Saturday, September 29, 2007

Effort to Help Smoker Who Was Refused Surgery Highlighted by British Newspaper; Role of the Rest of the Story Acknowledged

The effort being spearheaded by FORCES International to help a British smoker who was denied surgery for a painful and severely broken ankle because he smokes was highlighted Thursday in a Cornwall (UK) newspaper -- The Cornishman. The article notes the role played by The Rest of the Story in providing a forum where this news could be reported and discussed and on which this effort could originate.

As the article reports: "A pro-smoking group in the United States is pledging to pay for the private treatment of a Newlyn smoker who is being denied surgery on the NHS. FORCES International is waiting for permission from John Nuttall to start a fund-raising campaign. The human rights group, which proclaims to protect personal lifestyle choices, was alerted to Mr Nuttall's plight after it was documented on a Boston physician's website. Michael Siegel's article stimulated 131 replies with many involved in a debate demanding action. Twenty-nine pro-smokers pledged 1,545 in individual donations of 20 to 100. FORCES International president Maryetta Ables said the John Nuttall fund-raiser would meet the full cost of private care. Speaking to The Cornishman from West Virginia, she said: "All we need to know is our target goal and he will be free to go get his surgery." Mr Nuttall's story hit the national headlines this month.The 57-year-old, who broke his ankle two years ago, has been repeatedly turned down for surgery and is being prescribed a daily dose of morphine tablets for pain."

Mr. Nuttall is presently weighing his decision about whether to pursue surgery or not. He expressed tremendous appreciation for the concern expressed by those who pledged money on this blog, which has lifted his spirits. He expects to make a decision early this week. Should he accept the offer, The Rest of the Story will publicize the fund and provide a link to the page where donations can be made.

Friday, September 28, 2007

New Study Claims that New York State Smoking Ban Reduced Heart Attack Admissions by 8%

A study being released today concludes that the New York State smoking ban, implemented in July 2003, resulted in an 8% decline in heart attack hospital admissions statewide during the first year and a half it was in effect. The study was published online ahead of print today in the American Journal of Public Health (see: Juster HR, Loomis BR, Hinman TM, et al. Declines in hospital admissions for acute myocardial infarction in New York State after implementation of a comprehensive smoking ban. Am J Public Health 2007).

Although the study did not determine trends in heart attacks in smokers versus nonsmokers, it notes that there was not a significant decline in smoking prevalence associated with the implementation of the statewide smoking ban; thus, the decline in heart attacks is attributed to decreased secondhand smoke exposure among nonsmokers.

The study examined trends by month in age-adjusted hospital admission rates for acute myocardial infarction in all non-federal New York hospitals between 1995 and 2004. It used regression analysis to control for the effects of seasonal and secular trends as well as the presence of local smoking bans.

The paper concludes: "Rates of hospital admissions for AMI [acute myocardial infarction] were reduced by 8% after a comprehensive ban on smoking in work sites, including hospitality venues (e.g., bars and restaurants), in New York State. This is equivalent to a reduction of approximately 3800 AMI hospital admissions in 2004 and an estimated cost savings of $56 million. Our results show that enactment of clean indoor air laws was associated with an accelerated decline of hospital admissions and that a comprehensive statewide law had the largest effect."

The study results were first reported by the Associated Press here.

The Rest of the Story

While I do not dispute the conclusion that there was an 8% decline in hospital admissions in New York State during the second half of 2003 and all of 2004, I do not believe that these data support a conclusion that the observed decline in heart attack admissions is attributable to the statewide smoking ban.

Why? Because there is no control or comparison group. The article examines trends in heart attacks in New York, but it does not examine what happened to heart attack admissions anywhere else during the same time period.

Sure - there was an 8% decline in heart attack admissions in New York during 2004. But this doesn't mean anything unless there was not an 8% decline in heart attack admissions in other states, that did not implement smoking bans, in 2004. Without knowing what the heart attack trends were elsewhere, there is no basis to conclude that the observed decline in heart attack admissions in New York was attributable to the smoking ban.

This is essentially an uncontrolled study - a study without a control group. It represents a very weak study design for this type of analysis. Even the shoddy Bowling Green and Pueblo studies employed a comparison group to evaluate whether the observed changes in heart attacks in the cities with smoking bans were also occurring in comparable cities without smoking bans.

So what did happen in other states between 2003 and 2004? Were heart attack admissions stable in states without smoking bans, while dropping by 8% in New York state with its smoking ban in place?

Well, in South Carolina, heart attack admissions fell by 12.5% from 2003 to 2004. This is also in marked contrast to the existing trend in heart attacks in that state. Heart attack admissions were increasing by an average of 3.0% per year during the period 2001-2003 in South Carolina. So was the 12.5% decline in heart attack admissions during the same time period in South Carolina due to the absence of a statewide smoking ban?

In Nebraska, heart attack admissions fell by 28.5%from 2003 to 2004. This is in marked contrast to the existing trend in heart attacks in the state. Heart attack admissions were increasing by an average of 2.3% per year during the period 2001-2003 in Nebraska. Was this dramatic drop in heart attack admissions in Nebraska, which occurred during exactly the same period as the decline in New York, attributable to the absence of a smoking ban in the Cornhusker state?

In fact, in all other states for which data are available, heart attack admissions fell by 5.1% from 2003 to 2004. So does the decline in heart attacks in New York represent a dramatic effect of the smoking ban, or is it simply a change that would have been expected based on the secular trends occurring across the nation during the same time period?

The article in question does not allow us to answer that question. And that is precisely why its conclusion is unwarranted.

Based on the available data, it certainly appears that large declines in heart attack admissions were occurring across the nation in 2004. The observed decline in New York was far less than was observed in Nebraska and South Carolina - two states without smoking bans.

So does this mean that the absence of a smoking ban in those two states was the reason why their heart attack admissions dropped far more than in New York? Of course not. The point is that there are large year-to-year variations in heart attacks that have nothing to do with smoking bans and in order to conclude that a small decline (such as 8%) in heart attacks was due to a smoking ban, you absolutely have to show that the decline would not have occurred in absence of the smoking ban. And to do that, you need to look at what is happening in other states.

One lesson here is that even if a study is published, you still need to review it critically and you should not necessarily assume that its conclusions are valid and well-supported. And if this is what can happen with a published article, you can only imagine how much more difficult it is to accept the conclusions of a study that is neither published nor available (i.e., the Scottish smoking ban heart attack study).

As much as we might like to believe that reducing secondhand smoke exposure prevents thousands of heart attacks in a matter of months, the evidence is simply not there to support such a conclusion. By jumping the gun and drawing conclusions prematurely, I fear that we are hurting our overall scientific credibility. In the long run, that may harm the effort to promote smoking bans far more than spreading the belief that such bans are going to immediately prevent heart attacks is going to help enact these bans.

Thursday, September 27, 2007

The Dangers of Science by Press Release: Putative Effects of Scottish Smoking Ban on Heart Attacks Gets Widespread, Uncritical Media Coverage

An article published earlier this week in Spiegel Online informs the public that the smoking ban in Scotland resulted in a dramatic 17% decline in heart attacks during the first ten months that the ban was in effect. According to the Spiegel article, there were 551 heart attacks that failed to occur due to the smoking ban.

The article is based on unpublished data released via a press release by the University of Glasgow, home of the lead researcher on the study. To the best of my knowledge, the study itself is not easily available for public scrutiny.

In an uncritical recounting of the data and conclusions in the press release, Spiegel writes as follows:

"it seems a miracle has happened: The number of heart attacks in Scotland has suddenly dropped by no less than 17 percent in a single year. What has happened? Have the Scots stopped eating red meat? Has the whole country started knocking back cholesterol medication? Are they all training for the marathon? No. The reason is much simpler: Scots are having fewer heart attacks because they are no longer inhaling other people's cigarette smoke when they sit in the pub, the train or the office. Scientists at the University of Glasgow reported last week that things have become remarkably quiet in the country's heart clinics since smoking in public was banned in Scotland in March 2006. In nine selected Scottish clinics, 3,235 heart attack victims were brought in during the 10 months before the ban. In comparison, the number for the 10 months after the ban was only 2,684. Now the Scots and the rest of the world are marvelling at 551 heart attacks that never happened -- simply because of cleaner air."

