg, D-Wappinger, said the county's parks are intended to be a "family place" and the presence of smokers is not only harmful to those forced to breathe second-hand smoke, but it sets a bad example for children. Nearly the entire Democratic caucus in the county Legislature supports the Dutchess measure, Goldberg said."

The Rest of the Story

We will be in serious trouble when we start outlawing health behaviors in public merely because they set a bad example. Are we going to outlaw eating french fries in public because it sets a bad example to children regarding a healthy diet? Are we going to outlaw severely overweight people from public parks because they set a bad example for children? What about teenagers who have babies? Should they be banned from public parks because it sets a bad example for children?

The same reasoning that Majority Leader Goldberg is using to support banning smoking in county parks would also support each of these other measures.

The danger here is that Goldberg is turning smoking into a moral, rather than strictly a health issue. It is crossing that line from health into morals, with regards to smoking or any other health behavior, that I find unacceptable, inappropriate, and frankly - dangerous.

As I see it, smoking is not a moral issue. It is a health issue. And that's all.

Prohibiting certain behaviors in public places - such as drinking alcohol, public nudity, public sex, etc. - is justified on the grounds of public morals. There are certain behaviors which in the collective wisdom of society are viewed to violate public morality, particularly as they relate to being viewed by children.

What Goldberg is essentially doing is equating smoking with these other behaviors. She is, in fact, making a moral argument about smoking. This does cross the line from treating smoking as a public health issue to treating it as an issue of public morals.

If Goldberg and other legislators want to argue that smoking needs to be banned on all county property because it represents a substantial threat to the public's health, then they are free to make that argument and I have no problem with it. Good luck to them in trying to garner evidence to support the contention that smoking in parking lots at county parks or county buildings is a serious public health problem, but they are free to attempt to do so.

However, to argue that smoking needs to be banned on all county property because we need to protect kids from seeing this morally inappropriate behavior is no longer a public health argument. It is a public morality argument and it has no place in this debate.

Scene Smoking Still Claims that Tobacco Kills 124,000 Young People A Year; We Can Safely Conclude that They Do Not Care About the Facts

Eight and a half months after pointing out directly to Breathe California of Sacramento-Emigrant Trails that a central "fact" on its Scene Smoking web site was incorrect, the "fact" remains unchanged. The Scene Smoking web site of Breathe California of Sacramento-Emigrant Trails still claims that: "Smoking Kills About 340 Young People A Day."

This claim, which is equivalent to stating that smoking kills 124,000 young people each year, is blatantly absurd, and false on its face. Obviously, smoking doesn't kill 124,000 young people each year.

In its communications with me, Breathe California of Sacramento-Emigrant Trails has never argued the point. They have not defended the claim. Instead, they have maintained that they intend to change it but that the web master is away and unavailable, and that the claim cannot be changed without the web master.

The Rest of the Story

At this point, almost nine months after first reporting this "mistake" to the organization, it is becoming apparent to me that Breathe California of Sacramento-Emigrant Trails just doesn't care about whether the information on its web site is accurate or not. What else can I possibly conclude, given that they have known about this blatant factual error for more than eight months and have still failed to correct it?

It appears that this anti-smoking group, like an increasing number of such groups in my experience, believes that the cause is so important that the facts really don't matter. It doesn't matter whether you are telling the public the truth, because the cause is so important and valuable. The ends justifies the means. It is acceptable to communicate false information to the public because the ultimate cause is a good one. When you are made aware that information you are communicating is false, it is not important to correct it. You can get to it whenever you get around to it. Let people continue to be misled and deceived. It's OK, because this is all for a good cause.

I'm sorry, but I just don't accept this attitude. I don't know what is more important to the tobacco control movement than its scientific integrity. Moreover, I believe we have an ethical obligation to communicate accurate information to the public. Certainly, we make mistakes, but when that occurs, you correct them as soon as possible. Eight and a half months and counting is not "as soon as possible."

This also leads me to question whether the original claim is actually a mistake. It seems difficult to believe that the organization could have made a simple careless error and ended up with the claim that smoking kills about 340 young people a day. It's not like a simple typographical error or careless construction of the statement could have resulted in the erroneous nature of the claim. It's a pretty simple and straightforward assertion, and it's hard to believe that one could make such a claim without really meaning it, or that one could fail to be aware of what one is actually asserting by such a statement.

Add to this the organization's failure to correct the statement and one is left with the impression that this may not be a mistake, but that it may be an intentional effort to deceive. In fact, one could argue that since the organization was aware of the inaccuracy of the claim eight and a half months ago, its continuing dissemination of the claim to the public represents intentional deception.

For the past eight and a half months, this certainly cannot be an example of an unknowing deception of the public. It is now being done in a deliberate way. The organization has apparently made a choice to leave the claim on the web site for the past eight and a half months.

I don't mean to pick on this one organization, but I think this is an important story because it demonstrates why I have come to believe that the tobacco control movement largely doesn't care any more about its scientific accuracy. It is truly becoming clear to me that the cause is more important than anything, even the truth. If we need to tell lies to accomplish our goals, so be it, because the cause is just so important.

I find it ironic that much of the basis for tobacco control is the premise that the tobacco companies have been communicating misleading and inaccurate information to the public for many years. Interestingly, there are few examples of outright material misrepresentations of facts by the tobacco industry. Mostly, the examples are those of misleading portrayal of information. But here, we have an example of outright dishonesty. I would argue that the statement in question is not merely misleading; it is demonstrably false.

Do we really need to stoop down so low, below the level of even the tobacco industry, to make our points to the public?

ASH Reiterates its Claim that 30 Minutes of Secondhand Smoke Increases a Nonsmokers' Risk of a Heart Attack to that of an Active Smoker

Action on Smoking and Health (ASH) has reiterated its claim that 30 minutes of secondhand smoke increases a nonsmoker's risk of suffering a heart attack to the same level as that of an active smoker.

On its web site, ASH now repeats its claim that "even 30 minutes of exposure to small amounts of drifting secondhand tobacco smoke can increase a nonsmokers' risk of a heart attack to that of a smoker."

