Camel No. 9 Cigarettes Being Targeted for Removal from the Market

The American Legacy Foundation and a group of health and anti-smoking groups has called upon R.J. Reynolds Tobacco Company to remove its Camel No. 9 cigarettes from the market, on the grounds that the tobacco company should not target particular populations for death and disease.

According to a letter sent from the American Legacy Foundation and 48 co-signers to R.J. Reynolds chairman Susan Ivey: "As public health and women's health leaders, we are incensed by your latest shameful new cigarette brand, Camel No. 9, and your offensive ad campaign for this brand. This campaign is nothing more than a veiled attempt to sell more cigarettes to girls and young women, putting them at grave risk for disease and a premature death. In the wake of the Camel No. 9 launch, more than 40 Members of Congress have called on women's magazines to refuse cigarette advertising aimed at young women. We join their appeal and go a step further in calling for Camel No. 9's complete removal from the marketplace."

The letter concludes: "As individuals and organizations dedicated to improving the health and welfare of our citizens, we call on you to stop enticing our nation's young women and girls to serve as your replacement smokers. Stop designing products targeting particular populations for death and disease. Remove Camel No. 9 from the market today."

The co-signing organizations include the Campaign for Tobacco-Free Kids, American Cancer Society, American Heart Association, American Medical Association, American Public Health Association, and Americans for Nonsmokers' Rights.

The Rest of the Story

And the reason why Camel No. 9 cigarettes, with virtually no market share among female adolescents, should be removed the market but all other Camel brands, which command 5% of the female youth market, should not be removed from the market is...?

And the reason why Camel No. 9 cigarettes, with virtually no market share among female adolescents, should be removed the market but Marlboro cigarettes, which command 40% of the female youth market, should not be removed from the market is...?

And the reason why Camel No. 9 cigarettes, with virtually no market share among female adolescents, should be removed the market but Newport cigarettes, which command 12% of the female youth market, should not be removed from the market is...?

Do you mean to tell me that Camel No. 9 advertisements entice teenage girls to smoke but Marlboro ads do not?

Do you mean to tell me that Camel No. 9 advertisements entice teenage girls to smoke but other Camel ads do not?

Do you mean to tell me that Camel No. 9 advertisements entice teenage girls to smoke but Newport ads do not?

I apologize, but the rationale for selectively calling on the removal of Camel No. 9 cigarettes from the market escapes me. If anything, wouldn't we want to call for the removal of the products that are actually enticing, addicting, and eventually, killing our girls and young women? Camel No. 9 is currently the least of the offenders. Marlboro is the worst. Why should Marlboro go unscathed while Camel No. 9 faces this vicious, coordinated attack?

Once again, I get the feeling that anti-smoking groups are taking the politically easy action of going after the least significant aspect of the problem. Why not go after a brand that is not currently the problem, while ignoring and essentially condoning the effects of brand which are actually enticing girls to smoke? This is kind of like banning smoking in cars but allowing parents to smoke as much as they want, for as long as they want, around their children in the home.

Don't get me wrong. I'm not calling for the removal of all cigarettes smoked by youths from the market. In fact, I'm not calling on the removal of any cigarettes from the market. To me, they are all the same. They all kill people. They all use advertising. Most of them are successful in getting youths to smoke their brands. They all target specific groups in the population.

It was never clear to me, by the way, why targeting one particular group for death and disease is worse than targeting some other demographic group. Or why targeting the general population for death and disease would somehow make us feel better. Frankly, if cigarette companies only targeted males, it wouldn't make me feel much better.

I actually agree with R.J. Reynolds when it argues that it should be targeting whatever adult customers it wants to. No cigarette companies should be targeting youths. But if customers are of legal age, I don't see why they should not be able to go after those customers. It certainly is their First Amendment right to do so.

I don't see the problem as being the targeting of any particular adult customers. I see the problem as being that cigarettes are a deadly product. The gender and race/ethnicity of the people dying are not what makes it a tragic situation. What makes it a tragic situation is that people are dying.

I agree that the targeting of youths is unacceptable. But it makes no sense to me to single out Camel No. 9 for its appeal to youths when we know for a fact that Marlboros are by far the cigarettes that have the greatest appeal to youths. And Newports are the brand with the second greatest appeal to youths. In fact, non-Camel No. 9 cigarettes are currently the brand with the third greatest appeal to youths.

While actions like this one by the American Legacy Foundation gain headlines and sound great on the surface, what they are actually doing, I fear, is to frame the problem as being one only of extremes. The problem is being framed essentially as the use of the color pink in advertising. This is a very shallow definition of the problem. There is a wide variety of advertising that appeals to youths. Clearly, Marlboro ads have been the most successful; Newport ads have been tremendously successful; and Camel ads - without the pink color - have been extremely successful in recruiting youth smokers.

It is this kind of shallow thinking and framing of the problem of cigarette use that is reflected in the legislation being supported by most of these same groups: legislation which concerns itself with banning chocolate, strawberry, and cherry flavorings - which are not being used at all - but allowing menthol - which is enticing millions of youths and adults to smoke - to remain untouched.

This approach makes no sense to me. It is basically window dressing. It gains media attention, sounds great on the surface, and allows these groups to say that they are doing something about the problem. However, if you look below the surface, you'll see that these are shallow approaches that really fail to address the underlying problem. But they feel good and they are politically popular.

This tale of protest against Camel No. 9 cigarettes is certainly full of sound and fury, but I'm afraid that it really signifies nothing.

Religious Groups Take Hypocritical Stand on FDA Tobacco Legislation

According to an article in today's Winston-Salem Journal, a group of religious leaders - working under the coalition name Faith United Against Tobacco - has declared that enacting the proposed FDA tobacco legislation is a "moral imperative."

According to the article: “'Every day we must bury mothers, fathers and sisters and brothers who die early from preventable deaths caused by tobacco addiction that more often than not began at a relatively young age,' said Land, the president of the Baptist convention’s Ethics and Religious Liberties Commission. 'It is morally wrong to know the good that should be done and not to do it.'”

According to the article, the American Heart Association added: "The bill would significantly increase the number of smokers who quit and reduce harm to those who are unable to quit."

The Rest of the Story

I think it's a mistake to make a moral issue out of this.

You want to talk ethics - what about the ethics of religious leaders standing together to back the attempt of the nation's largest cigarette company to pull the wool over the eyes of the public?

What about the ethics of supporting a bill that provides unprecedented special protections for Big Tobacco by precluding the FDA from taking any of the few possible actions it could take to actually prevent the death of our mothers, fathers, brothers, and sisters:

• removing the nicotine from cigarettes;
• making cigarettes available on a prescription-only basis;
• raising the legal age of purchase of cigarettes;
• regulating the places where cigarettes can be sold; and
• eventually banning cigarettes altogether.

If it is truly unethical to "know the good that should be done and not to do it,” then how could these religious leaders possibly support a bill that includes these loopholes that were inserted specifically to protect the profits of Philip Morris and other tobacco companies at the expense of the public's health?

Do the religious leaders not know the good that should be done by removing each of the above provisions from the proposed legislation? Do the religious leaders not recognize the harm that is done by not allowing the FDA to remove nicotine completely from cigarettes? Do they not recognize the harm that is done by not allowing the FDA to make cigarettes available on a prescription-only basis? Do they not recognize the harm that is done by tying the FDA's hands in increasing the legal age of purchase of cigarettes? Do they not recognize the harm done by not allowing the FDA to regulate where tobacco is sold, even at youth community centers?

Don't get me wrong. I'm not arguing that the FDA should do these things right now. However, I am calling these groups on their hypocrisy.

If it is indeed morally wrong to know what should be done but not to do it, then it is morally wrong to know that all these loopholes are present in the bill, and not to demand that they be removed.

Perhaps the religious leaders have not actually read the bill. Perhaps they have merely bought all the rhetoric put out by the Campaign for Tobacco-Free Kids. Perhaps they are not aware of the fact that the bill represents the result of a negotiation between Philip Morris and the Campaign for Tobacco-Free Kids.

If so, then this is an embarrassment at the hands of the Campaign for Tobacco-Free Kids. But it also seems rather irresponsible to support a complex, major piece of legislation like this without having read it.

If they are aware of this fact and the presence of loopholes that are present for no reason other than to appease Philip Morris, then it is unconscionable, based on the religious groups' own stated principles, that they would support this legislation.

Thus, the religious groups are guilty - at best - of irresponsibility in not having read the legislation. At worst, they are guilty of hypocrisy for claiming that it is unethical not to support the strongest possible legislation against Big Tobacco, but then going ahead and pushing forward a bill that has numerous serious loopholes which were inserted specifically to protect Big Tobacco and which have no public health justification whatsoever.