The Rest of the Story

While Spiegel Online may be reporting that there were 551 fewer heart attacks in Scotland due to the smoking ban, Siegel Online is reporting that this conclusion is far too premature, and that the simple fact that there was a reduction in heart attacks from one year to the next is not sufficient evidence to conclude that this reduction is attributable to the implementation of the smoking ban.

In fact, I presented evidence that a 17% drop in heart attack admissions occurred in the 3 months prior to the smoking ban -- obviously, that much more drastic decline in heart attacks was not attributable to the smoking ban. Clearly, it is premature to jump to these conclusions.

This story demonstrates the danger of the science by press release approach. This is precisely why it is not prudent to issue findings that have not been validated by a peer review process. Suppose that upon peer review, it turns out that the study findings are unwarranted and invalid. Are the researchers going to then issue a press release stating that they were wrong, that their conclusion was premature and invalid, and that all news articles that the public throughout the world read to the contrary should be disregarded?

I highly doubt it.

Should these findings be invalidated based on peer review, it will at this point be inconsequential. The point is that the word is already out there. The conclusions have already been disseminated. It is too late to retract them if they are indeed wrong.

I view it to be inappropriate and perhaps unethical to release the results of a scientific study prior to peer review and publication. There is one exception, and that is IF (and only if) one makes the study available for public scrutiny and review. If you are going to go to the press to disseminate study findings, then you have to be willing to allow the public to see the study upon which those findings are based. Otherwise, there is no opportunity for review and scrutiny of your work.

To see how science by press release subverts scientific integrity, suppose that RJ Reynolds were to come out with a press release stating that Camel No. 9 cigarettes were found to reduce cancer risk by 20%. Newspaper headlines widely carried the headlines that Reynolds has produced a safer cigarette.

The first thing that anti-smoking groups would want to know is whether or not this research had been peer-reviewed and published. Suppose that it had not, and that the company did not release the study upon which these conclusions were based. There is no doubt that anti-smoking groups would condemn RJ Reynolds, question the validity of the study results, and claim that the company was widely misleading the public. RJ Reynolds would be attacked for violating established scientific standards.

Well if those standards apply to RJ Reynolds, then why don't they also apply to research which draws conclusions that are "favorable" to the anti-smoking cause?

Are we no longer required to adhere to solid scientific practice in tobacco control?

Apparently, we are not. Somehow, I must have missed that memo.

Wednesday, September 26, 2007

Paper Shows No Increase in Marlboro Nicotine Yields from 1997-2006, Yet Concludes There Has Been a Linear Trend of Increasing Yields During this Time

An article published online in this month's issue of the journal Tobacco Control concludes that there has been a linear, non-random trend of increasing nicotine yields in Marlboro brand cigarettes during the period 1997 to 2006 (see: Connolly GN, Alpert AR, Wayne GF, Koh H. Trends in nicotine yield in smoke and its relationship with design characteristics among popular US cigarette brands, 1997-2005. Tobacco Control 2007; 16:e5).

The paper presents a figure (Figure 1) which shows the trend in average nicotine yields of 18 Marlboro family brand styles between 1997 and 2006. The paper concludes: "A multilevel regression analysis of the nicotine yields in smoke of the 18 Marlboro brand styles reported in each year from 1997 through 2006, as reflected by the MDPH data, shows a statistically significant increasing temporal trend of 0.008 mg/year (p,0.001). Average figures for nicotine yield for these Marlboro brands and the regression line showing a linear, nonrandom trend in nicotine yield in smoke are shown in fig 1."

This finding directly contradicts the public statement of Philip Morris regarding Marlboro's nicotine yields. According to the Tobacco Control article: "PM USA issued press releases, observing that the apparent trend in nicotine yield in smoke from 1998 to 2004 was not present when data from 1997, 2005 and 2006 were included. The PM USA website also shows simple linear average nicotine yields in smoke for 18 Marlboro cigarette styles reported in all years from 1997 through 2006, claiming no significant temporal trend and concluding that ‘year-to-year variations in nicotine occur as part of the normal processes of growing tobacco and manufacturing cigarettes.’ The present analysis shows a significant temporal increase in nicotine yield in smoke, contradicting the PM USA claims."

Importantly, the paper also notes that: "All cigarettes are highly addictive and deadly, and relatively minor changes in nicotine yield may not significantly alter the product’s addictive properties." and that "The increase over time in nicotine yield in smoke does not necessarily signify any change in exposure within the population of smokers, particularly as smoking behaviour among humans is compensatory and will adjust for differences in smoke yield."

Finally, the paper notes that "Human studies, including measures of smoking topography and biomarkers of exposure, may be necessary to predict consumer and population effects."

The Rest of the Story

The rest of the story is that the article reports an average nicotine yield of Marlboro cigarettes in 1997 of approximately 1.85 mg/cigarette, and an average yield in 2006 of approximately 1.85 mg/cigarette.

You're not reading that incorrectly.

The average nicotine yield of Marlboro cigarettes in 2006 was, according to this article itself (not relying upon Philip Morris' own data), no higher in 2006 than it was in 1997.

So if the nicotine yield of Marlboro cigarettes was no higher in 2006 than in 1997, then how could there have been a significant, linear trend of increasing nicotine yields of Marlboro cigarettes during this time period?

The answer is: there could not have been such a trend. Such a trend of linearly increasing yield of nicotine yields is not consistent with the study findings, which demonstrate essentially no difference in the yields of Marlboro cigarettes in 2006 vs. 1997.

The curious reader may ask himself or herself: then how does one conclude that there was a trend of linearly increasing nicotine yields?

The answer is that you fit a line to data which clearly do not show a simple linear pattern.

If you examine Figure 1, what you'll see is that the nicotine yield of Marlboro cigarettes increased rather steadily from 1997 through 2003, and then decreased rather steadily from 2003 through 2006. The nicotine level ended up exactly where it had started. But it went up for a few years, and then back down.

In other words, the trend in nicotine yields exhibits an upside-down "V" pattern.

The appropriate way to model this would be to fit two lines: a line with increasing nicotine yield between 1997 and 2003, and a line with decreasing nicotine yield between 2003 and 2006.

In other words, what appears to have actually happened is that Marlboro's nicotine yields increased between 1997 and 2003, but decreased between 2003 and 2006.

Because the period of time during which the increase occurred was longer than the period of time during which the decrease occurred, if you fit a simple line (a single line) to the data, you are going to find a line with a positive slope. But that line does not really indicate what occurred during the study period.

In my opinion, these data clearly demonstrate that Philip Morris was correct and the article is wrong regarding the observed pattern. There was indeed no net increase in nicotine yields of Marlboro cigarettes between 1997 and 2006. The nicotine yields did not increase by 0.008 mg/year. What happened is that the nicotine yields increased by about 0.016 mg/year between 1997 and 2003, and then decreased by about 0.033 mg/year between 2003 and 2006.

What's most interesting to me is the fact that while Philip Morris is apparently being blamed for increasing the nicotine yield of its Marlboro cigarettes between 1997 and 2003, the company is not simultaneously being praised for having decreased the nicotine yields between 2003 and 2006.

In fact, the decreasing nicotine yield of Marlboros between 2003 and 2006 is "impressive." The rate of decline in nicotine yields is twice what the rate of increase was between 1997 and 2003.

Note that I'm not arguing here that Philip Morris did or did not intend to increase or decrease its nicotine yields within Marlboro cigarettes. These data cannot demonstrate whether or not the changes reflect a true attempt to control these levels on the part of the company, or whether the changes merely reflect random variations. While the variation in nicotine does not appear to be random, neither does it appear to represent a linearly increasing trend.