ASH states that its claim is based on the following two statements made in the scientific literature:

Statement 1
"the effects of even brief (minutes to hours) passive smoking are often nearly as large (averaging 80% to 90%) as chronic active smoking."

Statement 2
"Even 30 minutes of exposure to a typical dose of secondhand smoke induces changes in arterial endothelial function in exposed non-smokers of a magnitude similar to those measured in active smokers."

The Rest of the Story

This claim by ASH is not only inaccurate, but it is absurd on its face. There is no way that 30 minutes of secondhand smoke can increase the risk of a heart attack to the same level as that observed in a chronic, active smoker. If this were true, then the tobacco industry could legitimately claim that: "active smoking is no worse [in terms of heart attack risk] than being exposed to drifting tobacco smoke for 30 minutes." Obviously, a smoker's risk of a heart attack is far greater than the risk for a nonsmoker exposed to secondhand smoke for a half hour.

So ASH has got it completely wrong here. But how? How could ASH so thoroughly distort the science that it became blatantly false?

The answer is that ASH has conflated endothelial dysfunction with heart attack risk. Both statements #1 and #2 above relate to endothelial dysfunction. What the key study found (there is really only one study here, but the same study is being referred to in both statements) is that 30 minutes of secondhand smoke exposure increased endothelial dysfunction (as measured by coronary flow velocity reserve) to the same extent in nonsmokers as in smokers.

The study did not find that 30 minutes of secondhand smoke increases heart attack risk to the same level as that of smokers.

Had ASH stated: "even 30 minutes of exposure to small amounts of drifting secondhand tobacco smoke can increase a nonsmokers' risk of endothelial dysfunction to that of a smoker," or "even 30 minutes of exposure to small amounts of drifting secondhand tobacco smoke can decrease nonsmokers' coronary flow velocity reserve to that of a smoker" then the statement would
have been correct.

But by distorting the statement to assert that a nonsmoker's risk of a heart attack is increased to the same level as that of a smoker, ASH has factually misrepresented the truth.

I am not accusing ASH of intentionally lying. Another possibility is that they are lawyers and not physicians, simply do not understand the difference between measuring endothelial dysfunction and measuring heart attack risk, and are simply out of their league in interpreting science like this. However, if this is the explanation for this scientific misrepresentation, then it is still inexcusable. A public health organization that puts itself forward as being a trustworthy source of medical and scientific information to the public has a responsibility, I believe, to be reasonably careful in crafting its public communications. If scientific incompetence is the explanation for ASH's dissemination of false information, then ASH remains guilty of failing to exercise even the most minimal level of care in communication of health information to the public.

There are a number of adverse implications of ASH's actions.

First, by blatantly distorting and misrepresenting the science, ASH has threatened the credibility and reputation of all of us in tobacco control. It is quite obvious, even to much of the lay public, that ASH's claim is absurd. There is no way that 30 minutes of secondhand smoke exposure can put nonsmokers at the same level of heart attack risk as smokers. I am afraid that people are going to realize this and realize that the tobacco control movement is misrepresenting the science. While it is one particular group making this claim, I think people will attribute the behavior more generally to the entire movement.

Second, by being untruthful in its health claims, ASH has threatened the scientific integrity of the tobacco control movement. There is an ethical public health standard of honesty in scientific communication which I believe ASH is violating here (whether intentional or not) and it reflects poorly on the entire movement, even groups which are not making this claim.

Third, by distorting the science so severely, ASH risks undermining the public's appreciation of the hazards of active smoking and undermining years of public health efforts to educate the public about the severe cardiovascular disease harm of cigarettes. If the public truly believes that the heart attack risk associated with active smoking is only as bad as that produced by breathing drifting tobacco smoke for a half hour, then the public's perception of the severity of the heart attack risk of active smoking will certainly decrease. This statement could easily lead smokers to believe that they are not at a particularly high risk of a heart attack. It could easily deter smokers from quitting and undermine efforts to prevent youths from starting to smoke.

Remember that in an equation, it doesn't matter which side you put first. If you state that A = B, then you are also stating that B = A.

Thus, if you state that a nonsmoker's risk of a heart attack after exposure to 30 minutes of tobacco smoke is the same as that of a smoker's, you are also stating that a smoker's risk of a heart attack is merely that of a nonsmoker who breathes in drifting smoke for a half hour.

Had ASH stated the claim that way, I think it would have been immediately obvious to people that they were pulling their legs. In fact, if the tobacco industry put out such a claim (which they could easily do based on ASH's statement), I am sure anti-smoking groups would be attacking the industry for making such an absurd claim.

In fact, I have a brilliant idea for the tobacco industry which I'd like to pass along. They can, without any risk of liability, point out to their smoking consumers that "Even anti-smoking groups agree that your risk of suffering a heart attack is no higher than that of someone who doesn't smoke but merely breathes in tobacco smoke for 30 minutes."

I would make that the basis of an education campaign directed to all smokers, and to the public. I would call the "Understand Your Risk" campaign. In all literature or other communications produced by the campaign, I would clearly cite Action on Smoking and Health for the statement, so that there is no risk of liability for making a false claim. In the statements, I would make sure to specify: "according to an anti-smoking group....".

Since ASH didn't specify a maximum smoking duration in its claim, as a tobacco company, I believe I could safely reassure my long-term customers of 30-40 years not to worry, because their risk of a heart attack is no worse than it would be if they had never smoked, but had simply once walked into a smoky bar for a half hour.

Clearly, ASH's claim also undermines the importance of the dose-response relationship between cigarette smoke exposure and heart attack risk. If it is true that a smoker's risk of a heart attack is no higher than someone who walks into a smoky rib shack for 30 minutes one time, then smoking for 40 years doesn't put you at any increased heart attack risk as smoking for 20 years, or for 1 year for that matter. Smoking 4 packs a day isn't any worse than smoking a few cigarettes a day. And most devastatingly, quitting smoking apparently will not reduce your heart attack risk at all if you still hang out with your smoking friends for a half hour on occasion. So why quit smoking?

