Conflating Coronary Blood Flow and Coronary Flow Velocity Reserve: The Basis for Anti-Smoking Groups' Misleading Health Claims

I thought it might be worthwhile to devote one post to explain the basis for much of the deception of the public that is going on regarding the acute cardiovascular effects of brief secondhand smoke exposure, including the deception by ClearWay Minnesota which I highlighted yesterday, the deception of ANR which I highlighted back in March, and the deception of the American Cancer Society and Campaign for Tobacco-Free Kids which I highlighted in May.

You may recall that one of the deceptive claims being made by ClearWay is that secondhand smoke exposure decreases coronary artery blood flow in healthy young adults.

First, it is important to recognize the significance of this claim. A reduction in coronary artery blood flow implies that there is a serious risk that not enough blood flow which reach the heart muscle. And if that occurs, the person will suffer a heart attack. Such a heart attack can be fatal. Therefore, what ClearWay and other anti-smoking groups which have made similar statements are implying is that a healthy young adult exposed to secondhand smoke is at risk of death due to that exposure.

That bears repeating. What anti-smoking groups are implying is that a healthy young person exposed to secondhand smoke is at risk of death due to that exposure.

If this claim were accurate, then I think it would provide strong justification for banning smoking altogether. After all, how can we take the risk that healthy young people who are simply walking down the street and happen to be exposed to secondhand smoke might suffer a decrease in coronary artery blood flow and drop dead from a heart attack?

Not only is Clear Way Minnesota making this claim, but they are encouraging local anti-smoking groups to make the same claim. The claim appears in a smoking ban manual whose purpose is to provide direction and advice to anti-smoking groups advocating for smoking bans. ClearWay is essentially telling these groups that an appropriate tactic for promoting smoking bans is to publicly state that exposure to secondhand smoke can kill healthy young adults by decreasing the blood flow in their coronary arteries.

Note that whether ClearWay intends to imply this or not isn't important. What's important is that their statement inherently implies the risk of heart attack and death. So if this implication is false, then the statement is what I would consider to be wildly deceptive.

A similar claim is being made by Americans for Nonsmokers' Rights (ANR), which claims that: "Even a half hour of secondhand smoke exposure causes 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."

Clearly, this statement is implying that a half hour of secondhand smoke exposure impairs the body's ability to get life-giving blood to the heart, putting even a healthy young individual at risk of a heart attack and therefore of death.

If this statement is false, then ANR's statement is wildly deceptive. After all, would it not be deceptive to imply that secondhand smoke impairs the body's ability to provide adequate blood to the heart and therefore puts a person at risk of a heart attack and death if that is untrue?

At an even higher level, a similar claim is being made by the American Cancer Society and the Campaign for Tobacco-Free Kids in a strategy document intended to guide anti-smoking groups nationwide in communication tactics to promote smoking bans.

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 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."

Here, not only are anti-smoking groups instructed to tell the public that 30 minutes of secondhand smoke reduces blood flow to the heart, but they are told to explicitly state (rather than merely imply) that this 30 minute exposure causes atherosclerosis, heart disease, heart attacks, and stroke.

What the American Cancer Society and Campaign for Tobacco-Free Kids are stating, then, is that just 30 minutes of secondhand smoke exposure reduces blood flow to the heart and causes hardening of the arteries, heart disease, heart attack, and stroke. This particular communication leaves little to the imagination.

The Rest of the Story

So here's the truth: The truth is that what acute secondhand smoke exposure does is to reduce not coronary artery blood flow, but coronary flow velocity reserve. There's a huge difference between these two, and they should not be conflated.

Coronary flow velocity reserve is a measure of the ability of the coronary arteries to dilate in order to increase blood flow under experimental conditions. What a decline in coronary flow velocity reserve indicates is something called endothelial dysfunction - an impairment of the ability of the coronary arteries to dilate in response to a variety of stimuli. This ability to dilate is mediated by the endothelial cells -- the cells which line the blood vessel.

The endothelial cells respond to certain stimuli by producing nitric oxide and other chemicals which diffuse into the smooth muscle in the artery wall, sending a chemical message that causes the muscle to relax and therefore causing the artery to dilate. There are a number of exposures that impair the ability of the endothelium to accomplish this function; among them are active smoking, secondhand smoke, high cholesterol, consumption of trans-fats, and consumption of a high-fat meal.