While I would not have thought that I would be taking the side of Philip Morris in a conflict over the interpretation of scientific data, I do find myself in that position based on my review of this research.

Perhaps an even most interesting aspect of the paper, to me, is the fact that the article itself acknowledges that the observed changes in nicotine yield are essentially meaningless, because "relatively minor changes in nicotine yield may not significantly alter the product's addictive properties," and because "the increase over time in nicotine yield in smoke does not necessarily signify any change in exposure within the population of smokers, particularly as smoking behaviour among humans is compensatory and will adjust for differences in smoke yield."

If it is true that relatively minor changes in nicotine do not necessarily alter the product's addictive properties and that the increase (or decrease) in nicotine yields in smoke does not necessarily signify any change in exposure within the population of smokers, then what exactly is the significance of this research?

If it is true, as the authors conclude, that one can only draw inferences about "consumer and population effects" by conducting "human studies, including measures of smoking topography and biomarkers of exposure," then what exactly does this paper tell us about consumer or population implications of the data reported therein?

The answer is: nothing. And the paper acknowledges that, quite appropriately.

But that raises the question of what the value or importance of this research is. It's not clear to me. However, there's no question that the research has been used to support two things: (1) promotion of a specific policy end - the FDA tobacco legislation; and (2) the opportunity for anti-smoking groups to take a crack at the tobacco companies for increasing yields which, on our own admission, have nothing to do with actual human consumer or population effects, addiction potential, or health.

Tuesday, September 25, 2007

Car Smoking Ban Supporters Call Smoking in Cars Worse Than Child Abuse, State that Secondhand Smoke is as Bad as Active Smoking

According to an article in Newsday, two New York legislators who are supporting the state's proposed ban on smoking in cars carrying children under 16 years of age have issued the following one-two punch of arguments in support of their position:

Assemblyman Ivan Lafayette, the sponsor of the car smoking ban bill, was quoted as stating that smoking in a car with a child is worse than child abuse (slapping a child in the face): "I think smoking in a car with a child has a more lasting effect than giving a child a slap in the face," said Assemblyman Ivan Lafayette, D-Queens. "They're both horrible things, but one is going to kill the child ... I know that's a hard comparison, but that's the reality of it."

Assemblywoman Sandra Galef, who is sponsoring a separate bill which would ban smoking in playgrounds, stated: "The scientific reports say that secondhand smoke has as much of a negative effect on your health as smoking directly. And we certainly want to be sure we keep smoke away from children who don't have the opportunity to walk away from it, and I think adults have to learn more responsible behavior around children."

The Rest of the Story

What more can I say about Assemblyman Lafayette's statement than to condemn it as being disgusting and completely insensitive to, and dismissive of, all those who have been victims of child abuse.

How can one suggest that physically abusing a child is no worse than exposing a child to secondhand smoke? How can one suggest that physically abusing a child results in effects that last for a much shorter time than a child breathing in secondhand smoke?

Anyone who has experienced abuse as a child or treated victims knows that the effects of childhood physical abuse last a lifetime. Anyone who is abused suffers harm. That harm is severe and in some respects irreparable.

In contrast, the majority of children who are exposed to secondhand smoke in cars do not suffer any long-term effects. There is an increased risk of ear infections and lower respiratory tract infections. But to compare that to child abuse?

It appears that at least some car smoking ban supporters are having a difficult time making a distinction between risk and harm. While physically abusing a child causes immediate, direct, severe, and intentional harm, smoking around a child merely increases the risk of adverse health consequences. And in almost all cases, that increased risk is not intentional.

To equate intentional infliction of direct injury with the unintentional imposition of increased health risks is unwarranted.

And in this case, it is also disrespectful, insensitive, and damaging.

Is this what is really behind car smoking bans? It has to make you wonder.

While not disgusting or insensitive, Assemblywoman Galef's argument is scientific rubbish. It is manifestly untrue that secondhand smoke exposure is as bad as active smoking. Clearly, active smoking has a far more detrimental effect on one's health than secondhand smoke exposure.

The relative risk of lung cancer associated with active smoking is about 17, yet only about 1.3 for passive smoking. Active smoking is a major cause of emphysema and chronic bronchitis (chronic obstructive lung disease), while secondhand smoke has not yet been shown to cause these conditions. Active smoking causes cancer of many other organs besides the lung, while secondhand smoke has been shown to be a cause only of lung and nasal sinus cancer.

To suggest that secondhand smoke is as harmful as active smoking is to undermine the public's appreciation of the hazards of active smoking. Do we really want smokers to believe that the health effects of their smoking are really only as bad as if they were exposed to secondhand smoke? A statement like that may generate headlines and scare people into supporting a car smoking ban, but it is false and damaging to public health messages about the hazards of smoking.

Of course, another problem with Galef's argument is that children cannot walk away from secondhand smoke in the home either. So if secondhand smoke is really as bad as active smoking, then how can we possibly allow parents to smoke around their children in the home? The New York smoking ban legislation chooses not to regulate smoking in the home, allowing parents to hold their kids captive and expose them to the equivalent of active smoking.

Why is it that parents must learn "more responsible behavior around children" in their cars, but not in their homes? Is it the harm being done to children that bothers our legislators, or is it just seeing the parents smoking that is the problem?

When one sees arguments in favor of a public policy deteriorate to this level, one should take a good hard look at the validity of the position in support of the policy. If this is the best that supporters can come up with, then I'm afraid I cannot find their position to be at all compelling.

One thing is for certain: the arguments being advanced by these car smoking ban proponents do cause harm. Harm to real victims of child abuse. And harm to public health efforts to educate the public about the hazards of smoking.

Thursday, September 20, 2007

Utah Car Smoking Ban Proposal Shows Hypocrisy of this Public Health Approach

According to an article in the Salt Lake Tribune, the Utah legislature is considering a bill that would prohibit smoking in cars carrying children under 6 years old. The bill, which is apparently supported by the Utah chapter of the American Cancer Society, would make smoking in cars with young children a secondary motor vehicle offense, meaning that a car could not be pulled over simply to enforce this particular law. A person could only be pulled over for another motor vehicle offense, and then if also found to be smoking, that individual could then be fined. The fine would be $45, but would be waived if the individual enrolls in a smoking cessation course.

The sponsor of the measure - Senator Scott McCoy of Salt Lake City - argued that the bill is needed because: "They [children] are essentially captives in a very small space with deadly smoke."

The Rest of the Story

There are three elements to the hypocrisy behind this public health measure.

First, if it is true that children riding in a car with a smoker are essentially captives in a small space with deadly smoke, then it is also true that children living in a home with a smoker are essentially captives in a small space with deadly smoke. In fact, children spend a lot more time exposed to smoke in the home than in a car. Even when the magnitude of the exposure is factored in, exposure to secondhand smoke in the home far exceeds exposure in cars, and is a much more important source of childhood health problems, including respiratory symptoms, respiratory infections, ear infections, and asthma. So why would legislators aim to ban smoking in cars with children, but to allow parents to continue to expose their captive children to deadly smoke in the home.

The fact that the sponsor of this bill is willing to intervene in the private car because he sees it as a situation where parents are holding their children captive and forcing them to inhale deadly smoke suggests that he should also be willing to intervene in the private home, where children are exposed - to a far greater extent - to deadly smoke.

How can a legislator acknowledge that:

(1) exposing a child to tobacco smoke is essentially holding them captive and forcing them to inhale a deadly gas;

(2) holding a child captive and forcing them to inhale a deadly gas is unacceptable and must be outlawed by the government; AND

(3) we must allow parents to continue to hold their children captive and force them to be exposed to the same deadly gas, only for far greater lengths of time, in the home.

I can follow arguments #1 and #2, but I don't then follow argument #3.