Before closing, I think it is important to point out that ASH's original claim, which it maintains to this day on this web page, appears to be false. ASH claims that "the CDC has warned that breathing drifting tobacco smoke for as little as 30 minutes ... can raise a nonsmoker’s risk of suffering a fatal heart attack to that of a smoker."

However, I can find no evidence that the CDC has indeed warned that "breathing drifting tobacco smoke for as little as 30 minutes can raise a nonsmoker's risk of suffering a fatal heart attack to that of a smoker." The CDC did warn that breathing secondhand smoke for as little as 30 minutes can reduce coronary flow velocity reserve to that of a smoker. But nowhere did CDC warn that brief tobacco smoke exposure increases heart attack risk to that of an active smoker.

My argument of course hinges on their being a critical difference between the finding of reduced coronary flow velocity reserve and the finding of an increased heart attack risk. In fact, having reduced coronary flow velocity reserve does not equate to being at an increased risk of a heart attack. In the healthy volunteers who were studied by Otsuka et al., there was no increased heart attack risk faced by these patients. Had there been such a risk, then the study would have been unethical and it never would have been approved by an institutional review board. Certainly, the subjects would have had to be warned that they would face an increased risk of heart attack and possibly death.

Moreover, eating a hamburger reduces coronary flow velocity reserve to roughly the same extent as in an active smoker. Would it therefore be accurate for ASH to claim that "eating a single hamburger can increase a person's risk of a heart attack to that of a smoker?" Of course not. If you walk into McDonald's and order a hamburger, you may be at risk of disease, but not from immediately keeling over from a heart attack.

Luckily, the tobacco companies are a little more honest than ASH is being here, and they have not taken this opportunity to claim publicly that: "Smoking puts you at no more risk of a heart attack than eating a single hamburger." Based on ASH's statement, the tobacco companies could accurately make such a claim. The tobacco companies aren't misrepresenting the science about this. Why is ASH?

IN MY VIEW: Study on Effect of England's Smoking Ban on Quit Rates Not Only Represents Science by Press Release; It Also Appears to Be Shoddy Science

I have already discussed why the study on the effect of England's smoking ban on quit rates is problematic on the grounds of it representing science by press release. Today, I posit, based on the limited information available about the study, that its conclusions are questionable as well. In light of science by press release approach, this is extremely problematic, because the conclusion has already been widely disseminated by the media.

Based on the little information we have available (i.e., the limited information that was provided by Cancer Research UK in its press release and which is publicly available on the internet), it appears that the conclusion of this study - that the smoking ban substantially reduced the quit rate in England - is based on a comparison of two data points: the quit rate during the nine months preceding the smoking ban (which was 1.6%) and the quit rate during the nine months following the smoking ban (which was 5.5%).

While it may appear, on the surface, that the smoking ban had a dramatic effect on the quit rate, increasing it from 1.6% to 5.5%, one cannot conclude that there was a causal effect of the smoking ban on the quit rate unless one can rule out the possibilities that the change in quit rate represents: (1) random variation in the quit rate over time; (2) a secular change in the quit rate that would have occurred in the absence of the smoking ban; and (3) a change that is attributable to some other factor.

In order to accomplish the above, one needs to do three important things:

(1) calculate the quit rate for several years prior to the smoking ban, preferably for about 8 years or so, in order to establish the baseline variability in the quit rate over time;

(2) compare the change in quit rates over time to changes in the quit rate in a comparison location, presumably a nearby country or countries without a smoking ban; and

(3) somehow rule out the possibility that there is another factor which may explain the change in quit rate -- in this case, that includes the implementation of another important policy change in October 2007: an increase in the legal age of purchase of tobacco from 16 to 18.

From what I can tell, the study did none of these three important things.

First, its conclusion appears to be based on a comparison of just two data points: the quit rate in 2006-2007 and 2007-2008. It doesn't even appear that data for the entire year following the smoking ban were used. It doesn't appear that the quit rate was determined for the years prior to the smoking ban. Rather than going back 8 years or so, it doesn't even appear that the study went back for a full year prior to the smoking ban.

While the Smoking Toolkit Study made an attempt to estimate historical quit rates, these rates were not actual rates but were very rough estimates, and they cannot be compared with the quit rate as calculated after the smoking ban. The methods are completely different and cannot be compared directly. The investigators themselves acknowledge that the historical quit rate calculations are very rough and should be taken with a grain of salt: "We do not have the data to be able to calculate background quit rates in the UK population but we can estimate historic rates and rates in the past year indirectly as long as certain assumptions hold true. ... Because of the assumptions involved in the estimates and the sample size used to calculate these figures, these figures must be treated with caution."

Even more troubling is the fact that there has been an impressive trend of declining smoking prevalence in England. In fact, one article pointed out that there was a reduction of 400,000 smokers between 2003 and 2004 -- the same reduction that between 2007 and 2008 is being attributed to the smoking ban. The article reports that there was a decline of 1.2 million smokers in England from 1998 to 2003. It was in 1998 that the Smoking Kills White Paper was released.

Second, it does not appear that any comparison country or location was used. This makes it very difficult, if not impossible, to conclude that any observed changes in quit rate would not have occurred anyway in the absence of the smoking ban.

Third, it does not appear that other potential causes of an increase in quit rate were ruled out, including the potential effects of the increase in the legal age of purchase of cigarettes and all the media attention to tobacco produced by the debate over the proposed smoking ban.

It is unfortunate that the investigators have issued this press release and garnered widespread media coverage of their conclusions without making the study available for review, so that we could ask precisely the above questions and review the methodology to examine how these three important issues were addressed, if at all.

This is now extremely problematic because if I am right and these conclusions are not justified based on the study's major limitations, it is really too late. The conclusions have already been widely disseminated to the public. Are newspapers going to run a special article that says: "Remember that story last year about how the smoking ban dramatically increased quit rates in England? Well, it turns out that the conclusion was invalid because the investigators could not rule out the possibility that the observed increase in the quit rate was due to random variation, rather than to a causal effect of the smoking ban."