Don't give me a song and a dance about burying all of our mothers and fathers and brothers and sisters and then come out and support a bill which allows the tobacco companies to continue killing our mothers and fathers and brothers and sisters.

If you're going to play the "burying our mothers and fathers" card, then at least have the decency to support a bill which would actually stop the cigarette companies from killing our mothers and our fathers, not a bill which Philip Morris essentially wrote in such a way that it could continue killing our mothers and fathers and could in fact work towards achieving a monopoly in this killing of our mothers and fathers.

Incidentally, the Enzi bill, in my opinion, does just that (actually makes a dent in the cigarette companies' ability to continue addicting and killing large numbers of Americans). It's quite interesting, then, that the leaders of the faith community are supporting the Kennedy bill (which protects Philip Morris by tying the hands of the FDA) rather than the Enzi bill (which drives a stake through the financial heart of the tobacco industry).

While a group might legitimately respond by stating that the Enzi bill doesn't have a chance of passage, and so it makes sense to support a weaker bill, the religious groups have lost that explanation by their insistence upon making this an issue of moral imperative. That's why I think they made a big mistake in playing the religion card on this largely political issue.

Finally, the American Heart Association states that the legislation "would significantly increase the number of smokers who quit and reduce harm to those who are unable to quit."

I have just one question: ..........................................................................................how?

How will the bill significantly increase the number of smokers who quit? It doesn't increase the tobacco tax. It doesn't fund an anti-smoking media campaign? It doesn't restrict cigarette advertising to adults? It doesn't limit the availability of cigarettes. It doesn't change social norms with regards to smoking. So exactly how is this bill going to increase the number of smokers who are going to quit?

In contrast, I believe the bill will actually greatly reduce the number of smokers who will quit. It will do so by giving an FDA seal of approval to cigarettes, making the public think that cigarettes have been made safer or at least that they are under the capable jurisdiction of the FDA, and undermining years of public health efforts to convince the public of the tremendous health hazards of smoking.

Also, how will the bill "reduce harm to those who are unable to quit?"

Name one change in cigarette design, ingredients, components, etc. that you assert will make the nation's cigarettes safer to smoke.

Anybody? Anybody? AHA? ACS? ALA? TFK? AMA? APHA? Religious leaders?

It's Time to Debate: Two Questions Car Smoking Ban Proponents Must Answer

An article published Saturday in the Vancouver Sun states: "It's time to debate a ban on smoking in vehicles carrying children." In that light, the editorial discusses one of the central issues in such a debate: what health risks to children are the proper subject of government intervention?

The editorial ends up taking the side of car smoking ban proponents, arguing: "After all, if we can through government regulation increase the chance that children will grow up to become healthy adults, why not do so?"

However, the editorial also acknowledges that "smoking in cars is not the only thing parents do that can be construed as harmful to their children. Smoking in the home is another. As are allowing them to eat junk food or to become obese through poor diets and a lack of exercise. How about regulating the amount of time children spend in front of a computer or watching television? It's not easy to make hard and fast rules about when the right of parents to raise their children as they see fit should be overruled by the state."

The Rest of the Story

I found it fascinating to read this editorial. It raises what I think is a profound and critical question about the difficulty of setting rules about when the right of parents to raise their children as they see fit should be overruled by the state. But that's not what was fascinating to me.

What was fascinating was the fact that after raising this important question, the editorial concludes, without any reasoning given, that of all the examples it provides, smoking in cars should be outlawed, but none of the other parental behaviors that the editorial acknowledges harm children.

It's like pulling a rabbit out of a hat. All of the behaviors are listed which are similar in that they are all examples of parents harming their children. But the conclusion is that - magically - only smoking in a car ought to be regulated.

I agree with the editorial that "smoking in cars is not the only thing parents do that can be construed as harmful to their children. Smoking in the home is another. As are allowing them to eat junk food or to become obese through poor diets and a lack of exercise. How about regulating the amount of time children spend in front of a computer or watching television?"

So if that's the case, then shouldn't we also be supporting laws that would ban smoking in the home, prohibit feeding children excessive junk food or failing to provide them with enough opportunities for exercise, and regulate the amount of time that parents can allow their children to sit in front of a computer or watch television?

If it is true that the chief criterion for evaluating a policy proposal is whether or not "we can through government regulation increase the chance that children will grow up to become healthy adults," then why not promote these other measures, such as a ban on smoking in homes, as well?

I have been trying for some time to initiate a debate within the tobacco control community about this very issue. However, so far, anti-smoking groups which support car smoking bans have not been willing (or able?) to answer the following two questions which I think are critical to the discussion:

1. If it is true that smoking around children in cars is intolerable and must be prohibited and that government intrusion into parental autonomy and privacy in their cars is justified, then why should we not also prohibit smoking around children in the home, or in other locations besides a car?

2. If it is true that the government is justified in interfering with parental autonomy in order to merely protect children from an increased risk of adverse health outcomes, then why should we not also prohibit a host of other parental behaviors that cause significant harm to children's health, such as feeding them food with trans-fats, relentlessly feeding them excessive junk food, and allowing them to engage in health-risky behaviors such as rollerblading, playing hockey, or sitting all day at the computer and television screen?

It is time for this debate. I look forward to hearing from the other side. I'd love to be able to be talked out of my current position.

The Science Doesn't Matter: All Three Anti-Smoking Groups Fail to Defend or Correct their False Claims About Acute Cardiovascular Effects of ETS

One week ago, I discussed a new research article showing that eating a single high-fat meal causes the same degree of endothelial dysfunction as 30 minutes of exposure to secondhand smoke. In light of these findings, I questioned the widespread assertions by a large number of anti-smoking groups that 30 minutes of exposure to secondhand smoke causes hardening of the arteries, atherosclerosis, heart disease, decreased coronary artery blood flow, strokes, heart attacks, and death. After all, based on this new research, there is no reason to view 30 minutes of secondhand smoke any differently than we would view eating a high-fat meal.

While the research shows that a high-fat meal can cause endothelial dysfunction and therefore trigger the initial stages of atherosclerosis, it clearly takes many high-fat meals, eaten for years and years, before atherosclerosis, heart disease, decreased coronary blood flow, strokes, heart attacks, and death ensue.

But for some reason, the anti-smoking groups are taking the identical evidence with respect to secondhand smoke and concluding, instead, that a single 30-minute exposure to secondhand smoke can and does cause these consequences.

Last Monday, I challenged three of the anti-smoking groups which are most responsible for spread of these fallacious claims to either defend these claims, explaining how they could possibly be correct, or to issue retractions or corrections of their public claims, thus instructing other groups nationwide to do the same.

In response to my questioning of the scientific validity of these claims, I was personally attacked. However, none of the three groups either defended their claims or retracted, corrected, or clarified them.

The groups and their claims are as follows:

1. American Cancer Society - "Immediate effects of secondhand smoke include cardiovascular problems such as ... arteriosclerosis (hardening of the arteries) or heart disease..." (link is here).

2. TobaccoScam - "30 minutes exposure = stiffened, clogged arteries" (link is here).

3. Americans for Nonsmokers' Rights - "Just thirty minutes of exposure to secondhand smoke can cause heart damage similar to that of habitual smokers" (link is here).

The Rest of the Story

Before commenting on the lack of a substantive response from any of the anti-smoking groups, let me first try to show why each of the three claims is absurdly false on its face (without even needing to be an expert in vascular biology).

1. The American Cancer Society claims that atherosclerosis is an "immediate effect" of exposure to secondhand smoke. Fortunately, it is medically impossible for a brief exposure to secondhand smoke (or even primary smoke) to immediately cause heart disease. Can you imagine how many people would be walking around with hardened arteries if all it took was a single brief exposure? Clearly, the American Cancer Society's statement is false. Atherosclerosis takes many years to develop. Even in active smokers, it takes no less than about 20 years of exposure before heart disease develops. So how could heart disease be an immediate effect of secondhand smoke exposure?

2. TobaccoScam claims that 30 minutes of secondhand smoke exposure results in clogged arteries. Again, the process of artery clogging is not one that occurs in minutes. It takes many years of exposure in order for the process of atherosclerosis to occur to the extent that an artery becomes clogged. Even in active smokers, it takes no less than about 20 years of exposure before their arteries even begin to become clogged. So how could this occur after just 30 minutes of secondhand smoke exposure?