If we stipulate, for the sake of argument, that points #1 and #2 are accurate, then it not only seems illogical not to reject point #3, but it seems almost callous. How can we knowingly allow parents to expose their kids to a deadly poison? Especially when we have acknowledged that exposing their kids to this deadly poison is completely unacceptable and that government must intervene to outlaw it?

The second element of hypocrisy behind this proposal is the fact that the violation is only made a secondary offense. If parents are truly holding their young children captive and forcing them to inhale deadly and poisonous smoke, and we feel this is an important enough problem to regulate it, then how can we allow police officers to turn a blind eye when they see someone committing this violation?

How can we tell our police: we are serious enough about the problem of parents smoking in cars with young children to ban it, but we are not serious enough to ask you to actually enforce this ban unless someone is committing some other traffic offense?

The third element of hypocrisy is this: if someone merely agrees to enroll in a smoking cessation class, the fine is waived. They don't actually have to quit smoking. They just have to want to quit smoking. Or at least to say that they want to.

If we're really talking about parents exposing their kids to a poisonous and deadly gas, then does it really matter what the perpetrator's intentions are? How does the fact that the person wants to quit smoking affect whether or not they committed an offense which warrants punishment?

What if the person had already enrolled in a smoking cessation class, but had not succeeded? Should that person have to pay the $45?

What about someone who went beyond a smoking cessation class and actually used a nicotine patch for several months? Do we fine them?

How about someone who had actually quit successfully three or four times in the past, but just happened to relapse two days ago?

What about someone who feels that it would be more effective for them to quit without a smoking cessation class? If they promise to quit on their own, does the fine get waived?

What if a violator enrolls in such a class, but never shows up? Do they still have to pay the fine? Who is going to track them down? Are the police going to check the sign-in sheets at all the smoking cessation classes in Utah to see who is there or not?

And how many classes do you actually have to attend? What if you realize that this is not going to work for you after two classes? Do you get called in to pay your fine? What if you actually succeed in quitting after just one class? Do you still have to go to the rest of the classes to avoid having to pay your fine? And who is going to keep track of all this? If no one, then what would stop every violator from simply telling the police officer: "Sorry, officer. I was actually just on my way to sign up for a smoking cessation class."

That's the answer for Utah smokers who want to continue imprisoning their kids and exposing them to deadly smoke. If you get pulled over, just tell the police you were on your way to sign up for a smoking cessation class. Then you need not worry about any penalties. Then, while you're at it, tell them that after registering for the smoking cessation class, you're going to go home and imprison your child in the home, exposing them for hour upon hour to deadly and poisonous smoke, and there isn't a damn thing that the police officer can do about it.

By the way: there is a better way. And there are public health practitioners who are really sincere about trying to protect children from secondhand smoke. At least one state health department - the New York State Department of Health - is putting up $5 million to educate parents about the dangers of secondhand smoke and to encourage parents not to smoke around their children. The campaign will encourage parents not to smoke, but will leave the decision up to them. For those who choose to continue smoking, their decision will be respected, and they will merely be encouraged to avoid exposing their children to the smoke.

Tuesday, September 18, 2007

Editorial Predicts that All Outdoor Smoking will Soon be Outlawed

An editorial in the Walla Walla (Oregon) Union-Bulletin commends the recent decision by the Oregon Health & Sciences University in Portland to ban smoking completely on its campus (indoors and outdoors). In doing so, the editorial predicts that over time, smoking will be outlawed in all outdoor public places.

The editorial states: “Last week officials at Oregon Health & Science University in Portland decided that its entire campus - indoors and outdoors - will be tobacco free as of Sept. 17. The new policy will apply to employees, students, visitors, patients and patient family members. … So why has OHSU taken this ultra-bold step? Officials say OHSU wants to set the highest standard in maintaining a healthy environment. It also wants to serve as a model for others. The reasoning is sound. … bans of this type will occur. Slowly, one by one, outdoor smoking in public places will be outlawed. Society is moving in that direction, and the shift is occurring far faster than we would have imagined even two years ago. And we believe - as do many others who have grown tired of inhaling second-hand smoke - the new direction is a very good one.”

The Rest of the Story

This is an important editorial; the reason I chose to highlight it is that it demonstrates that there is a public perception that the smoke-free air movement is not simply about protecting workers and the public from significant exposure to secondhand smoke which increases the risk of significant health hazards. Instead, it appears that there is a public perception, exhibited by this editorial, that the movement is simply about clearing the air completely of all tobacco smoke and preventing nonsmokers from ever having to inhale any secondhand smoke.

In other words, the editorial is expressing what smokers’ rights group have been saying for many years in their opposition to workplace smoking bans: that this is not just an attempt to protect workers’ health, but instead, is the beginning of an effort whose real goal is to prohibit all smoking outside the home (and maybe even inside the home as well – see this article from Wales).

In testifying in support of well over 100 local smoke-free workplace, bar, and restaurant ordinances, I was often confronted by opposition groups which argued that our (“the antis”) true goal was to ban smoking everywhere. I repeatedly countered these groups by emphasizing that the goal was merely to prevent workers and the public from situations of substantial exposure that could lead to significant, and often devastating health effects. This was not a back-door route to prohibition. This was not an attempt to moralize to smokers and to force them to quit. This was not an attempt to protect nonsmokers from every possible wisp of secondhand smoke exposure. This was truly a life and death issue for nonsmokers who are exposed under conditions where they cannot easily avoid substantial exposure to secondhand smoke.

Unfortunately, it appears that I was wrong. Increasingly, it appears that the actual goal is to completely eliminate all exposure – however brief or insignificant – to secondhand smoke, and to control the behavior of smokers by making it unlawful for them to smoke (not by outlawing smoking, but by disallowing smoking in any particular locations). If you can’t smoke indoors in any public place, you can’t smoke outdoors, and you can’t smoke in your home, then you can’t lawfully smoke.

To my disappointment, not a single anti-smoking group has spoken out to clarify their goals. Not a single group has even bothered to point out that the goal is not to protect nonsmokers from every wisp of tobacco smoke, but instead, to regulate what is a significant health hazard.

When Calabasas proposed an ordinance which essentially banned smoking everywhere outdoors, but exempted the crowded (and financially lucrative) Calabasas Commons, I was the only anti who publicly spoke out against that ordinance. In fact, at least seven anti-smoking groups actively supported that proposal.

When Belmont proposed to ban all smoking outdoors, including at the homes of members of the public – a move which would certainly increase children’s exposure to secondhand smoke (since their parents would be forced to smoke indoors instead of outside) – I was again the only anti to publicly oppose this measure. And I was lambasted for that by my colleagues.

I feel like I was running a marathon and I reached the 26.2 mile mark and stopped running, and everyone else around me just kept on going.

Ironically, I think that it severely weakens our case for workplace smoking bans. For when the opponents get up and suggest that this is just the first step to eventual elimination of smoking everywhere, we can no longer rise and say that they are exaggerating and misreading our true intent.

School Employee Loses Job Because She Smelled of Smoke

According to a Fox News Dallas report, a Denton (Texas) school district employee has lost her job because she smelled of smoke, which apparently aggravated allergies of a special needs student with whom she was assigned to work.

According to the report: “The Denton Independent School District has removed an employee from her position because she smells like cigarette smoke. Suzanne Lidster was thrilled when she was recently hired to assist a student with disabilities at L.A. Nelson Elementary. … But after less than two weeks on the job, Lidster said she received a voicemail informing her that she had lost her position. The school's principal left a message on her cell phone Tuesday morning saying that a doctor said the odor of smoke on Lidster had aggravated the student's allergies. The principal also said that Lidster was not a good fit for the job.”

Lidster reportedly told Fox News that while she smokes about ½ pack per day, she never smokes on the school campus.