(Thanks to GreatScot and Tim Clarke for ideas used in this post).

Special "Independence" Day Post: Australians May Need a License to Smoke

Adults in Australia who smoke may soon be required to obtain a "license to smoke," according to an article in the Victoria Herald-Sun.

According to the article: "Health Minister Nicola Roxon has warned smokers she is prepared to take radical action to force them to give up. A smoker's permit could be among the "innovative options" employed to get Australians to quit. The permit, which smokers would have to buy annually and display every time they bought cigarettes, has been mooted in Britain. ... Under Britain's permit proposal, smokers would have to renew their permit every year and display it when buying cigarettes."

This proposal has been endorsed by a leading tobacco control researcher and advocate - Dr. Simon Chapman of the University of Sydney School of Public Health - who writes in a July 4 column on an Australian news web site: "Why not license smokers? After all, doctors issue tens of thousands of temporary licences every day in the form of prescriptions to allow us to access drugs that can save lives and improve health. Critics scoff at the idea, arguing that there would be too many difficulties in policing it, or that an underground market for cigarettes would develop. Given that obtaining a licence for other activities is so straightforward, these arguments hold little weight. Introducing a smoker-licensing scheme could be readily managed by allowing all current adult smokers over the age of 18 to acquire a permit. To be eligible, smokers would need to have their doctor affirm that they are smokers and then apply for a photo ID swipecard. Any new smokers wanting a licence after the scheme's starting date would be required to take a test, proving they fully understood the many health risks of smoking. ID cards could be swiped at stores to limit the number of cigarette packs that could be bought at a time. Two packs a day maximum, say. This would help to minimise a blackmarket of cigarettes being sold on to unlicensed or under-age smokers. And, just as for a driving licence, smokers would need to renew their commitment to smoking every five years."

The Rest of the Story

This is a wonderful idea, but why restrict it just to smoking? There are all sorts of health-related behaviors for which people should be required to have a permit.

First of all, people should have to hold a license to drink. I propose a system of licenses by which you are certified at a certain level of drinks allowed per time period. You have to first take a drinking test to see how well you hold your liquor. Based on your test score, your license then indicates how much you can drink without posing a threat to yourself or others. A doctor would have to certify that you indeed do drink alcohol. Upon entering a bar, the bouncer would check your license and then stamp your hand with the appropriate number of allowed drinks. The bartender would check off your stamps as each drink is served.

Second, if you need a license to fish, you definitely should need a license to become a parent (to borrow a motif from the movie "Parenthood"). A quick parenting test could be required. Baby dummies could be used with real sound effects to simulate the conditions you need to be able to recognize. You should be required to demonstrate your ability to change a diaper while talking on a cell phone and with a dummy toddler in a standing position, useful when you are using your drinking license in a bar with bathrooms that are not baby-friendly.

Prior to your child becoming an adolescent, you would need to renew your parenting license. You would be tested in a simulation in which you would try to conduct a conversation with a testing official who refuses to listen to anything you have to say and doesn't want to be seen in your presence or acknowledge that you exist, except to ask for money to take when he goes out with his testing buddies.

Third, you should need a license to buy red meat. With a doctor's certification, you get a permit that allows you to purchase red meat at the grocery store. However, there is a strict limit of two steaks at a time, to prevent a possible black market for rib eye and rump. Before receiving your license, you would of course be required to pass a test demonstrating knowledge of the harmful effects of eating high amounts of fat.

Licenses to purchase tater tots should also be required, but available only through a highly competitive lottery system.

Fourth, a permitting system should be established for sunbathing. Licenses would be granted only after completing an educational program about skin cancer and methods to help prevent sun exposure.

On a similar note, licenses should also be required to go to a tanning salon. A physician's note as well as successful completion of a course in dermatological oncology would be required.

Restaurants which continue to serve trans-fats should require their customers to hold a permit before ordering any food that contains more than 0.5 grams of trans-fat. A swipe card system could be developed which automatically keeps track of your trans-fat intake for the week. Once you reach the weekly maximum, you would be denied any further trans-fat containing menu items.

Unsafe sex would still be permitted under this system, but would require a license, for which one would need a doctor's note and successful completion of an exam on sexually transmitted diseases. There would also be a weekly partner maximum.

Fat people would need a license to eat out in restaurants, and would have to pass an additional certification exam to eat out at fast food restaurants. A special mark on the license, obtainable only with a doctor's permission, would be necessary to supersize it.

A special thrill-seeking license would be required for activities like bungee jumping, skydiving, rock climbing, sky surfing, and freestyle motocross. Skateboarding permits would be on a graded system, with funbox, grind box, quarterpipe, and halfpipe levels.

Swimming permits would follow the traditional YMCA levels of: guppy, minnow, tadpole, fish, flying fish, and shark.

New Meta-Analysis of Effect of Smoking Bans on Heart Attacks Shows Bias in Tobacco Control Research

A new meta-analysis that is in press at Preventive Medicine purports to show that smoking bans result in a 19% immediate decline in heart attack admissions. The meta-analysis pools data from 8 published studies which have examined changes in heart attack admissions following implementation of smoking bans. The study, funded by the National Cancer Institute, concludes that smoking bans result in an immediate reduction in heart attacks, estimating the drop to be 19%, with a 95% confidence interval of 14% to 24% (see: Glantz SA. Meta-analysis of the effects of smokefree laws on acute myocardial infarction: an update. Preventive Medicine 2008 [in press]).

The Rest of the Story

Unfortunately, a meta-analysis is only as good as the studies that go into it. Since the studies used in this meta-analysis have each been discredited, the meta-analysis is not of particular value. A meta-analysis cannot legitimately show that smoking bans dramatically and immediately reduce heart attacks if the individual studies have no validity in drawing such conclusions because they are based on shoddy science.

So it troubles me that tobacco control researchers would even think of conducting a meta-analysis at this early point in time, when we don't even have a single convincing study to suggest that there is a causal relationship between smoking bans and immediate, dramatic reductions in heart attacks.