3. Americans for Nonsmokers' Rights claims that 30 minutes of secondhand smoke exposure causes heart damage similar to that seen in active smokers. First of all, if 30 minutes of secondhand smoke causes heart damage, then certainly it would have been unethical for Otsuka and colleagues to have exposed their research subjects to secondhand smoke. You cannot knowingly expose research subjects to something that is likely to cause heart damage. If ANR is correct, then I sure hope that Otsuka and his colleagues have very good lawyers to protect them from malpractice lawsuits. Second of all, the heart damage that is seen in active smokers is due to heart attacks from smoke-induced atherosclerosis. So ANR is implying that this same process of atherosclerosis, heart attacks, and heart damage can occur from 30 minutes of secondhand smoke. That is an absurd claim because it takes years for the atherosclerotic process to take place to such a degree that a person suffers a heart attack and heart damage.

Despite my attempts, for over a year now, to generate some discussion within the tobacco control movement about the scientific validity of the statements we are making to the public, it is now apparent to me that none of these organizations care.

You see - after this experience, it has become clear to me: the science doesn't matter.

Our cause is a good one; therefore, it doesn't really matter whether or not the science supports the specific claims that we are making. We are trying to save people's lives. We are doing this, ultimately, for the children. Thus, we don't need to defend our claims against legitimate scientific challenges.

It's clear to me now that to the anti-smoking groups, it doesn't matter whether I am right or wrong. There is no need to defend the claims if they are right. There is no need to retract the claims if they are wrong. There is no need to clarify the claims if they are technically accurate, but misleading. It just doesn't matter. The overall goal is a noble one, so it doesn't matter if we forget to dot a few "i's" and cross a few "t's" along the way. Any of our inaccuracies pale in comparison to those of the tobacco industry anyway. In the end, this is good versus evil and if good needs a little help from some stretching of the science, so be it.

My mistake all along has been thinking that the tobacco control movement and its organizations actually care about their scientific integrity. Because I thought that they truly cared, but for some reason were just not able to see the truth about these particular statements, I was able to convince myself for nearly two years that if only I kept bringing this to these groups' attention, they would eventually attend to either invalidate my arguments or to clarify, correct, or retract their claims. I thought they would do this because they really cared about their scientific integrity...because they really had scientific integrity.

Now I realize my flaw all along was that I made a false assumption. I assumed that these groups had scientific integrity and truly cared about it.

I was wrong.

The only thing that matters is the ends to which these groups are working. How they get there is of no particular consequence. If it means stretching the science, so be it. No group would have the integrity to admit making a mistake and to correct it. It simply is not in the playbook.

It is the playbook of a crusade, not of a science-based public health movement.

Staten Island Advance Op-Ed Argues that Smoking Around Children is a Form of Child Abuse

In an op-ed column published Tuesday in the Staten Island Advance, New York family court Judge Daniel Leddy argues that smoking around children is a form of child abuse because it causes a protracted impairment of an exposed child's lung function. Further, he argues that New York City should adopt a bill introduced by Councilmember James Gennaro which would prohibit smoking in cars when minors are present because it would simply ensure that this form of abuse is not allowed.

According to Judge Leddy: "Abuse is more serious than neglect, although either can result in the removal of a child from his parents. The distinction generally rests on the nature of the injuries sustained by the child or the potential injuries of which he was placed at risk. To constitute abuse, they must involve a "protracted impairment" of physical health or a "protracted impairment of the function of any bodily organ." Because of the long-term implications for even healthy children, it could well be argued that parents who expose their children to secondhand smoke subject them to both a substantial risk of a protracted impairment of their health, and a protracted impairment of the function of their lungs. ... Gennaro's proposal thus complements existing New York State law insofar as it would require parents to protect their children from this preventable health hazard. Privacy concerns about his proposal do not withstand scrutiny."

The Rest of the Story

There are two serious flaws in Judge Leddy's argument.

First, it is not true that healthy children exposed to secondhand smoke necessarily suffer protracted impairment of their lung function. It is certainly a risk of exposing a child to secondhand smoke, but exposure does not necessarily translate into harm. It translates into an increased risk of adverse effects on lung function. Specifically, childhood secondhand smoke exposure increases the risk for asthma and for decrements in lung growth and function. But risk is not the same as harm, and as Judge Leddy himself acknowledges, to be a form of child abuse, smoking around children would have to result in protracted harm.

I think it would be a grave mistake to consider smoking around children to be a form of child abuse. If we deem as child abuse the failure to protect one's child from exposures that merely increase the risk of adverse health consequences, then there is a long list of parental behaviors that would fall into the category of child abuse. These include the following behaviors, each of which represents a failure on the part of parents to protect their children from exposures which significantly increase the risk of potentially serious adverse health consequences:

• repeatedly feeding your child high-fat, high trans-fat, fast foods and sweetened juices and soda;
• allowing your child to watch hours and hours of television every day, get no exercise, and take part in no physical activities;
• allowing your child to play hockey;
• allowing your child to drink alcohol; and
• allowing your child to drive in a car late at night.

In addition to placing a host of common parental behaviors that put their children at increased risk of severe health consequences into the category of child abuse, one has to ask the question: Does it really protect healthy children to allow the government to take them away from their parents in order to protect them from secondhand smoke exposure? Is it somehow more beneficial to deprive a child of their parents than to allow the child to be at increased risk of ear infections? If we treat smoking as a form of child abuse, this is exactly the judgment we are making.

The second flaw is the argument is that the characterization of smoking around children as child abuse justifies a law which bans smoking in cars with children present. If, as Judge Leddy argues, exposing children to secondhand smoke is child abuse, then it is abusive whether it takes place in a car or in the home. If smoking around children really is child abuse, then there is nothing to justify the argument that smoking around a child is acceptable in the home, but not in a car. If privacy concerns truly do not withstand scrutiny, then there is no justification for not interfering in the home as well as in the car to "further children's legitimate right to an environment that safeguards their health and promotes their wellbeing."

In fact, it seems that if one truly believes that smoking around children is child abuse and that privacy concerns do not withstand scrutiny, then it becomes unconscionable that the New York City Council would fail to protect children from exposure to secondhand smoke in the home. And it should be noted that exposure in the home is by far the predominant source of children's tobacco smoke-related health problems. Car exposure does not even begin to compare to home exposure.

If New York City lawmakers are sincerely concerned about protecting children from the hazards of secondhand smoke exposure, then they must have the courage to face the difficult issue of household secondhand smoke exposure. There are a number of interventions, short of removing children from homes and criminalizing their parents, which have proven to be effective. Programs that educate parents about these hazards, encourage them to smoke outside, and provide financial support and services to actually help parents quit smoking are reasonable measures. But treating smokers as child abusers is neither justified nor wise.

American Legacy Foundation Condemns Magazines for Running Camel No. 9 Ads, But Fails to Put Money Where Its Mouth Is

The American Legacy Foundation is spearheading a campaign which condemns magazines for running Camel No. 9 cigarette advertisements and calls for those magazines to refuse to publish such advertising. Legacy, along with a number of other medical and health groups, claims that the advertising is directly targeted to teenage girls and young women.

According to an American Legacy Foundation press release: "More than 45 groups dedicated to protecting and improving women’s health are calling for R.J. Reynolds Tobacco Company to remove its Camel No. 9 cigarettes from stores across the nation. With its stylish packaging and advertising featuring black, bright pink and teal colors, a female-friendly design motif and a name evocative of women’s fashion icons, Camel No. 9 is directly targeted to teenage girls and young women. The impact of Camel No. 9 advertising and packaging on young women is a serious public health threat. In the wake of the Camel No. 9 launch, more than 40 members of Congress called on women’s magazines to refuse advertising for this product, because the members see such ads as direct attempts to attract girls and young women to smoking. On August 1, 2007, members of Congress sent a follow-up letter to leading women’s publications, urging them to consider to “voluntarily adopt an institutional policy of rejecting cigarette advertising aimed at young people” and asking for a response by August 15."

In a letter sent by the American Legacy Foundation to R.J. Reynolds, the Foundation complains that: "ads for the brand are being run in fashion magazines, like Vogue and Cosmopolitan, that have millions of young female readers."

The Rest of the Story

The rest of the story is that while the American Legacy Foundation's mouth is busy complaining about how Vogue and Cosmopolitan are carrying these malicious advertisements which are directly targeting girls, the Foundation has done something very different with its financial interests: maintained a corporate partnership with these very magazines.

According to its website, the American Legacy Foundation has honored Vogue and Cosmopolitan with a corporate partnership: Legacy listed Conde Nast Publications - the publisher of Vogue - and the Hearst Corporation - publisher of Cosmopolitan - as being its corporate partners.

According to a Legacy report, the Foundation reaped a significant financial benefit from these corporate partnerships: substantial advertising discounts in these companies' magazines.

So the truth of the matter is that the American Legacy Foundation is (or at least was - the Foundation is now hiding the identity of its corporate partners) a corporate partner of the very companies which are carrying these supposedly despicable Camel No. 9 advertisements to our nation's girls.