When endothelial dysfunction is triggered repeatedly over a long period of time, it has been shown to result, ultimately, in atherosclerosis (narrowing of the coronary arteries). When this occurs, coronary blood flow is reduced.

It is important to note that a reduction in coronary blood flow is not observed acutely when the endothelial dysfunction is being measured from a single experimental exposure (such as in the Otsuka et al. study). The reduction in coronary blood flow does not occur until the process has been sustained long enough that atherosclerosis has progressed and the coronary artery has actually narrowed. It is the narrowing of the artery that causes reduced coronary blood flow.

A single high-fat meal has been documented to cause endothelial dysfunction. If you were to go to Burger King for a Whopper, fries and a milk shake and then go to a laboratory to have your coronary flow reserve velocity tested, you would find that it is reduced. In fact, it will probably be reduced to the same level as in an active smoker.

Would it therefore be accurate for an anti-obesity group to claim that eating a hamburger reduces coronary artery blood flow in healthy young adults?

I would argue that it would not. In fact, I think such a statement would be very misleading and deceptive to the public.

Instead, what the science shows is that eating a hamburger or any high-fat food causes endothelial dysfunction. Therefore, if you chronically eat lots of fatty foods over a long period of time (many years), the evidence indicates that this could cause atherosclerosis and heart disease. If you do develop heart disease, then your coronary blood flow will be decreased and you will be in danger of possibly suffering a heart attack. But there is no danger of death or a heart attack after simply eating one Whopper.

By conflating coronary blood flow with coronary flow velocity reserve, anti-smoking groups have, I think, been able to deceive people into thinking that the effects of acute secondhand smoke exposure are much more severe than they actually are.

This is a clever tactic, I believe, because it sensationalizes the acute health effects of secondhand smoke, implies to the lay public that a brief exposure can be fatal for even a healthy, young person, and I think it would scare people sufficiently that it would increase support for smoking bans - which is the ultimate goal (and a goal I support [at least workplace smoking bans]).

But in order to achieve the "benefit" of a much more shocking and emotional public communication, have we not distorted the science and ended up misleading and deceiving the public?

I think the answer is a definite "yes." I see no compelling way to argue that by using the term "coronary blood flow" rather than "coronary flow velocity reserve," we have not ended up deceiving anyone. In fact, I think the difference is enormous and the difference in the implications are even more enormous.

I don't think it's fair to do this to the lay public, because they are simply not in a position to be able to understand and interpret these communications in a critical and informed manner. When they are told that coronary blood flow is reduced, they are naturally going to assume (at least many of them will) that this is reducing blood flow to the heart, which even the lay public understands is what causes a heart attack.

There is no question in my mind that the implication of these public statements to a large segment of the lay public is that acute and brief secondhand smoke exposure can cause death by heart attack among healthy young adults. Such an implication, it is important to point out, is completely false.

I think the conclusion is therefore inescapable that these anti-smoking groups - such as ClearWay - which have stated that brief exposure to secondhand smoke reduces coronary blood flow in healthy young adults, are deceiving the public.

Since we criticize the tobacco companies all the time for deceiving the public in their public communications, especially regarding the effects of tobacco smoke, what possible justification can we provide for deceiving the public ourselves in our own public communications?

I don't think there is one. I think this deception is unjustified and wrong. It is unethical, and I think it needs to stop. I also think we need to retract or correct our statements and apologize for having deceived the public, whether that deception was intentional or not.


UPDATE (December 8, 2006; 12:30 pm): ClearWay Minnesota's smoking ban manual, which contained the statement referred to in this post, has been removed, at least temporarily, from its website (it is unaccessible). It will be interesting to see whether the deceptive claims are being retracted or corrected, but at any rate, this appears, possibly, to be an encouraging sign.

Minnesota Anti-Smoking Organizations Fail to Respond to Challenge; What May Have Been Simple Mistake Now Appears to Have Become Intentional Deception

Last Tuesday, I issued a challenge to two Minnesota anti-smoking groups to retract or correct inaccurate public statements that they made or were making about the acute health effects of secondhand smoke. This challenge was communicated directly to representatives of both groups via email.