But more troubling to me is the fact that researchers would include in a meta-analysis (of the effects of smoking bans on heart attacks) studies in which there is no control or comparison group to determine whether observed changes in heart attacks are merely mirroring trends that are occurring everywhere, despite the smoking ban.

If smoking ban opponents produced economic impact studies using the same methodology (showing that there was a decline in restaurant sales or a decrease in the number of restaurants in a particular location, but not employing a control or comparison location), we in tobacco control would trash those studies, pointing out that without a comparison group, one cannot legitimately demonstrate that the smoking ban was what caused the change in restaurant business.

Professor Glantz certainly understands the importance of a comparison group because in his own study (the Helena study), he used a comparison group of non-Helena residents to make sure that the observed changes in heart attacks that occurred in Helena did not also occur outside Helena.

The authors of the studies in Pueblo and Bowling Green also understood the importance of a comparison group because their conclusions were largely based on the finding of a reduction in heart attacks in those cities which did not occur in the comparison areas (El Paso County and Kent, respectively).

Unfortunately, only 3 of the 8 studies used in the meta-analysis employed a comparison group (Helena, Pueblo, and Bowling Green). The other 5 studies did not have a comparison group (Italy x2, Ireland, Saskatoon, and New York State).

There is simply no way that the studies without any comparison group should have been included in this meta-analysis. I don't believe that an objective scientific approach would allow one to use such studies. How can one possibly know that the observed changes in heart attacks were simply a reflection of changes that were taking place everywhere, or at least in similar, neighboring areas?

You can't possibly know that unless you specifically check for it. And 5 of these studies failed to do that.

The more I examine these smoking ban and heart attack studies, the more I am realizing that tobacco control science has become a very highly biased field right now. The bias is so apparent in these studies that it is practically dripping off the pages. Why peer reviewers of the journals do not pick this up is a mystery to me. One possibility, however, is that it is the same set of also-biased tobacco control researchers who are reviewing these articles.

I would be very interested to see how a statistician or econometrician - someone not associated with the tobacco control movement in any way - would review these studies.

Another major problem with the meta-analysis is that it fails to address the very strong possibility of publication bias. It is very likely that tobacco control researchers have only written manuscripts about this issue when they have found or suspected a decline in heart attacks. There has so far been no systematic study of changes in heart attacks in a number of locations to see objectively whether or not this hypothesis is correct. All the studies have been single-site studies.

I myself have examined the heart attack data throughout the U.S. in a systematic way, and based on my review of these data, I was not able to find any evidence that statewide smoking bans led to a dramatic, immediate decline in heart attack admissions. I suspect that if a systematic study were conducted, it would not find any dramatic effect. I think that publication bias is a severe problem in this situation.

The bottom line is that I think it is far too premature to be conducting a meta-analysis in the first place. But if you are going to conduct one, at least have some decent criteria for inclusion of studies.

The rest of this story is not so much about whether smoking bans affect heart attacks or not. It is more about how investigator bias is creeping into tobacco control research these days. And I'm not sure what can be done to stop it.

More Science by Press Release: Cancer Research UK Touts Effects of England Smoking Ban on Cessation Rates, But Refuses to Release the Study

On Monday, Cancer Research UK issued a press release in which it boasts about the results of a new study which purportedly shows that the national smoking ban in England caused 400,000 people to quit smoking, which will result in 40,000 fewer deaths over the next 10 years.

According to the press release: "Smokefree law in England has helped more smokers to quit than ever before and will help prevent an estimated 40,000 deaths over the next 10 years - according to new research being presented in Birmingham tomorrow (Tuesday). The Smoking Toolkit Study - funded by Cancer Research UK, McNeil, Pfizer and GlaxoSmithKline and presented at the UK National Smoking Cessation Conference - interviewed more than 32,000 people in England over the nine months before and nine months after last year's smokefree law took effect on July 1. The decline in smoking prevalence for the nine months pre-July was 1.6 per cent compared to an impressive 5.5 per cent in the nine months post July. Based on the findings researchers estimate that at least 400,000 people quit smoking as a result of the ban."

These results and conclusions were widely disseminated by the media (article 1; article 2).

The Rest of the Story

The rest of the story is that although Cancer Research UK released its conclusions from the study, it refused to release the actual study itself, including details about the study methodology and results. Thus, there is no possibility for anyone (including myself) to review the methodology and determine whether the conclusions are valid or not.

It is problematic that the study authors will not release the full results because without the full methods and results, it is not possible for others in the field to adequately review the work and assess its validity. I personally feel that researchers should not publicize study findings prior to publication unless they are willing to make the full findings and methods available. Releasing results via press release to the media and the public should not be done until publication, or if it needs to be done before publication, then it should only be done with concomitant release of the entire study.

I have a lot of interesting data about changes in smoking prevalence and quitting myself, but I am not going to release them publicly until after they are published. The problem is that if I release these data without the full study, then no one has an opportunity to review the study. It is very possible that upon peer review, my conclusions might be found to be invalid, or at very least, there might be some changes I need to make in my methods to correct the analysis (this is quite common). But here's the rub: if my results and conclusions have already been disseminated in newspapers throughout the country, it's too late to correct them when the corrected - or valid - results are actually published.

To me, the story here is not so much about quitting rates in England, which we have no ability to evaluate, but instead is about the appropriateness of what I like to call "science by press release," by which I mean trying to communicate important scientific findings to the public via the media, but without making the full methods/results available for scrutiny and review. The problem with this approach is that should the results subsequently be found to be invalid upon peer review, it is too late: the information has already been disseminated.

Interestingly, I have observed this problem most readily with studies of the effects of smoking bans (particularly studies on the changes in heart attacks as a result of these bans). Interested readers may want to see some of the other posts I have written about the hasty conclusions about the effect of smoking bans on heart attacks, as well as the general approach of "science by press release." (post 1; post 2; post 3; post 4; post 5)

Tobacco-Free Kids and Other Health Groups Actively Working to Protect Cigarette Sales; With Enemies Like These, Philip Morris Doesn't Need Friends

According to an article published today in the New York Times, the Campaign for Tobacco-Free Kids, American Heart Association, American Lung Association, and other health groups are actively working to prevent Congress from amending the FDA tobacco legislation to ban menthol flavoring in cigarettes; thus, these groups are working to protect cigarette sales and prevent a potentially significant decline in smoking prevalence, especially in the African-American community.