If Legacy were sincerely interested in ending the advertising of Camel No. 9 cigarettes, I should think that the first thing it would do is to end its corporate partnership with Hearst and
Conde Nast (and do so in a very vocal manner), or at very least, to issue an ultimatum to these companies that they either halt the advertising of Camel No. 9 cigarettes or Legacy will end its partnership and stop honoring these companies as public health contributors.

While Legacy is easily able to write a stinging letter demanding that magazines cease their advertising of Camel No. 9, it does not appear to be so willing to risk its financial benefits by threatening or ending its corporate partnership with the very same magazines.

Interestingly, while Legacy mentions that Vogue and Cosmopolitan are carrying the Camel No. 9 ads, it is careful not to mention the names of the companies that publish these magazines. Apparently, this is one benefit of a corporate partnership with Legacy: protection from public criticism.

The point of this post is not, by the way, to comment on the Camel No. 9 product or its advertising. What I am addressing here is what I see as the lack of integrity of a major national anti-smoking group.

Campaign for Tobacco-Free Kids Again Deceives the Public About FDA Tobacco Legislation; Honesty is Apparently Not Possible

In a press release last Thursday, the Campaign for Tobacco-Free Kids once again deceived its constituents and the American public by stating that the proposed FDA tobacco legislation would require the tobacco companies to reduce or remove the harmful ingredients in their products.

According to the press release: "Legislation pending in Congress would ... require that tobacco companies disclose the contents of tobacco products and reduce or remove harmful ingredients."

The Rest of the Story

The truth is that the legislation does not require tobacco companies to reduce or remove the harmful ingredients from their products. What it does is give the FDA the authority to require the reduction or removal of select, specific constituents in tobacco products. It is grossly deceptive to tell the public that the legislation requires companies to reduce or remove harmful ingredients from their products. In fact, the legislation specifically provides Congress with veto power to ensure that the tobacco industry retains the political power to block any FDA requirement for the removal of harmful ingredients that it does not like.

There is a huge difference between legislation which requires tobacco companies to reduce or remove harmful ingredients from their products and legislation which gives the FDA the authority to require changes in product ingredients.

The difference is one between telling the truth and massively deceiving the public. Despite this being pointed out to the organization, it continues to be dishonest about the nature of the legislation. In my view, the Campaign for Tobacco-Free Kids does not seem capable of being honest about the legislation.

Perhaps that is the strongest argument yet for opposing this legislation. If it is so bad that telling the truth about what the legislation does is too risky, then it seems there is very little reason to support such a bill. If telling the public the truth about the bill would result in losing support for it because the public would realize that it is not as strong as we are being told, then perhaps the bill is so weak that there is no reason to support it in the first place.

I have come to the conclusion that the Campaign for Tobacco-Free Kids is either unable to tell the truth or is uninterested in being truthful about this legislation.

The Campaign is doing exactly what the tobacco companies did for years: deceiving the public in order to gain public support for its policies.

The sad thing is that while the tobacco companies appear to have largely discontinued this practice, the Campaign has taken over the practice and put it in full swing.

I guess that's one advantage of fighting an opponent for so long. You can start to borrow pages from their playbook and use them to your advantage.

And of course, the ultimate irony is that the Campaign claims that this legislation is necessary specifically to stop the tobacco companies from deceiving the public.

Would somebody please introduce some legislation to stop the Campaign for Tobacco-Free Kids from deceiving the public? I don't think I can stand it any longer to wake up every morning and find yet another deceptive communication coming from a supposed leader in the tobacco control movement.

TobaccoScam Responds with Attack, But Does Not Address Substance of Criticism of Its Claim that 30 Minutes of Secondhand Smoke Exposure Clogs Arteries

I had planned to wait until Friday to report back on responses I received to my post criticizing certain claims made by three prominent anti-smoking groups regarding the acute cardiovascular effects of secondhand smoke. However, the first response I received is too important to pass up.

TobaccoScam responded yesterday with the following statement, which was sent to thousands of tobacco control advocates worldwide:

"The finding of similar changes in endothelial function with a high cholesterol load is not new. It just shows that the high oxidant load has effects similar to SHS (which is probably also acting, at least in part through the oxidant load in the smoke). We published the first paper on this over ten years ago, when I was an associate editor of the Journal of the American College of Cardiology. (The "intervention" there was an Egg McMuffin.)

In addition to the acute effects, the associated insult to the vascular endothelium is important for the long-run development of atherosclerosis.

Mike's comments are further evidence that he just does not understand modern vascular biology."

The Rest of the Story

The issue at hand, however, is not vascular biology. The issue is the clinical significance of that vascular biology.

I am not contesting the vascular biology itself, which is quite clear: brief exposure to secondhand smoke, like eating a high-fat meal, induces endothelial dysfunction, as measured by a reduction in endothelial-dependent flow-mediated dilatation.

What I am contesting is the conclusion that this transient alteration of endothelial dysfunction caused by a brief exposure to secondhand smoke results in clogged arteries, narrowed arteries, heart disease, stroke, and heart attacks.

Certainly, with respect to the endothelial dysfunction caused by eating a high-fat meal, we do not conclude that eating a meal at McDonalds results in clogged arteries, narrowed arteries, heart disease, stroke, and heart attacks. So how can we make the same claim with respect to secondhand smoke?

Actually, I agree completely with TobaccoScam that there are similar changes in endothelial function that occur with a high cholesterol load and with brief secondhand smoke exposure. I also agree that the high oxidant load presented by a high-fat meal has effects similar to secondhand smoke, which is probably also acting, at least in part, through the oxidant load in the smoke. And further, I agree that the associated insult to the vascular endothelium is important for the long-run development of atherosclerosis.

However, the point of contention here is not whether secondhand smoke impairs endothelial dysfunction or whether it causes heart disease. The point of contention is whether 30 minutes of exposure to secondhand smoke clogs arteries, causes hardening of the arteries, results immediately in heart disease, and causes strokes and heart attacks.

And rather than address these critical issues, TobaccoScam has chosen instead to attack me and my knowledge of medicine, rather than to discuss and defend its claims that brief secondhand smoke exposure clogs arteries, inducing heart attacks and strokes.

In fact, anyone familiar with my commentaries or research will know that I have clearly stated my belief that chronic secondhand smoke exposure is a cause of heart disease. I think the evidence on this point is quite strong. I also think the evidence that there is acute impairment of endothelial dysfunction (as well as activation of platelets and other adverse physiologic changes) is also strong.

However, what is not strong is the evidence that the transient impairment of endothelial dysfunction induced by brief exposure to secondhand smoke results in clogging of the arteries which therefore causes heart attacks and strokes.

In fact, it is not only the case that there is not strong evidence that the transient impairment of endothelial dysfunction results in clogged arteries and heart attacks, but it is medically implausible that such an effect could happen in a healthy person. As I have pointed out repeatedly, the process of artery clogging (atherosclerosis) does not occur quickly. It cannot happen after a single 30 minute exposure to secondhand smoke. It takes many years of exposure. Just as it takes many years of eating high-fat foods before a person develops atherosclerosis. You don't drop dead of a heart attack after eating a single Big Mac. If you did, you would see a long line of stretchers being carted off from McDonalds.

If we're not going to communicate that eating a high-fat meal is equivalent to clogged arteries, then we shouldn't communicate the same thing with respect to brief secondhand smoke exposure. And the same goes with heart disease and heart attack and stroke risk.

As I've also said before, I'm not even contesting a statement that a brief exposure to secondhand smoke could have severe consequences for an individual with severe, pre-existing coronary artery disease. But that's not even the statement that's being made by these anti-smoking groups. In every case, what I've taken issue with is an unqualified statement that applies to all individuals, not just those with severe, pre-existing disease.

Even for individuals with severe coronary artery disease, we wouldn't take the evidence that a high-fat meal causes endothelial dysfunction and platelet activation and communicate to people that eating a Big Mac might cause a fatal heart attack.

I think it's time for a serious discussion in the tobacco control movement about the validity of the actual claims that are being made publicly by numerous anti-smoking groups. Whether such a discussion is even possible is not clear to me. There seems to be no interest in discussing the substance of these scientific and ethical issues, merely a desire to discredit and blackball the person who is pointing out these scientific flaws in the tobacco control movement's communications.

I apologize for my apparent complete ignorance of vascular biology. I guess I was out touring the beautiful sights of New Haven when the rest of my medical school class was attending our vascular biology lectures, discussing vascular biology research and its clinical implications, and diagnosing and treating patients with vascular disease. If anyone has a copy of "Vascular Biology for Dummies," I'd greatly appreciate a copy.