The first challenge, issued to the Association of Nonsmokers - Minnesota, was to retract its fallacious (and absurd) claim, issued in an August 30 press release, that just 30 seconds of secondhand smoke exposure causes damage to the coronary arteries of nonsmokers that is equivalent to the damage suffered by active smokers:

"Research studies have shown that even just thirty seconds of exposure to secondhand smoke can make coronary artery function of non-smokers indistinguishable from smokers."

The second challenge, issued to ClearWay Minnesota, was to retract or correct its fallacious claims that: (1) brief exposure to secondhand smoke causes decreased coronary artery blood flow in healthy young adults; and (2) eating in a smoky restaurant increases the risk of fatal and non-fatal cardiac events in nonsmokers by 30%:

(1) "Blood flow in the coronary arteries is decreased in healthy young adults exposed to secondhand smoke."

(2) "Current scientific data suggest that eating in a smoky restaurant can precipitate myocardial infarctions in nonsmokers and increase the risk of fatal and non-fatal cardiac events in nonsmokers by about 30 percent."

In response to this challenge, neither the Association for Nonsmokers - Minnesota nor ClearWay Minnesota took any action of which I am aware.

Nowhere on the Association for Nonsmokers website can I find a retraction, correction, or apology of any kind for it deceiving the media and potentially the public into believing that the coronary artery function of an active smoker is no worse than that of a nonsmoker who is exposed to tobacco smoke for just 30 seconds. And I am similarly unaware of any subsequent press release issued by the group to correct its original press release.

ClearWay Minnesota did not correct either its inaccurate and deceptive claim that a healthy young nonsmoker exposed to secondhand smoke will suffer a decrease in coronary blood flow or its claim that a nonsmoker who eats in a smoky restaurant will suffer a 30% increased risk of a heart attack. The smoking ban manual retains the original fallacious claims.

The Rest of the Story

It has been 9 days since I issued the challenge, and much longer than that since I first communicated my concern over these inaccurate and misleading claims to these organizations. There has been plenty of time for these anti-smoking groups to correct, retract, or otherwise alter these public claims if they really wanted to do so.

Therefore, I am left in the uncomfortable position of having to infer that the deception of the public about the acute effects of secondhand smoke inherent in these claims is not any more simply an innocent mistake. It appears to me that at this point, this rises to the level of intentional deception of the public.

In other words, it certainly appears to me that both organizations have made an intentional choice, with awareness of my contention of the accuracy of these claims, to retain and stand by their statements.

While I suppose there is a possibility that none of my emails to anyone in either of these organizations went through for some reason, I have no reason to believe that is the case, and I happen to know for a fact that my email to one of the organizations did go through and a key representative of that group was aware of my concerns. I think it is therefore not unreasonable to infer that the retention of these fallacious claims is being done with some intent, and not simply out of a complete lack of awareness that there might be something wrong with these statements.

If this is the case, then I believe that it demonstrates more than simply a mistake, oversight, or carelessness. At this point, it certainly appears that it demonstrates the intention of misleading the public about the health effects of secondhand smoke. This, in my view, is unethical.

As public health organizations, I believe it is our ethical duty to provide the public with accurate scientific information. And telling the public that 30 seconds of secondhand smoke can damage the coronary arteries as much as active smoking, that brief exposure reduces coronary artery blood flow in healthy young adults, and that eating in a smoky restaurant increases your chance of dying from a heart attack by 30% certainly doesn't qualify as communicating accurate scientific information.

Having apparently been made aware of these "mistakes" (giving these groups the benefit of the doubt on their original claims), it appears that the groups have no interest in correcting their statements and made a decision not to do so. To me, this suggests an intent to let these statements stand. The misleading public claims now become intentionally misleading public claims. I am left with no choice at this point but to infer that these groups are intentionally deceiving the public into believing things that are not accurate.

I hate to say it, but isn't this something that we criticize the tobacco companies for doing?

I need to emphasize that the factual inaccuracies we are talking about are not particularly subtle ones. There is not a shred of evidence that 30 seconds of secondhand smoke exposure causes any coronary artery damage, much less damage to coronary artery function that is equivalent to that suffered by a smoker.

There is no evidence that eating in a smoky restaurant increases the risk of a fatal heart attack by 30%. Chronic exposure to secondhand smoke over a lifetime increases heart disease risk by only 30%, so how could exposure for just an hour or so result in that same effect?