According to the article: "Some supporters of the bill’s current language on menthol have argued that, because menthol is widely used by many smokers, the effects of banning it outright are hard to predict. Among possibilities they have suggested is that menthol smokers would turn to an illicit cigarette market to obtain menthol cigarettes. In a letter to several lawmakers on June 11, a coalition of health groups, including the Campaign for Tobacco-Free Kids, the American Heart Association and the American Lung Association, reiterated their support for the bill without changes to the menthol provisions. 'The impact of modifying or prohibiting such a large portion of the current cigarette market is unclear,' said the letter, sent to Mr. Waxman as well as John D. Dingell of Michigan and Frank Pallone Jr. of New Jersey, House Democrats who head the Committee on Energy and Commerce and its health subcommittee."

The article also reports that the Congressional Black Caucus is calling for changes in the legislation to address the bill's exemption for menthol, which was inserted into the bill in a deal between Philip Morris and the Campaign for Tobacco-Free Kids in order to appease the financial interests of the nation's leading cigarette company. Philip Morris is the manufacturer of Marlboro Menthol, the 2nd leading menthol cigarette brand on the market.

According to the article, menthol has been used by the tobacco industry to market cigarettes to African Americans since the 1950s. It helps to mask the harsh taste of cigarettes and therefore to facilitate the smoking uptake and addiction process. The Centers for Disease Control and Prevention agrees that menthol might increase tobacco addiction among African American smokers.

The Rest of the Story

What this story shows, first and foremost, is that the Campaign for Tobacco-Free Kids is full of crap.

On the one hand, it argues that we need the FDA tobacco legislation because it will "end special protections for Big Tobacco," "save countless lives," stop consumers from being used as "guinea pigs in the tobacco industry’s deadly science experiments," "limit the industry’s ability to use product design to recruit youth, create and sustain addiction, and discourage smokers from quitting," and put an end to the tobacco industry's ability "to design and market products that recruit new youth users, create and sustain addiction to nicotine, and discourage current users from quitting."

On the other hand, it is actively lobbying to create an unprecedented special protection for Big Tobacco, threaten countless lives, continue the use of African American consumers as guinea pigs in the tobacco industry's deadly science experiments, and maintain the industry's ability to use product design to recruit youth, create and sustain addiction, and discourage smokers from quitting.

In fact, the Campaign for Tobacco-Free Kids is essentially promoting death and disease among African-Americans by interfering with legitimate Congressional efforts to rid the African-American community of the menthol scourge which has been ravishing that community for decades.

The Campaign and other health groups are turning to an interesting excuse for their opposition to the menthol ban: we should not modify a large portion of the cigarette market because the effects are unclear.

But the Campaign and these other health groups have argued that the very purpose of the legislation is to modify the entire cigarette market. If banning menthol is going to create a black market, then so will any of the other changes that the FDA might require. Thus, the Campaign is effectively arguing against the very bill it is supposedly supporting.

The bottom line is that I don't believe for a minute that the Campaign for Tobacco-Free Kids truly believes that the public health community should promote the sale of cigarettes. I believe that the Campaign has simply been cornered into an uncomfortable box, in which it has only two choices:

1. Admit the truth: that the Campaign negotiated this bill with Philip Morris and agreed to the menthol exemption as a favor to Philip Morris in order to maintain the company's support for the tobacco deal; or

2. Come up with some lame excuse for why the Campaign must support the menthol exemption, independent of whether Philip Morris will support the bill or not?

Don't you see that the Campaign has been backed up against the wall? If they admit the truth - that they negotiated the bill with Philip Morris and that the negotiated settlement is a back-room deal, with compromises like the menthol exemption inserted specifically to appease and protect Philip Morris' interests, then the Campaign looks terrible for having negotiated with Philip Morris and for having misled thousands of its constituents - including scores of youths - about the history and nature of this legislation.

On the other hand, if the Campaign tries to come up with a lame excuse to explain why the menthol exemption is mandatory, then it looks terrible for working to protect cigarette sales and interfering with the one aspect of the FDA legislation which probably would improve the public's health and save "countless" lives.

I guess the Campaign judged that the better of two evils was to put out this lame excuse. Or perhaps it actually thought that its constituents are so stupid that they would buy this excuse as being valid.

As Dr. Louis Sullivan said, the excuse is "poppycock." No one is going to buy this lame explanation. It is quite obvious that what is going on here is that the Campaign for Tobacco-Free Kids made a back-room deal with Philip Morris, and part of that deal - a deal-breaker - was that menthol cigarette sales were to be protected by exempting menthol from the immediate ban on "all" cigarette flavorings.

The Campaign is working at all costs to prevent this essential truth from coming to light. Because that truth will not only destroy the FDA legislation, it will also expose the Campaign's dishonesty and deception to all of its constituents and to the public.

The irony here is that the FDA legislation will do absolutely nothing to protect the public's health. It is exceedingly ironic that the only thing the legislation might do that would protect the public's health would be to get rid of the menthol which is contributing to the addiction of millions. This doesn't mean that everyone who currently smokes menthol would quit. But some of them would, and many future smokers would be deterred.

The Campaign is interfering with a legitimate Congressional effort to take the one action which actually might save countless lives.

How ironic that the Campaign is boasting about how the bill is going to get rid of all the candy flavorings which are supposedly a huge problem. Well, why are they such a problem if no one is using them? What is being used, and what is a problem, is menthol, and the Campaign doesn't want Congress to do anything about it, because the sales of a key Philip Morris product would be threatened.

By forging this deal with Philip Morris, the Campaign for Tobacco-Free Kids has ironically now become a key Philip Morris ally in the Beltway.