New Study Shows McDonalds Meal Causes Same Degree of Endothelial Dysfunction as Brief Tobacco Smoke Exposure; Anti-Smoking Groups' Claims are Flawed

A study published in the current issue of the American Journal of Clinical Nutrition finds that eating a meal at McDonalds -- even a "healthy" one -- results in the same degree of endothelial dysfunction as 30 minutes of exposure to secondhand smoke. This finding casts into serious doubt the widespread claims of anti-smoking groups that 30 minutes of secondhand smoke exposure causes hardening of the arteries, atherosclerosis, heart disease, decreased coronary artery blood flow, strokes, heart attacks, and death (see: Rudolph TK, Ruempler K, Schwedhelm E, et al. Acute effects of various fast-food meals on vascular function and cardiovascular disease risk markers: the Hamburg Burger Trial. American Journal of Clinical Nutrition 2007; 86:334-340).

In the study, flow-mediated endothelium-dependent flow-mediated dilatation (widening) of the brachial artery was measured after three different McDonalds meals: a hamburger with fries and soda; a veggie burger with fries and soda; and a veggie burger with salad, fruit, yogurt, and orange juice.

All three meals resulted in signficant endothelial dysfunction, as documented by a significant reduction in flow-mediated endothelium-dependent dilatation. Interestingly, the reduction in brachial artery flow after the highest-fat meal (meal #1) was 22.7%, identical to the reduction in coronary flow velocity reserve due to 30 minutes of secondhand smoke exposure in the Otsuka et al. study.

In a surprise to the authors, the supposed "healthy" option (meal #3) resulted in the same amount of reduction in flow-mediated endothelium-dependent dilatation as the highest-fat meal.

The authors concluded that there was "a decline in FMD [flow-mediated endothelium-dependent dilatation] after all 3 investigated fast-food meals... ."

The Rest of the Story

Begging the question of why someone would go to McDonalds to order a salad, fruit, yogurt, and orange juice in the first place, this study has very important implications for the widespread claims that anti-smoking groups are making about the acute cardiovascular effects of secondhand smoke.

The study casts into serious doubt the widespread claims of anti-smoking groups that 30 minutes of secondhand smoke exposure causes hardening of the arteries, atherosclerosis, heart disease, decreased coronary artery blood flow, strokes, heart attacks, and death. These claims are based largely on the Otsuka et al. study, which showed that brief secondhand smoke exposure causes endothelial dysfunction - as measured by a reduction in coronary endothelial-dependent flow-mediated dilatation - in healthy nonsmokers.

Here, however, we see that simply eating a single high-fat meal - even a seemingly healthy one - also causes endothelial dysfunction and to same extent as a brief exposure to secondhand smoke. Since it would be absurd to claim that eating a single high-fat meal causes hardening of the arteries, atherosclerosis, heart disease, decreased coronary artery blood flow, strokes, heart attacks, and death, it is equally absurd to make the same claims for a single, brief secondhand smoke exposure.

What these studies - both of them - demonstrate is that there is a plausible mechanism by which chronic exposure to high fat meals and secondhand smoke can lead to the development of atherosclerosis and eventually - to heart disease. But clearly, the process does not occur immediately.

Moreover, while it may be technically true that a brief exposure to secondhand smoke could hypothetically trigger a heart attack in someone with severe existing coronary artery disease due to its acute effects on endothelial dysfunction, the same can be said with respect to eating a high-fat meal. But you don't hear health groups going around warning people that eating a high-fat meal can trigger a fatal heart attack.

The point is this: if someone has such severe coronary artery disease that a heart attack can be triggered by an acute impairment of endothelial dysfunction due to a brief secondhand smoke exposure, then such a cardiac event can also be triggered by eating a high-fat meal. We are talking about a very specific situation, so the generalized claims being made by anti-smoking groups that 30 minutes of secondhand smoke triggers heart attacks are simply not supported by the science.

The rest of the story is that the "30 minute claims" being made by anti-smoking groups represent the most shoddy science and they have no place in the tobacco control movement if the movement wishes to maintain any sense of scientific integrity.

Of course, if the movement doesn't care about scientific integrity any more, then retaining these 30-minute claims is a great idea, because it makes for a more sensational communication and will falsely appeal to the public's emotions.

In other words, in making these 30-minute claims, anti-smoking groups are essentially borrowing a classic tobacco industry technique.

While there are over 100 groups making these claims (I have documented this extensively in previous posts), there are three websites in particular that I think need to be fixed immediately beacuse they represent - I believe - the source of the fallacious claims being made by many other groups and these groups are leading sources of health information on secondhand smoke for the tobacco control movement. If these three groups issue retractions or corrections of their public claims, then it will instruct other groups nationwide to do the same. The groups are:

1. American Cancer Society

The American Cancer Society secondhand smoke strategy guide falsely claims that brief secondhand smoke exposure causes atherosclerosis and reduces coronary artery blood flow:

In an internal strategy document entitled "Building Public Awareness About Passive Smoking Hazards," the American Cancer Society and International Union Against Cancer offer suggestions to anti-smoking advocates about how to increase the emotional appeal of secondhand smoke health hazard claims. The guide was designed "to help advocates develop practical strategies to overcome specific barriers to effective tobacco control policies."

One strategy put forward to help advocates overcome barriers to the adoption of smoking bans is to convey to the public that some of the effects of secondhand smoke are "virtually instant" because "these messages convey the issue's urgency." Specifically, the strategy urges advocates to emphasize the following two messages:

1. "Immediate effects of secondhand smoke include cardiovascular problems such as damage to cell walls in the circulatory system, thickening of the blood and arteries, and arteriosclerosis (hardening of the arteries) or heart disease, increasing the chance of heart attack or stroke."

2. "Short-term exposure to tobacco smoke has a measurable effect on the heart in nonsmokers. Just 30 minutes of exposure is enough to reduce blood flow to the heart."

As the Rudolph et al. study demonstrates, claiming that the immediate effects of secondhand smoke includes arteriosclerosis (hardening of the arteries) and heart disease and increased risk of heart attack or stroke is as absurd as claiming that eating a single healthy meal at McDonalds immediately causes atherosclerosis and heart disease and increases the risk of heart attack and stroke.

2. TobaccoScam

Based on the Otsuka et al. study, the TobaccoScam website claims that 30 minutes of secondhand smoke exposure is equivalent to clogged coronary arteries:

The specific claims are as follows:

"30 minutes exposure = smoker's arteries"

"Thirty minutes of secondhand smoke compromises a non-smoker's coronary arteries to the same extent as in smokers."

"30 minutes exposure = stiffened, clogged arteries"

"All of these effects not only increase the long term risks of developing heart disease, but also increase the immediate risk of heart attack."

Stating that 30 minutes exposure is equivalent to smoker's arteries or to clogged arteries, based on the Otsuka et al. study is as absurd as claiming that eating a McDonalds meal is equivalent to smoker's arteries or to clogged arteries, based on the Rudolph et al. study.

3. Americans for Nonsmokers' Rights (ANR)

ANR continues to claim in its "fact" sheet titled "Secondhand Smoke: The Science," that just 30 minutes of secondhand smoke exposure causes as much heart damage as is observed in active smokers. In light of the Rudolph et al. study, this claim is obviously very deceptive. One could just as easily state that someone who eats a veggie burger has heart damage similar to that of active smokers.

The specific claim is: "Just thirty minutes of exposure to secondhand smoke can cause heart damage similar to that of habitual smokers. Nonsmokers’ heart arteries showed a reduced ability to dilate, diminishing the ability of the heart to get life-giving blood."

I think that this is the moment of truth for the tobacco control movement. After this study, it should be very clear to tobacco control practitioners that the claims their groups are making are scientifically shoddy. I don't think the groups are going to be able to get away with this kind of shoddy science so easily. Now we will see the extent to which the movement is able to respond to this scientific crisis and restore its scientific integrity. Failure could mean the end of any semblance of scientific integrity and eventually, to the loss of the movement's scientific reputation.

Of course, another possibility is that the movement doesn't actually care about its scientific integrity, but only cares about the emotional impact of its public claims.

I think we'll find out this week. Just keep checking here and here and here. I'll summarize any response to this post, any defense of the claims, and any web site changes on Friday.


(Thanks to JustTheFacts for the tip. Jacob Sullum's take on this new article can be found here.)

More on New York City Car Smoking Ban Proposal

Audrey Silk of NYC CLASH has put together a nice web page summarizing many of my commentaries on the issue of car smoking bans. You can find it here.

In addition, CLASH took out an advertisement in the New York Sun today which features some excerpts from my commentaries on this issue. You can find the full text of the ad here.

My argument in opposition to car smoking bans is one that is difficult to summarize in the space allowed for an advertisement. Thus, it was kind of Audrey to provide links so that readers can appreciate the argument in its entirety.