And there is evidence that brief secondhand smoke exposure does not reduce coronary artery blood flow in healthy young adults (see the Otsuka et al. study in JAMA, 2001).

That the statements being made by these two anti-smoking groups are deceptive seems to me to be obvious to even someone who is not an expert on the health effects of secondhand smoke like myself. You don't have to be a rocket epidemiologist to know that 30 seconds of exposure can't possibly impair coronary artery function as much as in a chronic, active smoker.

In addition to doing a disservice to the public, which relies upon us for accurate, unbiased, complete, and trustworthy information, this is a major disservice to the anti-smoking movement itself. Because it speaks badly for all of us in the movement. It hurts every anti-smoking organization.

It gives the public reason to question our credibility as a movement. It contributes to the possibility of the public losing faith in our scientific accuracy and integrity.

But most importantly, it means that we don't have scientific accuracy and integrity anymore. This is very sad and discouraging for me. But I won't say that I'm surprised. I've seen enough of the anti-smoking movement's lack of interest in the scientific accuracy of its statements over the past few months to have expected both of these groups to fail to respond to my challenge.

The movement is rapidly losing its scientific accuracy and scientific integrity and frankly, I don't think any group in tobacco control really gives a damn.

Anti-Smoking Group Supporting Proposal That Will Increase Kids' Exposure to Secondhand Smoke

A national anti-smoking group - Action on Smoking and Health (ASH) - yesterday expressed its public support of a proposal that would increase secondhand smoke exposure of children by forcing their parents to smoke inside, rather than outside the home.

In its action alert, ASH supported the proposed ordinance in Belmont, California and urged its constituents to write letters to the Belmont City Council supporting the ordinance. While an actual ordinance has yet to be drafted, the Council has given approval to the drafting of a measure that would ban smoking in all indoor and outdoor areas of the city, with the exception of detached, single-family homes.

According to ASH's action alert: "The City of Belmont, California, is considering a comprehensive smoking ban ordinance. It would be the first to protect nonsmokers from secondhand tobacco smoke not only in public places and outdoors, but also in their own apartments and condominiums. It could serve as a model and as a catalyst for similar legislation throughout California and the rest of the country."

ASH urges its constituents to write letters to the Belmont City Council in support of the proposal and to "Be sure to state at the beginning of your email that you are urging the City Council of Belmont to pass a comprehensive ordinance to protect nonsmokers both outdoors and in their apartments."

The Rest of the Story

I agree with ASH that if Belmont enacts the ordinance as proposed, it will serve as a model for the rest of the country. Unfortunately, it will serve as a model of a disastrous ordinance that severely harms the health of the nation's children by forcing them to be exposed to increased levels of secondhand smoke by making it unlawful for their parents to smoke outside of the home and requiring them instead to smoke inside.

As I revealed two weeks ago, the Belmont proposal would increase secondhand smoke exposure among children because it makes it unlawful for smoking parents to considerately step outside to smoke in a way that prevents their kids from being exposed. Instead, smoking parents who live in detached, single-family dwellings will be encouraged by the law to smoke inside where their children will be exposed.

The only way that this proposed ordinance will not increase children's exposure to secondhand smoke is if parents intentionally disobey the law. And I would argue that any law which has to rely upon people disobeying it in order to avoid disastrous public health consequences is not a law that any public health group has any business supporting.

The irony of this story is that ASH is the very same group that just last week expressed such extreme concern about the exposure of kids to secondhand smoke in the home that it supported denying smokers the right to adopt children, even if they promise not to smoke in the presence of their children, simply because of the off-chance that a smoker might lie or change his or her mind.

This is also the same group that is supposedly so concerned about childrens' exposure to secondhand smoke that it supports policies to ban smoking in cars with children present and to ban smoking by foster parents in the home.

For ASH to then turn around and support a policy that would force children to be exposed to secondhand smoke by making it unlawful for smoking parents to smoke outside, keeping the smoke away from their children, is terribly inconsistent and makes me question ASH's integrity.

Is this truly a group interested in protecting the public's health, or is it just a group that wants to punish smokers and make their lives as difficult as possible, regardless of the consequences for our nation's children?