What a brilliant strategy by Philip Morris. I have to hand it to them. What shocks me is that the Campaign for Tobacco-Free Kids fell for it: hook, line, and sinker.

It was absolutely brilliant. Bring the Campaign on in a back-room deal, and then just sit back and let the Campaign do all your bidding for you. Ironically, Philip Morris doesn't have to do anything to try to get Congress to nix the menthol amendment to the legislation. The Campaign and its friends are doing all that work for them.

Philip Morris need not even waste the ink to type a letter to Congress. The Campaign has now become the protector of Philip Morris' financial interests (because it must preserve "the deal") and the Campaign will do all the dirty work for the nation's leading tobacco company.

If I believed that the Campaign were sincere in truly wanting menthol to remain on the market, I would have to condemn them for promoting disease and death among African Americans, which would be inexcusable and unconscionable.

However, instead, I believe that the Campaign is simply trying to protect itself and to prevent the truth from coming out. In my view, that is ....

....inexcusable and unconscionable.

Action on Smoking and Health Suggests Banning Smoking in All Homes

For the first time, to the best of my knowledge, an anti-smoking group has publicly and officially called for a ban on smoking in all homes, suggesting that this is the next front in the war against smoking.

In a press release issued on Wednesday, Action on Smoking and Health (ASH) - a Washington, D.C.-based national anti-smoking group - called banning smoking in homes the next front in the war on smoking and cited a new survey showing that a majority of people in Ireland expressed support for a total ban on smoking in homes and cars.

According to the press release: "A clear majority wants smoking banned in all homes, even if children are not present, and even if the smoke is not drifting into an adjoining dwelling. This could expand the latest front in the war to protect nonsmokers, says the man who started the nonsmokers' movement by getting smoking first restricted and then banned on airplanes and then in workplaces and public places, and who is racking up victories in the battle to ban smoking in private dwellings and cars. According to a new survey, 57% of the people in Ireland support a ban on smoking in all homes and cars."

"This could indicate growing support for smoking bans both here and abroad, says public interest law professor John Banzhaf of Action on Smoking and Health (ASH) -- America's first antismoking organization, and the group behind restrictions on smoking in homes in almost three fourths of the states -- because the percentage of smokers in Ireland is substantially higher than in the US." ...

"'As politicians in many states continue to debate whether to ban smoking in restaurants, bars, casinos, and other public places, it looks like legislators are once again far behind the growing public sentiment for smoking bans, and also far behind how far judges and regulatory agencies are willing to go,' says Banzhaf. ... Since restrictions of smoking are one of the most effective -- and virtually the least expensive -- way to help smokers quit, it is no surprise that there is growing support for smoking restrictions, even if no nonsmokers' health is being put at risk by the smoking, suggests Banzhaf."

The Rest of the Story

This is an important story and perhaps a sentinel moment in the history of the tobacco control movement because to the best of my knowledge, this is the first time that an anti-smoking group has publicly and officially called for a ban on smoking in all homes and suggested that this is the next front in the war against smoking.

This is a troubling development for many reasons. For one, banning smoking in homes for the purpose of protecting children from secondhand smoke exposure is an appallingly bad place to be in terms of public health policy. It represents an undue invasion of privacy and as well as an unwarranted interference with parental autonomy to make their own decisions regarding health risks to which their children are or are not exposed.

Banning smoking in homes to protect children would be qualitatively no different from prohibiting parents from taking their kids to fast food restaurants, feeding them food containing trans-fats, allowing them to engage in risky activities like ice hockey or football, allowing them to watch violence-ridden movies and play violence-ridden video games, letting them go to R-rated movies, and not forcing them to get enough physical activity.

Clearly, these other behaviors are not ones which society would choose to regulate. Smoking in the home is qualitatively the same. If one supports a ban on smoking in the home in order to protect children's health, then the same reasoning would lead to support for a ban on each of these other parental behaviors, which would clearly be unacceptable.

Second, banning smoking in homes in order to reduce smoking is even less acceptable. That would be a complete invasion of privacy and autonomy. It would represent completely unenlightened paternalism. Public health practitioners need to remember that there are other important values that need to be preserved in society beyond merely getting people to stop smoking. We also need to make sure that our interventions respect individual autonomy, freedom, and privacy. Banning smoking in homes to reduce smoking rates violates all three of these principles.

What scares me most about ASH's latest pronouncement is not merely ASH's support for this policy. I don't think that ASH's support alone would be enough to convince policy makers to enact such policies. However, what scares me the most is that if no other anti-smoking groups speak out publicly to reject ASH's statement, this will become the de facto policy position of the tobacco control movement. And because, as I have learned, dissent is not allowed in tobacco control and you cannot criticize another group in the movement, I fear that no anti-smoking groups will speak out to condemn ASH's support for banning smoking in homes.

I must also say that ASH is making the pronouncements of smoking ban opponents look good. Many years ago, when I was lobbying for smoke-free workplace laws, opponents of these laws argued that this was just the first step: workplaces were the first step and eventually we [the antis] would be trying to get smoking banned in the home. I countered these arguments by stating no - you're wrong - we are going to stop after getting smoking banned in the workplace. Unfortunately, it looks like I was wrong and the smoking ban opponents were correct. Thanks to ASH, all those smoking ban opponents can now say "I told you so."

Why would ASH make a public statement like this? Wouldn't ASH recognize that by doing this, it paints all anti-smoking advocates and groups as being complete fanatics whose ultimate goal is to ban smoking everywhere, even inside the home? Doesn't ASH recognize that its action is going to give smoking ban opponents great ammunition in their fight to oppose these ordinances - that they can now point to ASH's press release as evidence that the ultimate goal of the tobacco control movement is indeed to ban smoking everywhere, including the home?

This action by ASH puts a significant dent in the legitimacy of not only the tobacco control movement, but of public health in general. The only way to prevent damage from occurring would be if the public merely views ASH as a fanatic group that has gone off the deep end. But that will not happen unless other anti-smoking groups are willing to publicly condemn ASH's support for banning smoking in the home. As I don't see that happening due to the poisonous groupthink mentality in the tobacco control movement, I fear that ASH's action will damage the legitimacy of tobacco control.