It will be interesting to me to see if anti-smoking groups and advocates respond to the substance of the argument, or whether they stick to ad hominem attacks against me. I predict the latter.

New York City Council to Consider Bill to Ban Smoking in Cars Carrying Minors

The New York City Council is set to consider a bill that would ban smoking in all cars carrying passengers under the age of 18. The bill, which will be introduced by Councilmember James Gennaro – chair of the Council’s Environmental Protection Committee – establishes a fine of $200-$400 for a first offense, $500-$1000 for a second offense, and $1000-$2000 for third and subsequent offenses within a year. It would be enforced by the city’s police force.

According to a New York Sun article, Councilmember Gennaro explained the reasoning behind the bill as follows: “I am just seeking every opportunity I can to denormalize smoking and to try to put it out of the reach of kids. I've lost family members to lung cancer and I've seen what happens.”

In response to opponents who expressed concern about the invasion of privacy and interference with personal liberties, Councilmember Gennaro was quoted as stating: “Boo-hoo. You can't subject kids to 43 carcinogens and 250 poisonous chemicals and claim privacy. Get over it. Their right to privacy doesn't extend so far as to poisoning kids.”

Also according to the article: “A child who spends one hour in a very smoky room is inhaling as many dangerous chemicals as if he or she smoked 10 or more cigarettes, according to the Mayo Clinic. A U.S. Surgeon General's report from 2006 found there is sufficient evidence to infer "a causal relationship" between secondhand smoke exposure from parental smoking and lower respiratory illnesses in infants and children.”

Audrey Silk, the founder of CLASH (Citizens Lobbying Against Smoker Harassment) is quoted in the article as warning: "If they can come into our car, then they can come into our home. And everybody should be afraid of this, not just because of smoking."

The Rest of the Story

Although I am an anti-smoking advocate and a supporter of workplace smoking bans, I do not support this particular proposal. While recognizing the potential dangers of childhood exposure to secondhand smoke, I simply do not believe that the government should be in the business of dictating parental choices about the health risks to which their children are exposed.

Here’s the best way to look at this: If the car smoking ban is justified, then it is also justified to ban smoking in homes in order to protect children from secondhand smoke exposure. In fact, it is even more important to prevent tobacco smoke exposure in the home, since that is where the overwhelming majority of such exposure takes place. However, most people recognize that intruding into the home to regulate health risks to which parents expose their children does represent an undue intrusion, a violation of privacy, and an unacceptable interference with parental autonomy to make decisions regarding the health risks to which their children are exposed.

There is no question that the government has an interest in protecting children from secondhand smoke exposure. There is also no question that the government is justified in taking action that interferes with parental autonomy when it comes to behaviors or exposures that directly harm children or put them at substantial risk of extremely severe, immediate, life-threatening consequences.

But in my view, for the government to be justified in intruding into parental autonomy, one of these two conditions must be met. Either the activity in question has to be one which causes direct harm, or it has to be one which puts a child at risk of severe, immediate, life-threatening consequences.

Thus, for example, I believe that laws which prohibit parents from beating their kids are justified. Physical abuse represents direct harm. Furthermore, laws which require that children be restrained in safety seats are also justified, because the failure to protect a child in this way could result in death or severe, immediate injury in the case of an automobile accident.

However, a law requiring that parents place infants on their backs in their cribs would not be justified. There is no question that placing infants on their front sides tremendously increases the risk of sudden infant death syndrome (SIDS). And there is no question that a law requiring parents to place infants on their backs would save many lives. However, such a law would be unjustified because it interferes with parental autonomy regarding a behavior that merely presents an increased risk of death. It does not necessarily involve any harm to a child. Clearly, in most cases, the child will not die of SIDS, even if sleeping on his or her front side.

Similarly, a law requiring that parents not feed their children fast food, fluff, high-fat food, or food with high levels of trans-fats would also not be justified, as it interferes with parental autonomy regarding decisions about health risks. There is no question that parents who feed their kids junk food day and night are putting those children at increased risk of a number of serious adverse health outcomes. But decisions regarding behaviors that place children at increased risk of disease should remain highly protected aspects of parental autonomy.

There is another serious problem with this proposed law. If the City Council is truly concerned about reducing tobacco smoke-related morbidity in children and is willing to ban smoking by parents in order to reduce tobacco smoke exposure, then it makes absolutely no sense to ban smoking only in cars. The overwhelming majority of children’s exposure to secondhand smoke occurs in the home.

While kids may be in a car with their parents for a half hour or so, they are in the home all the time. Many kids in the City do not even ride in cars often. But they are in the home all the time. There is no question that to put a substantial dent in tobacco smoke-related morbidity among New York City’s children, one would have to address smoking in the home.

In some ways, what this proposal does is to take the easy way out. It takes the less politically courageous step of only addressing smoking in cars, allowing policy makers to feel good that they have done something to protect kids, but with the truth being that they have failed to protect kids from the major source of the very problem that the policy makers claim they are interested in addressing.

You see – once the policy makers have declared that their intention is to protect kids from parental exposure to secondhand smoke and that they are willing to override parental autonomy in order to do so, then they are (in my view) ethically obligated to ban smoking in homes as well.

One must ask the question: why ban smoking in cars to protect kids from fleeting exposure, and allow parents to continue exposing their children to secondhand smoke for hour upon hour, day after day, in the home?

The only way out of this predicament would be to argue that you believe that interfering with parental autonomy in the home would be a violation of privacy. However, Councilmember Gennaro has already said: “Boo-hoo. You can't subject kids to 43 carcinogens and 250 poisonous chemicals and claim privacy. Get over it. Their right to privacy doesn't extend so far as to poisoning kids.”

Fine – but if parents’ right to privacy doesn’t extend so far as to poisoning kids with secondhand smoke with its 43 carcinogens and 250 poisonous chemicals, then that right to privacy doesn’t extend to smoking in the home either.

So then why isn’t the Councilmember proposing to prevent parents from poisoning kids in their very own homes?

The answer, I believe, is that a home smoking ban would not be politically popular. Far easier it is to take the politically expedient route and ban smoking in cars so that you can claim you are doing something when in fact, you are neglecting the bulk of the very problem you claim to be addressing.

The rest of the story is that by focusing on such a small aspect of childhood exposure to secondhand smoke, these car smoking bans are actually distracting attention from where it needs to be: developing and funding programs to educate parents about the effects of secondhand smoke and to encourage them (not force them) to avoid smoking around their children – no matter where they are.

What good does it do for a parent to avoid smoking around their children in the car, but to smoke around them all day long in the home? And I can assure you, if a parent is smoking with their kids in the car, they sure as heck are going to be smoking in their own home.

I know that I am going to be attacked by my colleagues for taking this position in opposition to a smoking ban. But the reality is: I feel my position is a much more productive one that seeks to actually address the most significant problem. Car smoking bans are largely window dressing that allow us to feel good about ourselves, but which do very little to actually prevent childhood morbidity due to tobacco smoke exposure.

Ultimately, I agree with Audrey Silk: “If they can come into our car, then they can come into our home. And everybody should be afraid of this, not just because of smoking.”

At issue here really is the sanctity of parental autonomy over decisions regarding the welfare of their children. If we are willing to supersede parental autonomy when it comes to one health behavior that increases children’s risk of adverse health consequences, then we are going to be willing to do so for other health behaviors. And that would take us to a place that I assure you we do not want to go.

New Study Shows that Spontaneous Quit Attempts are More Successful than Planned Attempts; Focus on Pharmacotherapy May be Misguided

A new study published in the British Medical Journal reports that spontaneous quit attempts are more successful than planned quit attempts, a finding which casts doubt on the current preoccupation with pharmacotherapy as the mainstay of the national smoking cessation strategy.

As I explained in the HealthDay article about the study: "Planned quit attempts are implemented gradually and thus the level of motivation is probably rather low. But these unplanned, sudden attempts probably reflect some sentinel event or great tension that precipitates a very high level of motivation to quit. And thus these attempts are more successful."

According to the article: "Study authors Robert West and Taj Sohal liken the unplanned quit attempt to what mathematicians call "catastrophe theory." The idea is simply this: As tensions build up, even small triggers can lead to sudden and dramatic shifts in action. In nature, such forces might lead to, say, an avalanche. In much the same way, a smoker becomes disgusted with his habit, creating tension that, eventually, triggers a split decision to kick the habit."

The Rest of the Story

These findings cast doubt on the national smoking cessation strategy that was developed by an expert panel which consisted of several members with severe conflicts of interest by virtue of their financial ties to pharmaceutical companies. The chair of the panel - Dr. Michael Fiore - served as a consultant for, gave lectures sponsored by, or conducted research sponsored by Ciba-Geigy, SmithKline Beecham, Lederle Laboratories, McNeil Consumer Products, Elan Pharmaceutical, Pharmacia, and Glaxo Wellcome.