The Rest of the Story

Even if it is true that merely the smell of smoke on this woman aggravated a child’s allergies, it seems to me like the school handled this inappropriately. At the very least, I would have thought that the principal would meet face-to-face with the employee to inform her that her position was being terminated because she smelled of smoke. In addition, I think a more prudent course of action would have been to at least give the woman a chance to remediate the situation. Perhaps she would quit smoking. Perhaps she could find a way to eliminate the smell that was allegedly triggering an allergic reaction. Perhaps she could have been reassigned to work with a special needs student who is not sensitive to the smell of tobacco smoke. There seem to be a whole range of viable options available short of leaving a message on her cell phone that she is fired because she smells.

Normally, this story might not have caught my attention. But coming in the wake of yesterday’s post about a man in the UK who is being denied surgery because he is a smoker, I felt it was worthy of reporting here.

While there is no legal issue here (with at-will employment, a worker can indeed be fired for almost any reason), there is an ethical issue. At very least, there is an issue of what is appropriate employer conduct relating to one’s workers. Here, I think the employer showed inappropriate judgment in handling the situation in this way. The interesting question is: Did the employer act this way because the worker being fired was a smoker? Or is this the way all school employees are treated?

Monday, September 17, 2007

UK Doctors Refuse to Fix Man's Broken Ankle Unless He Quits Smoking

According to an article in the Daily Mail, doctors at the Royal Cornwall Hospital in Truro have refused to perform surgery necessary to fix a 57-year-old Cornwall resident's severely broken ankle because he is a smoker.

According to the article: "A man with a broken ankle is facing a lifetime of pain because a Health Service hospital has refused to treat him unless he gives up smoking. John Nuttall, 57, needs surgery to set the ankle which he broke in three places two years ago because it did not mend naturally with a plaster cast. Doctors at the Royal Cornwall Hospital in Truro have refused to operate because they say his heavy smoking would reduce the chance of healing, and there is a risk of complications which could lead to amputation. They have told him they will treat him only if he gives up smoking. But the former builder has been unable to break his habit and is now resigned to coping with the injury as he cannot afford private treatment."

"He is in constant pain from the grating of the broken bones against each other and has been prescribed daily doses of morphine. Mr Nuttall, of Newlyn, Cornwall, broke the ankle in a fall in 2005. Initially he refused surgery because he had caught MRSA at a different hospital four years earlier, and was terrified of history repeating itself. He hoped the fractured bones would knit together with a standard plaster cast to immobilise his ankle. But six months and three plaster casts later, it became clear that an operation to pin the bones was the only solution." ...

"A spokesman for the hospital trust said: 'Smoking has a very big influence on the outcome of this type of surgery, and the healing process would be hindered significantly.'"

The Rest of the Story

This is truly disturbing, and it makes me quite irate. The man obviously needs to have this surgery. The ankle is broken in three places. This is not elective surgery. Refusing to perform the surgery really is sentencing this poor man to a lifetime of chronic pain. The poor fellow is on morphine, for goodness sake!

And all of this is simply because smoking presents an increased risk of surgical complications?

How can you ethically, as a physician, prescribe this patient morphine, which is quickly going to turn him into an opiate addict, yet refuse him surgery that would most likely repair the ankle, simply because he happens to be addicted to nicotine?

The same rationale for refusing surgery for a broken ankle could be used to deny surgery to a patient who is obese or overweight. To be sure, excess weight impairs the healing process and increases the complication rate following surgery. In fact, in my experience, overweight is a far more important than smoking in terms of impaired wound healing and post-operative wound infection.

Are these physicians also going to deny surgery to overweight patients with broken ankles unless they lose weight?

This action by these physicians violates two tenets of the Hippocratic Oath. First, it violates the promise to do no harm to one's patients. By refusing to fix this poor man's broken ankle, the physicians and the hospital trust are undoubtedly doing him harm. The harm is pretty severe: he is being sentenced to chronic pain, so severe that he requires daily morphine injections.

Second, this action violates the provision of the Hippocratic Oath whereby physicians pledge to keep the good of the patient as the highest priority. Here, the good of the patient is being sacrificed in order to save the government money.

In a British Medical Journal commentary supporting the idea of refusing surgery to smokers, Dr Matthew J. Peters argued: "Increased use of hospital beds and associated costs mean less opportunity to treat other patients. Based on these data, five non-smokers could be operated on for the cost and bed use of four smokers and the non-smokers' surgical outcomes would be better. A well informed smoker, unwilling or unable to quit, might assume an increased risk for himself, but the decision is not his alone when it can indirectly affect others. Then, the community must involve itself."

Here is where I think the idea of refusing surgery to smokers becomes dangerous (and not merely callous). The community must involve itself in the individual medical decisions regarding individual patients? That is very scary.

Are we going to start imposing community decisions about whether to allow women to have abortions? Are we going to start refusing medical treatment to heroin abusers when they develop phlebitis from shooting up heroin with unclean needles? Are we going to refuse medical treatment to alcoholics who abuse alcohol and end up with liver disease or esophageal varices? Do we just let them bleed to death unless they promise to stop drinking?

If I may close by borrowing the opening words of the opposing BMJ commentary written by my colleague at Boston University - Professor Leonard Glantz: "One of the noblest things about the profession of medicine has been its single minded devotion to patients. Doctors routinely treat patients who are despised by the society in which they live—enemy troops, terrorists, murderers. Given this, it is astounding that doctors would question whether they should treat smokers. The issue for doctors is whether they will allow the current antismoking zeal in America, the United Kingdom, and western Europe to infect their practice and undermine the doctor-patient relationship."

I would extend that statement to say that the issue is whether the current antismoking zeal with infect anti-smoking groups. The easiest way to put a halt to this type of nonsense would be for the anti-smoking groups to speak out against it. I just don't see that happening.

Thursday, September 13, 2007

Scottish Smoking Ban Study is Example of Science by Press Release

I have now confirmed that the Scottish smoking ban study which I discussed earlier this week is indeed an example of science by press release. An article from the Times Online confirms that the study was presented at a conference in Edinburgh on Monday and that the study has not yet been published. Furthermore, the media coverage of the study was not a coincidence; it was the direct result of a press release that was issued by the University of Glasgow (home of the lead study researcher) on Sunday. Finally, I was unable to find the actual study, so it does not appear that the study has been made readily available for review.

According to the press release: "A University of Glasgow study has found a 17 per cent fall in admissions for heart attacks in the first year after the smoking ban came into force. The evaluation, led by Professor Jill Pell from the University’s BHF Cardiovascular Research Centre, found that after the legislation came into force there was a 17 per cent reduction in heart attack admissions to the hospitals. This compares with an annual reduction in Scottish admissions for heart attack of 3 per cent per year in the decade before the ban."

Also of interest, data obtained from ISD (Information Services Division) Scotland reveal that between 1998/1999 and 1999/2000, total hospital discharges for acute myocardial infarction (heart attacks) in Scotland dropped from 19,216 to 17,208, a decline of 10.4%. This large single-year decline occurred during a period in which the smoking ban was not yet in effect.

These data also reveal that there was a steady decline in heart attack admissions in Scotland between January 2005 and September 2006 (the smoking ban was implemented in March 2006). From December 2005 to February 2006 (prior to the smoking ban), there was a 16.7% drop in heart attack admissions for the regions for which data were consistently reported throughout the study period.

The Rest of the Story

It does appear that the Scotland smoking ban/heart attack study is yet another example of science by press release. I view it as inappropriate and perhaps unethical to disseminate the results of a study widely to the media and the public before the research has been peer reviewed and published, unless one also releases the study itself so that the underlying methodology can be examined. Otherwise, we are all completely at the mercy of the researchers and there can be no independent review of the study findings and their validity.

In my career to this point, I have never released study findings to the public unless: (1) they had been peer reviewed and published; or (2) they were not yet published but I made the study readily available for review. I think that if you are going to release the results of a study, then it is your obligation to make the complete study (including the methodology and actual raw data) available for public review.

This science by press release approach is contributing to the decline in scientific integrity in the tobacco control movement.