Finally, I must note that it strikes me that ASH's actions appear to be motivated by something more than simply a concern for the health of smokers. Instead, I get the distinct impression that ASH is acting, at least in part, out of pure hatred for smokers and a desire to punish them. It seems to me like one can feel the hatred oozing out of the press release and that ASH is trying to punish smokers in any way it can find - no matter how much damage that might cause to the children of those smokers or to societal values like privacy and autonomy.

ASH seems to think that it is more important for kids to be protected from even the smell of tobacco smoke on a parent's clothing than for those kids to have a parent to be with in the first place. ASH's priorities are completely out of whack. And unless other anti-smoking groups speak out now, so will - by default - the priorities of the tobacco control movement. In some sense, we are only as strong as our weakest link. By pushing for home smoking bans, ASH is unfortunately painting the entire tobacco control movement as fanatics whose ultimate goal is to ban smoking everywhere. We can't prevent the movement from being successfully painted in that way unless we speak out and distance ourself from that paint brush.


(Thanks to Gilster for the tip).

Health Canada Toolkit Encourages Kids to Create Their Own Smoking-Related Research Facts; However, the Example Given to Guide them is Untruthful

Health Canada has produced a "Smokefree Spaces" activist toolkit to encourage school children in Canada to advocate for smoke-free places in their communities. One of the recommended activities is for the children to produce secondhand smoke-related "research facts" to educate the members of their community.

Health Canada provides the following as an example of a research "fact" that should be used: "A non-smoker in a smoky room, such as a bar, inhales the equivalent of 35 cigarettes an hour."

The Rest of the Story

It is far from a "fact" that nonsmokers in a smoky bar inhale the equivalent of 35 cigarettes an hour. In fact, it is false.

In terms of nicotine exposure, a nonsmoker in a smoky bar inhales the equivalent of less than one-thirtieth of a single cigarette in an hour. So clearly, you cannot accurately claim that a nonsmoker in such a situation inhales the equivalent of 35 cigarettes an hour. You are in fact in error - and by a whopping factor of about 1000. You're off by three orders of magnitude!

It is true that in terms of some smoke constituents - notably NDMA - which is much more concentrated in secondhand smoke than mainstream smoke, nonsmokers in a smoky bar may inhale the equivalent of about 2 cigarettes an hour. But even for NDMA, this "fact" is off by a factor of about 17.

I have no clue where the 35 cigarettes per hour figure comes from, but it is undoubtedly inaccurate. Even if one excludes from consideration all other constituents than NDMA - which is highly misleading - this statement is not accurate. But since the statement refers to overall exposure and not a particular constituent (it doesn't mention any particular constituent), it doesn't even come within a factor of 17 of being correct.

It is just inaccurate to assert that being exposed to tobacco smoke in a smoky bar for an hour is equivalent in terms of exposure to actively smoking 35 cigarettes.

And it is also irresponsible. This undermines the hazards of active smoking. Do we really want smokers to believe that smoking close to 2 packs of cigarettes per day is no worse than sitting in a smoky bar for an hour (and not smoking)?

So this "research fact" turns out not only to be false, but also to send a message that undermines decades of education about the severe hazards of smoking. If the children of Canada actually follow Health Canada's advice and disseminate this message, it may well undermine the government's important health message about the severe hazards of active smoking.

After all, if I were an active smoker of about 2 packs per day and I found out that my smoking was no worse than being a nonsmoker in a bar for an hour a day, I would conclude that the health effects of smoking are not as bad as they were made out to be.

This message, then, could actually inhibit efforts to promote smoking cessation.

I don't understand why Health Canada needs to use a false piece of information as an example to children. Are they trying to encourage students to exaggerate and distort the facts as anti-smoking groups are known to do? Are they honestly not aware that sitting in a bar for an hour is not the same thing as actively smoking 2 packs of cigarettes per day? Do they sincerely believe that the exposure in these two situations is identical? Or have they just been sloppy and not really thought about it?

I don't know the answer, but the question is quite clear: why is Health Canada providing a piece of false information to children and encouraging them to disseminate this information?

Incidentally, I am in a decent position to criticize this statement, since I myself have made statements about the cigarette equivalents of secondhand smoke exposure. However, in doing so, I have always been careful to specify exactly what constituent I was talking about. For example, if data shows that working in a smoky bar for 8 hours produces the same NDMA exposure as actively smoking one pack of cigarettes, then I have made it clear that NDMA exposure is what I am talking about. I have never suggested that secondhand smoke exposure for eight hours in a smoky bar is equivalent in terms of exposure to actively smoking a pack of cigarettes.

For a more detailed discussion of the dangers of using cigarette equivalents and the misleading health claims by numerous other health and anti-smoking groups, see my previous post.


(Thanks to Ann W. for the tip).

Authors of Flawed Study to Smoking Parents: If You Don't Want to Quit, Don't Bother Being Careful to Smoke Outside the Home; It Won't Help

The authors of the study discussed here yesterday which concluded that parents who smoke only outside the home still expose their children to dangerously high levels of tobacco smoke have instructed the public that there is no reason to smoke outside in an effort to protect children from secondhand smoke. As quoted in an article in the Victoria Herald-Sun, the authors told the public that smoking outside the home is pointless; the only way to protect children from tobacco smoke exposure is not to smoke at all.

According to the article: "Lead researcher Dr Krassi Rumchev said when smokers returned indoors, they still breathed out smoke that contaminated the air enough to cause damage. They also brought particles inside on their body and clothes. Dr Rumchev said parents must quit to make their home safe for children. 'If parents would like to provide a smoke-free home environment they have to stop smoking,' Dr Rumchev said. 'Smoking outside just isn't providing the protection that many Australian smokers believe it does.'"

The Rest of the Story

As I explained yesterday, this study is severely and fatally flawed because no effort was made to confirm the self-reported assertions of parents that they only smoke outside the home. The most likely explanation of the study results is not that outdoor smoking causes indoor exposure because of contaminat