In return for these financial contributions to the expert panelists, the panel produced a smoking cessation guideline that was heavily focused on the use of planned quit attempts using pharmacotherapy. The findings of this new study suggest that the approach adopted by the expert panel may be far less effective than a strategy that is based on triggering spontaneous quit attempts.

However, the use of a "triggering" strategy would downplay the use of pharmacotherapy. Thus, it would not receive as much consideration by a panel that is heavily influenced by pharmaceutical company conflicts of interest.

I have to note that the spontaneous quitting approach accords with my experience as a physician and a smoking cessation counselor. The overwhelming majority of patients and clients who I have seen quit successfully for the long-term have done so in response to a dramatic, often life-altering event or realization, and the quit attempt was unplanned and unaccompanied by any use of pharmaceuticals.

Mock News Article: Tobacco Companies Challenge FDA Advertising Restrictions in Court; Philip Morris Abstains from Suit, Citing Desire to Protect Kids

Philip Morris is so far ahead of the anti-smoking and health groups in its foresight on the issue of the FDA tobacco legislation that it is difficult for me not to admire its brilliance. The legislation offers so many advantages to the company, and it is hard to see all of them unless one actually envisions the consequences of enactment of the legislation. In contrast to what the Campaign for Tobacco-Free Kids and other health groups appear to be counting on, the tobacco companies will not respond to the FDA legislation by doing nothing. Here is what I imagine to be the likely response of the companies to the advertising restrictions alone in the wake of passage of this legislation:

(Mock News Article)

Tobacco Companies Challenge FDA Advertising Restrictions in Court; Philip Morris Abstains from Suit, Citing Desire to Protect Kids from Cigarette Ads

Just one month after Congress enacted legislation giving the Food and Drug Administration (FDA) the authority to regulate tobacco products and codifying strict rules limiting cigarette advertising to youths, a number of cigarette companies are challenging the constitutionality of the advertising limits.

Reynolds American, Lorillard, and the United States Smokeless Tobacco Company filed suit in a federal court yesterday, seeking to overturn the legislation's advertising limits. The companies claim that these restrictions violate their free speech rights under the First Amendment to the Constitution.

The companies cited a Supreme Court ruling in 2001, in which the Court ruled that Massachusetts regulations which banned cigarette advertising within 1,000 feet of schools and playgrounds violated the First Amendment because they unduly restricted the commercial free speech rights of cigarette companies.

In that case, the Court ruled that: "The State's interest in preventing underage tobacco use is substantial, and even compelling, but it is no less true that the sale and use of tobacco products by adults is a legal activity. We must consider that tobacco retailers and manufacturers have an interest in conveying truthful information about their products to adults, and adults have a corresponding interest in receiving truthful information about tobacco products." The basis of the Court's ruling was that the Massachusetts advertising restrictions were too broad.

The advertising restrictions in the law passed by Congress last month are even broader than the Massachusetts regulations. Like the Massachusetts regulations, they ban outdoor tobacco advertising within 1,000 feet of schools. However, they also limit advertising in magazines with greater than 15% youth readers to a black and white, text-only format, ban all tobacco company sponsorship of sports and entertainment events (even in adult-only venues), ban giveaways of non-tobacco promotional items (even with confirmation of adult age), and limit all outdoor and point-of-sale advertisements to black and white text only (even in adult facilities).

In a prepared statement, Reynolds American said: "These advertising restrictions are clearly much broader and more sweeping than fits the stated purpose of keeping advertising away from minors - a goal that we support. By banning sponsorships of events in adult-only venues, prohibiting promotional marketing to confirmed adults, and placing limits on advertising even in adult-only establishments, Congress has clearly overstepped its intended purpose of limiting advertising targeted at minors. Because the restrictions are not tailored narrowly to achieve that purpose, they violate the First Amendment. We feel confident that the Supreme Court will agree, and will protect our right to communicate with our legal-age customers."

A coalition of anti-smoking and health groups countered with a statement of their own, imploring the Supreme Court to uphold the advertising limits: "This is too important an issue for the Supreme Court to let the Constitution get in the way. These advertising restrictions will save countless lives. This is all about the children. Millions of children will die if the Supreme Court does not take the responsible action and curtail the marketing of deadly products to children."

In a surprise to many, the nation's leading cigarette company - Philip Morris - did not join the other tobacco companies in bringing the lawsuit. In a statement released yesterday, the company said: "We believe that the FDA legislation represents an effective and meaningful regulation of tobacco products. Our chief concern is for the health of our nation's children, and we support the limits that the legislation places on advertising that might unintendedly reach young people. Minors should not be smoking and we will, as we have done for years, continue to do everything we can to ensure that minors do not smoke."

Many analysts believe that by separating itself from the other tobacco companies on the issue of advertising restrictions, Philip Morris may gain from a boost in its public image. The separation allows Philip Morris to paint itself as a company that really cares about keeping cigarettes out of the hands of children. Financial analysts believe that the company is casting itself as a changed and more socially responsible one.

IN MY VIEW: Campaign for Tobacco-Free Kids' Claims that FDA Legislation Would Reduce Youth Smoking are Based on Faulty Reasoning

In its propaganda regarding the proposed FDA tobacco legislation, the Campaign for Tobacco-Free Kids tries to lead the public to believe that through its restrictions on tobacco advertising, the bill would substantially reduce youth smoking.

The Rest of the Story

The rest of the story is that there's a critical thing that the Campaign for Tobacco-Free Kids is not telling its constituents and the public:

The advertising restrictions in the FDA legislation most likely violate the First Amendment to the Constitution and are almost certain to be overturned by the Supreme Court.

In Lorillard v. Reilly (533 U.S. 52, 2001), the Supreme Court held unconstitutional Massachusetts regulations that did nothing more than eliminate tobacco advertising within 1,000 feet of schools and playgrounds. The Court found that these regulations did not meet the fourth prong of the requirements set out by Central Hudson for advertising restrictions to comply with First Amendment commercial free speech protections: that the requirements be tailored as narrowly as possible to advance the relevant government interest.

In light of the Supreme Court's 2001 decision, it seems very unlikely that the much less narrowly tailored (and frankly, rather arbitrary) rules promulgated by the FDA, which were themselves overturned by the Supreme Court but which are contained in the legislation, would pass constitutional muster.

In other words, by boasting about how much the FDA legislation will do to curtail cigarette advertising to youths and how much that will reduce youth smoking, the Campaign for Tobacco-Free Kids is making a mountain out of a mole hill.

Here's what the Supreme Court had to say about merely a restriction on advertising within 1,000 feet of schools:

"Whatever the strength of the Attorney General's evidence to justify the outdoor advertising regulations, however, we conclude that the regulations do not satisfy the fourth step of the Central Hudson analysis. The final step of the Central Hudson analysis, the "critical inquiry in this case," requires a reasonable fit between the means and ends of the regulatory scheme. The Attorney General's regulations do not meet this standard. The broad sweep of the regulations indicates that the Attorney General did not "carefully calculat[e] the costs and benefits associated with the burden on speech imposed" by the regulations."

"The outdoor advertising regulations prohibit any smokeless tobacco or cigar advertising within 1,000 feet of schools or playgrounds. In the District Court, petitioners maintained that this prohibition would prevent advertising in 87% to 91% of Boston, Worcester, and Springfield, Massachusetts. ... Thus, the Court of Appeals concluded that the regulations prohibit advertising in a substantial portion of the major metropolitan areas of Massachusetts." ...

"The State's interest in preventing underage tobacco use is substantial, and even compelling, but it is no less true that the sale and use of tobacco products by adults is a legal activity. We must consider that tobacco retailers and manufacturers have an interest in conveying truthful information about their products to adults, and adults have a corresponding interest in receiving truthful information about tobacco products. In a case involving indecent speech on the Internet we explained that "the governmental interest in protecting children from harmful materials ... does not justify an unnecessarily broad suppression of speech addressed to adults."

The conundrum inherent in the attempt to reduce youth smoking by restricting cigarette advertising is that the 3rd and 4th prongs of the Central Hudson requirement for restriction of commercial free speech are such that any restrictions that are broad enough to actually make a difference in reducing youth smoking are also going to be construed as being overly broad to constitute the narrow tailoring that is required.

While the Campaign for Tobacco-Free Kids' hype may sound great in its propaganda campaign, the advertising restrictions in the FDA legislation will not reduce youth smoking. They will not even sustain a constitutional challenge. Therefore, all the talk about the FDA legislation reducing youth smoking by curtailing cigarette advertising that reaches kids is little more than baseless chatter. It is based on seriously faulty reasoning, and therefore, is simply more of the quackery and deception that we have come to expect from the Campaign.