IN MY VIEW: Anti-Smoking Group's Stance on Smoking by Adoptive Parents is Unacceptable

I reported here yesterday that a major national anti-smoking group - Action on Smoking and Health (ASH) - is pushing to bar prospective parents who smoke from being able to adopt children. The policy they are supporting does not bar adoption by parents who smoke in the home; it bars adoption by all smokers, even if they do not smoke in the home and they certify that they will not expose their child to secondhand smoke.

ASH shares a story about a "heartbroken" couple who was recently told that their desperate desire to adopt a child could not be fulfilled unless the prospective father quits smoking for six months and obtains medical documentation that he has quit. And ASH seems to derive some pleasure out of the fact that this couple was made to be heartbroken because the prospective father is a smoker.

While I didn't mention it in my original post, there is a fundamental flaw in ASH's argument in support of this policy.

One of the arguments ASH uses to support this policy is that a smoker might say he is not going to smoke in the home, but later change his mind. Thus, as long as a prospective parent is a smoker, he must not be allowed to adopt a child.

Well the same argument could be made for a smoker who quits smoking in order to adopt, something which ASH apparently supports. We know that relapse is very common. An ex-smoker could easily change his mind and resume smoking. It happens all the time.

In fact, the risks of a smoker relapsing are probably far greater than the risk of a smoker lying about not smoking in the home in the presence of his child.

Thus, if ASH really wants to protect children, it needs to bar all ever-smokers (current and former smokers) from adopting. Of course, that would wipe out the majority of the population as prospective adoptive parents.

Thus, ASH's policy makes no sense, even if it were appropriate for adoption agencies to disallow adoption if there was any possibility that a child would be exposed to secondhand smoke in the home.

But there is a far more troubling implication of ASH's support for this policy which I simply find unacceptable: the idea that if an individual is a smoker and is biologically unable to have children or married to someone who is unable to have children, that individual cannot be allowed to have children.

The Rest of the Story

Adoption of ASH's policy would result in a society in which no smoker who is biologically unable to have children could have the privilege and fulfillment of having and raising a child.

In fact, the policy would also eliminate the possibility of parenthood for all nonsmokers who are married to a smoker where either one of the couple was unable to have children.

Moreover, the policy would essentially bar gay couples where one partner smokes from having children, unless they are willing to use a surrogate father of some form of embryo implantation.

By the way, would ASH, if left to its own devices, even allow gay couples where one partner smokes to have children? By their logic, it would be appropriate to bar the use of embryo implantation in smokers. In fact, such a law would be less damaging than barring adoption because with adoption, there is already an existing child who is being deprived of loving parents. With barring embryo implantation, it is merely a theoretical child that is affected.

I want to make it clear at this early stage of the game that I find this policy to be completely unacceptable and I find the support of any anti-smoking group for this policy to also be unacceptable.

It would be a tragedy if we established a policy that prohibited smokers from having children if they could not, or did not want to bear children themselves.

It would be a tragedy if we established a policy that prohibited smokers from having children if they were gay and did not wish to utilize a surrogate partner or embryo implantation.

It would also be a tragedy if we established a policy that prohibited nonsmokers from having children if they married a smoker and either they or the spouse were unable to have children.

In fact, this would create a scenario in which nonsmokers might actually be encouraged to avoid marrying smokers because of this very possibility. Perhaps this what ASH wants. It would, after all, encourage smokers to quit.

To be consistent and effective, if we adopt ASH's reasoning, we'd have to support a policy by which any ever-smoker (current or ex-smoker) is barred from adoption because there is a risk of that person smoking around the child or relapsing and then smoking around the child. And as I have argued, the risk of a smoker relapsing is far greater than the risk of a prospective adoptive parent lying about his willingness not to smoke around a child.

I should note here that I haven't even addressed the issue of whether smoking status of the parent (even if they do smoke in the home) is a legitimate concern in the consideration of the fitness of a prospective adoptive parent. It is certainly a problematic idea, because the same reasoning would lead to an inquiry into a host of other behaviors by prospective parents that could increase their children's risk of adverse health effects.

We can leave that discussion for later because, unfortunately, the anti-smoking movement is so far beyond that issue - it has left that issue in the dust. The issue now is whether or not a smoker (or a nonsmoker married to a smoker) has the right to have children by means other than childbirth. The issue now is whether a gay couple where one or both partners smoke has the right to have children at all.

This is probably the most dangerous and intrusive anti-smoking policy that I have seen so far. I condemn it in the strongest possible terms.