To see why a thorough review of the actual study is necessary, just look at the hospital discharge data for heart attacks in Scotland. We find evidence of a large single-year decline in heart attacks of about 10% which occurred in the absence of any smoking ban. This indicates that there can be a large year-to-year variation in heart attacks in Scotland and makes it especially difficult to determine whether a 17% annual decline in heart attacks is due in part to random variation, and if so, to what extent. From the information that was provided to us, it is impossible to conclude that the smoking ban was responsible for the observed decline in heart attack admissions.

It is also important to consider the fact that the more rapid decline in heart attack admissions in Scotland appears to have begun prior to the smoking ban. A drop in heart attack admissions of 17% (equal to what was observed after the smoking ban) actually occurred during the three-month period immediately prior to the smoking ban. It would be very questionable to attribute the observed heart attack decline to the smoking ban in the face of this evidence that heart attacks were declining substantially prior to the ban. It is entirely possible that some other factor is responsible for the observed decline.

The point is - simply - that we don't know. The evidence is not sufficient to support the researchers' contention that the smoking ban in Scotland has caused a 17% decline in heart attacks. Without having the complete study in front of us to review, we cannot even judge the validity of the researchers' contention (except to say that based on the data that are available and have been presented, there is not sufficient evidence to support their conclusion).

Does it really advance the cause of accurate scientific reporting to have the media widely report these conclusions to the public in the face of this complete lack of documentation and support and in the absence of any possible way to confirm the validity of the results?

From what I can tell at present, there is not sufficient evidence to conclude that the observed decline in heart attack admissions in Scotland is attributable to the smoking ban. That conclusion is premature and should not be disseminated further by anti-smoking groups until we have the actual research study in front of us and can review it.

Why the rush to release the results before they were published? One has to wonder.

And one final question: Why does it seem that it is the weakest studies that are disseminated by press release prior to their actual peer review and publication?

Wednesday, September 12, 2007

USA Today Highlights Debate Over FDA Tobacco Legislation

Today's USA Today features a point-counterpoint debate over the proposed FDA tobacco legislation. The newspaper supports the FDA legislation because, as it argues, federal regulation of tobacco products simply makes sense. In the counterpoint, Dr. Alan Blum and I oppose the legislation as representing an absurd regulatory approach and containing numerous loopholes, inserted to protect Big Tobacco, which render the legislation ineffective.

The newspaper's position is that since Cheerios are regulated by the FDA, why shouldn't tobacco products also be regulated. The proposed FDA legislation would give consumers key data, according to the paper, such as the ingredients and the constituents present in the tobacco smoke. In addition, the legislation would prevent tobacco companies from making false claims about the health advantages of tobacco products. The piece concludes by arguing that "the alternative is doing nothing — leaving a rapacious industry free to deceive the public. FDA authority would give consumers a fighting chance to learn the facts and make more informed decisions about whether to use tobacco products. If a spinach leaf is worthy of government regulation, surely a tobacco leaf deserves at least as much scrutiny."

In the counterpoint, Dr. Blum and I point out that the bill was crafted, in part, by Philip Morris. The bill represents the results of a negotiation between Philip Morris and the health groups (represented by the Campaign for Tobacco-Free Kids) and key provisions of the bill were crafted in such a way to limit the FDA's power to actually do anything meaningful that would reduce tobacco use or protect consumers. These provisions were inserted specifically to appease Big Tobacco, especially Philip Morris.

For example, while the bill bans chocolate, strawberry, and grape flavorings -- which aren't used in cigarettes anyway -- the bill exempts menthol, a flavoring which is successfully used to help entice millions of actual Americans (and especially African-Americans) to smoke or continue smoking.

While the bill purports to aim to reduce youth smoking by controlling youth access to tobacco products, it precludes the FDA from doing the two things that would result in the most meaningful access restrictions: (1) increasing the legal age of cigarette purchase; and (2) limiting the places where cigarettes may be sold.

We argue: "That the bill was written with input by Philip Morris, America's largest cigarette maker with its top-seller, Marlboro, should make us skeptical that Congress is finally standing up to Big Tobacco. Though the bill would attempt to regulate new tobacco products, it would permit Marlboro and other popular brands to stay on the market virtually untarnished, even as they cause the deaths of nearly half a million Americans each year. Although the bill would ban the use of strawberry, grape and similar candy flavorings, it wouldn't require the FDA to ban menthol (the flavored anesthetic in brands advertised to African-American and Hispanic populations) or to eliminate the more than 40 known cancer causers in cigarette smoke. The bill's loopholes make Swiss cheese look like granite: One would preclude the FDA from making cigarettes non-addictive by eliminating nicotine."

The Rest of the Story

I congratulate USA Today for highlighting this important debate and I am grateful for them giving me and Dr. Blum the opportunity to lay out our position.

I would respond to their editorial position by making the following observations:

1. I think they are exaggerating the benefits of forcing tobacco companies to disclose the cigarette smoke constituents and ingredients. We already know that cigarette smoke is toxic and carcinogenic. We have already identified over 700 ingredients in the cigarettes, more than 40 carcinogens in cigarette smoke, and more than 4,000 other toxins in the smoke. The names of these chemicals are readily available. I don't see that knowing the names of these chemicals is making any significant contribution to informing people about the risks of these products. Nor do I see how it would help for consumers to have a complete list of the chemicals, rather than the information that they already have. How is it going to help consumers to have a list of perhaps 100,000 chemicals rather than a list of 4,000 chemicals?

2. While the fact that Cheerios are regulated and tobacco products are not regulated would certainly argue for some sort of tobacco product regulation, that does not necessarily mean that this particular legislation would be an effective public health measure. If the FDA were to be given unfettered authority to regulate tobacco products, I would agree that the public health benefits could be substantial. However, that's not what this bill does. What the bill does is tie the FDA's hands in every way that it could actually make a substantial dent in smoking rates. And it does this specifically to protect Philip Morris' profits. Exactly how is that good for public health?

3. The alternative to the proposed legislation is not the status quo. The alternative is for Congress to actually do something meaningful about the problem of tobacco use. Put money, for the first time, into a serious anti-tobacco advertising campaign (like the "truth" campaign). Create or restore well-funded anti-smoking media campaigns in all 50 states. These campaigns represent the most successful intervention available to reduce tobacco use. If Congress really wanted to do something about the problem, our legislators would put their money where their mouths are. They would allocate money to fund such a program in every state.

Of note, Senator Enzi has crafted a proposal that would accomplish just this. While I think the funding mechanism needs some work (the bill would fine cigarette companies if they fail to reduce the number of smokers of their brands to prescribed levels; it would also increase federal cigarette excise taxes), I think the general idea makes sense.

If the anti-smoking groups really want to do something meaningful about addressing the tobacco epidemic in this country, they should stop wasting precious time and resources supporting the FDA legislation and instead, they should work with legislators like Senator Enzi on crafting a bill that would utilize the approaches to reducing tobacco use that are tried and true prevention strategies.

Tuesday, September 11, 2007

Science by Press Release: The New Tobacco Control Approach for Disseminating Junk Science

In addition to representing shoddy science, the Helena and Helena-like studies of changes in heart attack admissions following smoking bans seem to have introduced a new style of scientific "inquiry" into tobacco control: science by press release.

Instead of waiting until research is peer-reviewed and published in scientific journals, anti-smoking researchers now seem to be releasing their results (but not their full papers) to the media prior to peer review. Just this week, we learned of two new studies - one in Ireland and one in Scotland - which purportedly show that the implementation of smoking bans in those countries resulted in a dramatic decline in heart attack admissions.

It appears that the Helena study set the trend for this science by press release approach. An April 2003 press release announced that the Helena smoking ban resulted in a 60% decline in heart attack admissions within the first six months that the ordinance was in effect. This press release was apparently issued when the paper was first presented at a scientific conference, but before it had been peer reviewed and published. The paper was not published until April 2004, one full year after its preliminary conclusions had been disseminated via press release. As it turns out, the data in the initial press release was wrong. The decline in heart attacks was only 40%, not 60%.