Clarian Health to Dock Employees' Pay if They Don't Quit Smoking and Control Weight, Blood Pressure, Cholesterol, and Blood Sugar; Unsafe Sex Still OK

According to an article in BusinessWeek Online, Clarian Health - an Indianapolis-based hospital system with 13,000 employees - has announced a plan to begin docking their workers' pay if they do not comply with a set of health guidelines, including requirements to quit smoking and keep their weight, blood pressure, cholesterol, and blood sugar in a specified range. The policy will apparently apply only to employees who are enrolled in the company's health plan.

According to the article, each paycheck will be docked by either $5 or $10 for each failure to comply with the following requirements:

• Quit smoking and maintain smoking abstinence;
• Keep blood pressure lower than 140 systolic and 90 diastolic;
• Keep LDL cholesterol less than 130;
• Keep blood glucose under 120; and
• Keep body mass index less than 30.

The article reports that: "For employees at Clarian Health, feeling the burn of trying to lose weight will take on new meaning. In late June, the Indianapolis-based hospital system announced that starting in 2009, it will fine employees $10 per paycheck if their body mass index [BMI, a ratio of height to weight that measures body fat] is over 30. If their cholesterol, blood pressure, and glucose levels are too high, they'll be charged $5 for each standard they don't meet. Ditto if they smoke: Starting next year, they'll be charged another $5 in each check. Clarian has been making headlines for its aggressive and unusual approach to covering escalating health-care costs. Rather than taking the more common step of giving employees incentives for merely participating in its wellness programs, such as joining a smoking cessation group or using a health coach, Clarian is actually measuring outcomes. And unlike most employers, it is penalizing workers for poor health instead of rewarding them for taking healthy steps."

The Rest of the Story

Apparently, employees of Clarian Health still have the go-ahead to have all the unsafe sex that they want. Generously, they are allowed to eat whatever they want as long as they keep the specified parameters in order. They can also drink excessively without hesitation, since excessive alcohol consumption does not have a direct effect on any of the measured parameters. Magnanimously, the company will allow employees to be completely sedentary and not get any exercise, so long as they keep their body mass index below 30.

For those who are not obese to begin with, there is no incentive provided to exercise at all. These workers have the green light to become couch potatoes. Clarian workers can also feel relieved that there is absolutely no requirement that they apply sunscreen before long days in the sun to avoid costly and potentially fatal skin cancer. While they can't smoke, they can take solace in the fact that they can suck up as much secondhand smoke as they want.

Also coming as a great relief is the fact that Clarian is not requiring female employees to be screened for breast cancer. No more need for uncomfortable mammograms which could prevent death from breast cancer. Perhaps even a greater relief is the absence of any requirement for men to obtain prostate exams to prevent potentially fatal prostate cancer and for both sexes, the absence of any colon cancer screening requirement.

Pregnant women seem to be faring best under Clarian's new policy. While they cannot smoke during pregnancy, they can drink alcohol to their heart's content. Plus, they can change all the cat litter they want without fear of repercussions from their employer. Amazingly, they don't even have to reveal to their employer if they are regularly changing cat litter.

To be sure, the Clarian Health policy leaves many aspects of employees' privacy completely intact. Imagine that Clarian's employees can have sex with whomever they want and do not have to report either the number of partners or the names of those partners. There is absolutely no duty to report the number of drinks that they are having when they get home from a stressful day at work.

Moreover, while employees must submit to a blood test so that their cholesterol and blood sugar can be measured, there is no need to provide a urine sample so that they can be tested for a whole host of other serious, but easily treatable medical conditions. And they do not have to provide evidence that they have received an annual PAP smear, rectal exam, or breast exam.

Employees who are experiencing exertional chest pain come out smelling like roses. Despite the probability of serious but treatable cardiac ischemia, there is no need to either be tested for heart disease or to document having been tested.

Employees with sexually transmitted diseases fare extremely well under the new plan. Not only are they free from disclosing their conditions, but there is no requirement for medication compliance. Unlike diabetics, who have to maintain their blood sugars within rigidly controlled parameters, STDs are unregulated and there is no need to submit blood work and other specimens to determine the presence or absence of an STD. Apparently, Clarian has the utmost respect for the privacy of their employees and their autonomy in making their own off-the-job decisions regarding legal behaviors.

Unfortunately, diabetics do not fare well at all under the plan. By requiring them to keep their fasting blood sugar levels below 120, the plan forces them to go up on their evening insulin doses, putting them at great risk of developing hypoglycemia at night. Brittle diabetics fare very poorly, since even attempting to keep their morning blood sugars below 120 is unwise, as it would put them at risk of dying from hypoglycemia during the middle of the night. If diabetic employees start failing to show up for work at Clarian, you'll now know why.

Former football players and other athletes, as well as bodybuilders and guys who just enjoy working out are also in serious trouble. Many of these individuals - among the healthiest in the population - have body mass indices above 30 based on their weights, even though they have very little fat and huge muscles. In fact, all members of the Olympic gold medal rowing team would be subject to having their pay docked, as would 200 players in the National Basketball Association.

Take solace chewers! Smokeless tobacco use seems to be sanctioned by Clarian. As long as you don't smoke, your paycheck appears to be safe. And don't bother with all these new snus products coming out. Go with the real thing - Skoal, Copenhagen, and Happy DaysMint. After all, you get no rewards for switching to snus.

String of Colleges Ban Smoking on Entire Campus; Is This Pure Paternalism Justified?

A string of colleges have announced recently that they will ban the use of any tobacco products on their campuses:

Minnesota State University - Moorhead: "Minnesota State University, Moorhead will be the first four-year public university in Minnesota to ban smoking anywhere on school grounds -- including outdoors. The policy, which will ... take effect Jan. 1, affects everything from residence halls and staff offices to parking lots and a 300-acre science center near Moorhead. Altogether, 440 campus-owned acres are affected. Use of tobacco products, including chewing tobacco, will be banned."

University of Minnesota Duluth: "The University of Minnesota Duluth ... will prohibit smoking everywhere on campus starting in May. With a statewide indoor smoking ban for most public places taking effect this fall, it made sense to push for a total campus-wide ban, said Brianna Peters, a senior and co-chairwoman of the UMD Student Health Advisory Committee. Minnesota State University Moorhead approved a similar ban last spring, but it won't go into effect until January. Campus grounds, buildings and university vehicles are included in UMD's ban."

Jamestown College: "Jamestown College is now a tobacco-free campus, school officials announced. Smoking and the use of chewing tobacco are prohibited on all college property, said Carol Schmeichel, vice president of student affairs."

The Rest of the Story

The point to emphasize is that these policies are an example of pure paternalism. We must dismiss outright the idea that these policies are necessary to protect nonsmokers from secondhand smoke. Clearly, it is not necessary to completely ban smoking on an entire college campus. Banning smoking inside and near buildings and in any crowded outdoors locations would be enough. Moreover, smokeless tobacco does not produce secondhand smoke, so including the use of smokeless products in the ban obviously is not consistent with a simple desire to protect bystanders from harm.

Clearly, these policies are intended to protect people not from others, but from themselves. They are intended to promote health by dictating that a particular unhealthy behaviors cannot take place on campus. Whether justified or not, the policy is purely paternalistic.

So is it justified?

It might be, if these universities were dictating a range of unhealthy behaviors that were not to be tolerated on campus. If the universities decided that they would simply not allow people to engage in unhealthy behavior on campus, then it might be reasonable to include tobacco use among those behaviors. But none of these colleges are doing that. They are singling out tobacco use, and leaving all other unhealthy behaviors -- such as excessive alcohol use, eating unhealthy foods, eating too much, not consuming enough antioxidants or fiber, consuming trans-fats, eating too much fat, or failing to get enough exercise -- alone.

For these other unhealthy behaviors, these colleges are appropriately addressing them through campus wellness programs. But for use of tobacco products, the colleges are simply banning it. If you are going to try to justify a purely paternalistic intervention like this on a college campus, then I think it really needs to represent a consistent, across-the-board policy.

One thing is for certain: these schools are going to discourage smokers from attending. They are basically saying that smokers are not welcome. If I were a smoker, I certainly would not care to attend one of these colleges. It might result in a slightly healthier student body, but it is also going to cleanse the student body of 20% of the population.

While I'm not aware that anti-smoking groups are behind these policies, I'm also not aware that any have spoken out in opposition to them. Unfortunately, that is the only way to make it clear to the public that the purpose of smoking bans is to protect people from secondhand smoke, not to express intolerance for a large segment of the population.