USA Today Editorial Says Anti-Smoking Movement is Going Too Far

An editorial published yesterday in USA Today argues that the anti-smoking movement is going too far by pushing to ban smoking in wide-open outdoors places like parks and private places like an individual's car. The piece, entitled "Smoking ban drifts too far," clearly acknowledges the need for protection of nonsmokers from secondhand smoke in public indoor places, including workplaces, but suggests that many anti-smoking groups just don't know when to stop:

"This [the spread of smoke-free workplace legislation] is a remarkable success story, but some people seem intent on proving that there can be too much of a good thing. The first signs of trouble were bans on smoking in places where secondhand smoke poses no threat to health. Last year, for instance, San Francisco banned smoking in public parks. Now the battleground is the family car. Earlier this year, Arkansas and Louisiana banned smoking in cars carrying young children. Similar proposals have been introduced in seven other states. The benefits are dubious. While children of smokers indisputably are the primary victims of secondhand smoke, cars aren't the biggest problem. Children are exposed to far more smoke at home. But with the home beyond the reach of regulation, anti-smoking advocates have struggled to find a way to protect them." ...

"With nearly 1,200 children younger than 10 killed in traffic accidents and 130,000 injured across the nation last year, shouldn't police focus on such violations as drunken driving, speeding or failing to buckle a child into a car seat or seatbelt? Rep. Bob Mathis, the author of the Arkansas bill, doesn't even expect the law to function as written. He set the fine at $25, which can be suspended if a driver attends a smoking-cessation program. He says he doesn't want the law to "be punitive"; he wants to educate parents. If Mathis wants to educate, he should have sought state funds for a public advertising campaign. When children are endangered, there certainly is reason for public attention and for government action. But not without limits and not for show. If smokers are to be stopped from letting their habit jeopardize their children's health, then it will have to done not by fiat, but by persuasion. That's not as easy as banning smoking on airplanes. But until the nation decides that parents no longer get to decide what's best for their kids, it's the only option that can work."

In an opposing viewpoint, Mathis counters that smoking bans in cars are necessary to protect children from secondhand smoke. While acknowledging that this does nothing to address the more serious problem of exposure in the home, he argues that in the home, education is what is needed:

"We need to get our priorities straight and do everything we can to make sure our children grow up in safe and healthy environments. That includes protecting them from secondhand smoke. The law I sponsored in Arkansas prohibits smoking in cars where young children are passengers. Obviously, cars are not the only place where children are exposed to tobacco smoke. For that reason, we must go further and encourage all parents of young children to stop smoking."

The Rest of the Story

I think USA Today wins this debate hands down. First of all, Mathis does not address the fundamental argument that the newspaper makes: how can one justify a coercive approach to protecting children from secondhand smoke in a private car, but only an educational approach to protect children from exposure in a private home?

In fact, Mathis essentially acknowledges this inconsistency in his argument, noting that while he favors a coercive approach to protect children in cars, he favors merely an educational approach (encourage parents to quit) to protect children in the home. Unless Mathis, and anti-smoking groups which support car smoking bans, can provide a compelling argument for why a coercive approach is justified in a private car but not a private home, I'm afraid that this public policy proposal will simply not hold water.

If Mathis is correct that we need to do everything we can to protect children from secondhand smoke, then is it not true that we need to ban smoking completely, or at least ban smoking by all parents? At very least, we would want to ban smoking by parents in the home when a child is present. But Mathis is not arguing in support of such a policy.

I really cannot see any qualitative difference between a private car and a private home in terms of the regulation of childrens' exposure to secondhand smoke.

There is, however, a quantitative difference: overall exposure in the home far exceeds exposure in cars, as do the resulting health effects. Thus, if you are going to choose just one policy to protect children from secondhand smoke, you'd want to focus on household exposure.

I think USA Today make a couple of insightful points about the anti-smoking movement. The paper correctly suggests that we have been very successful in promoting smoke-free laws, but that we don't seem to know when to stop.

Most importantly, the paper correctly notes a major distinction between workplace smoking bans and bans on smoking in wide-open outdoor spaces: the latter ban smoking where it poses no (or little) threat to health. Thus, the smoke-free movement has transitioned from one whose main concern was health to one whose main concern is something other than health protection.