After researchers noted a 27% decline in heart attacks in Pueblo following a smoking ban, the results of their study was also disseminated by press release prior to publication in any journal.

Now comes the Ireland study, the results of which were disseminated widely to the public last week through the media, via press release (see page 69 of the media guide). However, the study was merely presented at a conference. All that I could find was an abstract. Apparently, there was no paper available for public review, no peer review, no publication in any scientific journal.

Days later comes the Scotland study, the results of which again appear to be presented at a conference, but not peer reviewed or published, and the methodology of which does not appear to be available for public review.

The Rest of the Story

First, I would note that it appears to be the most shoddy scientific findings for which this science by press release approach is taken. This approach makes sense. Allow the results to have a maximum impact on the media and the public before they are peer reviewed. That way, if the results need to be toned down for publication, the damage has already been done.

This was certainly the case with the Helena study. The media - including this CBS news story - widely reported a dramatic 60% decline in heart attacks. That turned out to be wrong, but so what? The news had already been reported, and the damage was done.

Second, I have to say that I believe it is inappropriate, and perhaps unethical, to use this approach of science by press release. I firmly believe that the time to release scientific results to the public is when the paper is published in a peer-reviewed journal. If the results are not published in a journal, or if they need to be released prior to publication, then it is imperative that the researchers make the entire study easily available for public review. Otherwise, there is no way for the public to judge the validity of the results. The public becomes totally dependent upon the researchers' word.

I find this science by press release approach to be yet another disturbing development in the tobacco control movement. This, too, is in my view contributing toward the degradation of the scientific integrity of the movement.

Monday, September 10, 2007

New Research Suggests that Cigarette Price Increases No Longer Stimulate Smoking Cessation

A new study published online ahead of print in the American Journal of Public Health concludes that contrary to the popular wisdom in tobacco control, cigarette price increases are no longer an effective strategy to reduce adult smoking prevalence. In addition, the study concludes that cigarette price increases impose a disproportionate burden on poor smokers (see: Franks P, Jerant AF, Leigh P, et al. Cigarette prices, smoking, and the poor: implications of recent trends. Am J Public Health 2007; 97).

The study examined the relationship between cigarette price and smoking participation (not cigarette consumption) during the period 1984-2004. Overall, the study found that the increasing price of cigarettes over time was associated with a marked decline in smoking only for higher-income individuals, not for lower-income persons.

Prior to the Master Settlement Agreement (MSA), there was a strong association between increasing cigarette price and reduced smoking participation, with the price elasticity being significantly larger among lower-income (-0.45) versus higher-income (-0.22) persons. After the MSA, there was no significant association between cigarette price and smoking participation in either income group.

The authors conclude: "Despite cigarette price increases after the MSA, income-related smoking disparities have increased. Increasing cigarette prices may no longer be an effective policy tool and may impose a disproportionate burden on poor smokers."

The Rest of the Story

This is an important study because it challenges the popular wisdom in tobacco control that increasing cigarette excise taxes is an effective strategy to promote smoking cessation. That assumption is a key one that is being used by anti-smoking groups to support state and federal cigarette tax increases -- in particular, the proposed 61 cents per pack increase in the federal cigarette excise tax to provide revenues for the expansion of the State Children's Health Insurance Program (SCHIP).

For example, the Campaign for Tobacco-Free Kids has estimated that a 61 cents per pack tax increase will result in 171,000 adult smokers quitting. This estimate is based on a price elasticity of -0.2 for smoking participation among adults.

While the Campaign for Tobacco-Free Kids' assumption is supported by this new study using data for prior to the MSA, it is not supported by the post-MSA data. The post-MSA data suggest that smoking participation is no longer price sensitive, which would render the Campaign's estimate invalid.

It is important to note that according to these authors, the prevailing wisdom that there is a significantly negative price elasticity for smoking participation is based on data that were obtained prior to the MSA. The authors report that their study is only the second to use post-MSA data and that their results are in concordance with the one prior study that examined the more recent data (see: Colman G, Remler DK. Vertical equity consequences of very high cigarette tax increases: if the poor are the ones smoking, how could cigarette tax increases be progressive? Cambridge, MA: National Bureau of Economic Research; 2004. NBER Working Paper 10906).

The prior study concluded as follows: "We find that the price elasticity of smoking participation is -.14 for the lowest income tercile, -.05 for the middle income, and -.21 for the high income. We find that the price sensitivity of conditional consumption, cigarettes smoked by smokers, shows no robust pattern with income and is frequently insignificant. Thus, our results challenge the conventional view that price sensitivity falls monotonically with income. Our predictions of the equity consequences of tax increases show that using all traditional measures of progressivity, whether based on tax expenditures or welfare, cigarette tax increases are not close to progressive."

There are two important limitations to this study. First, it pertains only to smoking participation, not to cigarette consumption. Thus, it is still possible that smokers cut down on the amount they smoke in response to price increases.

Second, the study pertains only to adult smoking, not to youths.

In light of these limitations, I think there are two important implications of this research.

First, the research suggests that cigarette tax increases may no longer be effective in stimulating adult smoking cessation. It is possible that previous tax increases have "skimmed off" the less addicted smokers who were more motivated to quit smoking and thus left a population of smokers which is more addicted and less interested in quitting -- and thus much less price sensitive.

Second, the research suggests that cigarette tax increases are now increasing, not decreasing, income-related disparities in smoking prevalence. Combined with the Colman and Remler study, this new paper provides evidence that cigarette tax increases now do impose a disproportionate economic burden on the poor.

These are important considerations in light of the proposed use of an increased federal cigarette tax to fund an expansion of the SCHIP program. They add to the strength of my argument against this approach.

Wednesday, September 05, 2007

Editorial Notes Government's Addiction to Tobacco Revenues

An editorial in the Waterbury Republican-American (CT) cautions against the increasingly common practice of using cigarette tax revenues to fund critical government programs. The newspaper argues that relying upon cigarette taxes to fund ongoing programs creates a state dependence upon smoking by its residents, similar to an addiction to cigarettes themselves.

According to the editorial: "All together, taxes on smoking and drinking plus gambling revenues [in Connecticut] provided a hair over $1 billion in fiscal 2005, a year in which the state posted a surplus of $602 million. In other words, in fiscal 2005, money from smoking, gambling and booze made the difference between Connecticut showing a profit and running a deficit of more than $400 million. In fiscal 2006, the surplus came in at $925 million — uncomfortably close to the full amount the state collected from drinking, smoking and gambling — and the legislature promptly spent nearly all of that surplus on new programs that will have to be sustained from now on. Here's another way of looking at it: By committing "sin-tax" revenues to ongoing programs, the legislature has deliberately turned Connecticut's government into a gambling, nicotine and alcohol junkie. Lawmakers would be well advised to start weaning the state from such addictions before an unforeseen crisis forces the state to go cold turkey."

The Rest of the Story

This is an important argument and it is the primary reason why I think it is a great mistake for Congressional lawmakers to be proposing an increase in the cigarette tax to fund an expansion of SCHIP (State Children's Health Insurance Program).

While I think it would be important to expand children's health insurance coverage, I think there are far wiser ways to generate the needed revenue. Using cigarette taxes to do it is the least sensible option.

I hope that anti-smoking groups will reconsider their position and not force us into a situation where we will be dependent upon smokers to provide health insurance for our nation's children.

The Next Helena: New Study Concludes that Smoking Ban in Ireland Caused 15% Decline in Heart Attack Admissions

A new study presented this week at the annual scientific symposium of the European Society of Cardiology concludes that the smoking ban in Ireland resulted in a 14.5% decline in heart attack hospital admissions during the first year after its enactment.

A Reuters article from yesterday boasts: "Heart attacks tumble after Irish smoking ban" and quotes the study authors as arguing that their research demonstrates the need for further smoking bans.

According to the article: "Ireland's rate of heart attacks fell by around a tenth in the year following the introduction of the world's first nationwide ban on workplace smoking, boosting the case for more similar bans, doctors said on Tuesday. Edmond Cronin and colleagues at Cork University Hospital said an analysis of people admitted with heart attacks to public hospitals in southwest Ireland showed an 11 percent fall in the year after the ban came into effect in March 2004."

In a Telegraph article, the lead study author was quoted as stating: "A national ban on smoking in public places resulted in a decrease in admissions for heart attack, especially in smokers. Our study provides evidence of the rapid effect of banning smoking in public places on decreasing the burden of heart attacks."

The Rest of the Story

What these news articles and quotes do not tell you is that while the study authors compared the number of heart attack admissions in southwest Ireland in the year following the smoking ban with the number of heart attack admissions in the year preceding the smoking ban, they only looked back an additional nine months in order to assess the baseline trend and year-to-year variability in the number of heart attack admissions in this region.

What this means is that there is simply no way to assess whether the observed 14.5% decline in heart attack admissions from 2003 to 2004 was due to the smoking ban or if it was instead due to a pre-existing secular trend in heart attack admissions, or if the change merely reflects underlying variability in the data.

In order to establish the baseline trend in heart attack admissions over time and to assess the degree of year-to-year variability in heart attack admissions, one would need to go back in time much more than simply nine months. Otherwise, these data are virtually meaningless.

For example, the study reports that there were 1277 admissions in 2003 and 1092 admissions in 2004. Suppose that in 2001 there were also about 1280 admissions. This would be consistent with the conclusion that the smoking ban resulted in a significant decline in heart attacks.

However, suppose that in 2001 there had been 1500 heart attack admissions. Then, it would be clear that a 15% decline in heart attack admissions from one year to the next is a common occurrence and that it could not be inferred that the 15% decline from 2003 to 2004 was attributable to the smoking ban.

Complicating matters is the fact that the authors found no decline in heart attack admissions from 2004 to 2005, despite the continued presence of the smoking ban.

In fact, it turns out that there is a secular trend of sharply declining heart attack mortality in Ireland. While this doesn't necessarily mean that heart attack incidence is declining, it does suggest that there may have been a trend of declining heart attacks in Ireland even before the smoking ban went into effect.

Cardiovascular disease mortality in Ireland has in fact been falling rapidly. Over the past 15 years, it has declined by about half. Some of this decline is due to decreased heart attack incidence. And some of that reduced incidence is due to a drop in smoking rates. All of this happened, of course, before the smoking ban went into effect.

Ischemic heart disease mortality in Ireland decreased by 8.6% in 2003, the year immediately preceding the smoking ban. In 2004, ischemic heart disease mortality declined by only 1.8%.

Does this mean that the smoking ban resulted in an increased rate of death from heart attacks than would have been expected? Of course not. You can't simply look at a change from one year to the next and attribute it to the smoking ban. You have to carefully examine long-term secular trends, variability in the data, and other factors that affect cardiovascular disease rates.

These problems, however, did not seem to stop the authors of this study from drawing a sweeping conclusion that is completely unjustified by the data which they report. This seems to be par for the course in the tobacco control movement right now. Junk science is passing for perfectly valid science in tobacco control these days.

It will be interesting to see how long it takes for the anti-smoking groups to catch wind of these data and to start spreading these junk science claims widely to the public and policy makers. My guess: it will take only as long as it takes for secondhand smoke exposure to cause hardening of the arteries.

Tuesday, September 04, 2007

More than 6,000 U.S. Employers Refuse to Hire Smokers

According to a recent article in the Daytona Beach News-Journal, at least 6,000 U.S. employers refuse to hire smokers, and the number may be even higher than that.

The article states that "in recent years a growing number of firms nationwide have decided that allowing employees to smoke only outdoors is not enough. At least 6,000 employers refuse to hire smokers, according to the National Workrights Institute, an affiliate of the American Civil Liberties Union or ACLU. Jeremy Gruber, a spokesman for the group's New Jersey affiliate, said the figure is probably higher. 'That was an old survey,' Gruber said recently. 'It has become far more prevalent.'"

The article explains that: "At private companies, economics, not surprisingly, is the driving force behind the growth in anti-smoking regulations, with savings on health care as a primary reason. The Centers for Disease Control and Prevention estimated that it cost the nation $3,383 a year for every smoker. That breaks down to $1,760 in lost productivity and $1,623 in medical bills."

One such company is Orland Beach, Florida-based The Homac Companies, a designer, manufacturer, and distributor of electrical connectors. If you click on the Careers link looking for a position with the company, you will be greeted by the message "Tobacco Free Candidates Only." Even if you are just looking for an internship with Homac, you are also greeted by the message "Tobacco Free Candidates Only."

Homac's mission is "to be a premier manufacturer and supplier of Electric Power Delivery Connectors and Cable Accessories; we are committed to world class performance as demonstrated by continuous improvement in safety, innovation, quality, cost, flexibility, and customer satisfaction."

The Rest of the Story

This is a great example of blatant employment discrimination. Whether one smokes or not, or uses smokeless tobacco or not, has no relevance to one's qualifications for a job making and selling quality electrical connectors and accessories. Can you tell me in what way an employee's smoking status affects his ability to design, develop, make, distribute, or sell an aluminum bus support bolt circle height adapter or a #4 - 250 AAC bolted aluminum cable?

If anything, this job discrimination makes it more difficult and less likely that Homan will be able to produce quality bolted aluminum cables because they are automatically precluding from potential employment about 20% of the population, which undoubtedly includes some of the most qualified candidates for such a job.

Tobacco use status of an employee also has no relation to the Homan Companies mission. How does whether an employee smokes or not in the privacy of his or her own home affect the company's mission of being a premier manufacturer and supplier of electric power delivery connectors and cable accessories?

Perhaps I could understand if this were a company whose mission was to provide smoking cessation services to addicted smokers, but how does my smoking status affect my ability to make electrical connectors?

Perhaps more importantly, what right does my employer have to even inquire about my lawful personal behavior in my own home, if it is not directly related either to a bona fide job requirement or to the company's mission?

One might argue that the employer has the right to ask about my tobacco use in my home because he wants to reduce health care costs and he believes that my health care costs may be higher if I am a smoker. The problem is that if the invasion of my privacy about my own personal lifestyle is justified in order for the employer to reduce his health care costs, then the employer is also perfectly at liberty to ask me about my diet, the number of times I exercise each week, how much I weigh, and various aspects of my sexual behavior (limited only, in some states, by questions related to my sexual orientation).

For example, the company would be perfectly justified in greeting potential job applicants with the message "Fat People Need Not Apply," "One Sexual Partner Applicants Only," or "Applicants without Children Under Five Years Old Only."

My argument here is that not only is this blatant discrimination, but it is an undue invasion of individual privacy. Can you imagine having to fill out a questionnaire about all of your personal health habits, including your diet, physical activity, hours of sun exposure, use of sunscreen, use of seat belts, and sexual behavior before even being allowed to apply for a job?

It's pretty obvious to me that such a questionnaire would represent an undue, and obnoxious, invasion of privacy. So why then is it not similarly an inappropriate invasion of privacy to ask about my tobacco use history?

The answer is simple: it is an inappropriate invasion of privacy to ask about my tobacco use off-the-job, unless it is directly related either to the job requirements or to the company mission.

The failure of any U.S. anti-smoking groups to speak out against this widespread employment discrimination and invasion of privacy is unfortunate, and it illustrates the "end justifies the means" mentality of the modern anti-smoking movement.

Sure - discriminating against smokers and interfering with their privacy may help to lower smoking rates and save employers money. But it is inappropriate and has no place in public health. Anti-smoking groups should be ashamed of themselves for failing to speak out strongly against this obnoxious practice.