Finally, the paper makes an important point regarding the autonomy of parents to make their own decisions about health risks to which they expose their children. Our society has rightly decided to leave those decisions up to the parents. Anti-smoking groups which support policies like car smoking bans are attempting to take those decisions out of the hands of the parents and put them into the hands of the state. This represents an undue interference with parental autonomy.

And the interference with parental autonomy is no different in a private car compared to a private home. Thus, the inconsistency of these policies is laid bare.

Beyond the compelling arguments provided by the editorial, this story is important because it demonstrates that there is a growing public perception, now starting to take hold in the media, that the anti-smoking movement is going too far.

This should be a warning to us in the movement. Because the tide can turn extremely quickly. If we don't heed these early warning signs, it could very quickly be too late to save ourselves.

Anti-Smoking Group Pushing to Bar Smokers from Being Adoptive Parents

According to a press release issued last week by the national anti-smoking group Action on Smoking and Health (ASH), a potential adoptive couple has been denied the possibility of adopting a child because the would-be-father is a smoker, even though he states that he never smokes indoors and would not smoke in the presence of the child.

According to ASH: "A heartbroken couple has been told they cannot adopt a child because he smokes, even though he says he never smokes indoors. Indeed, the prohibition stands until he quits smoking for six months and provides medical documentation that he is no longer a smoker."

The press release does not merely report this news, however. It actively supports the decision to deny potential adoptive parenthood to this couple based solely on the fact that the man is a smoker.

ASH provides a number of reasons why it supports this policy, including the contention that smoking around children is the "most prevalent and dangerous form of child abuse."

In addition, ASH argues that if a person wants to adopt a child, he or she should and must quit smoking first:

"If, as the father claims, he is "desperate" to adopt a child, he should be willing to quit smoking, argues Banzhaf. Many people spend thousands of dollars to adopt, and may be required to make other significant changes in their lifestyles, notes Banzhaf."

Other reasons ASH provides in support of this policy are the fact that the child is more likely to smoke if the parent smokes and that the parent is more likely to die prematurely:

"If the father continues to smoke, the child is also substantially more likely to become a smoker himself even if the father never smokes in his presence, and the child is also substantially more likely to lose his father prematurely."

The Rest of the Story

This is a clear case of moralizing and paternalism, devoid of any meaningful public health protection consideration. If the parent does not subject the child to secondhand smoke, then the smoke poses no direct threat to that child. Thus, there is no health concern that would preclude such an individual from being an adoptive parent. Clearly, the over-riding motivating concern appears to be a moral one - somehow, a smoking parent is inferior to a nonsmoking parent. In fact, a smoking parent is so inferior that he or she cannot even be considered suitable as a parent.

Frankly, it is disgusting to me that ASH is supporting this policy. It is basically spitting in the face of the 50 million smokers throughout the U.S. and telling them that not only are they second-class citizens, but they are unfit parents.

Whether ASH likes it or not and is willing to admit it or not, there are millions of smoking parents in this country, and almost all of them are loving parents who are perfectly fit, according to society's standards, to be parents. In all cases, those who are not "fit" to be parents are not "fit" for reasons other than the fact that they smoke cigarettes.

Being a smoker should not preclude someone from being able to have children, even if they are unable to have children of their own and wish to adopt.

The world, ASH included, owes a debt of gratitude to the thousands of individuals who have adopted children and provide them with a loving home - thousands of these individuals are smokers and we owe them deep gratitude, respect, and appreciation - not spitting in their eyes and rubbing their faces in the dirt.

Denying parenthood to smokers who wish to adopt children will do a far greater disservice to the many children in need of loving parents than the very slight risk that an individual will blatantly lie to an adoption agency about his willingness to smoke outside the home.

Besides, what I would ask ASH is why should just adoptive and foster kids be protected from the moral depravity and abuse of smokers? If smoking is so abusive when one has children, then shouldn't we simply prohibit all parents from being smokers? In other words, shouldn't we just ban smoking by parents, period?

The argument that we need to protect adoptive kids from having a parent who smokes in order to decrease their own risk of smoking is disgusting. By those standards, we should also ban fat people from adopting, as well as people who eat lots of fatty foods and do not get enough exercise. And we should certainly ban people who drive cars from adopting.

Come to think of it - why not just let ASH set all of our moral standards and make all the decisions regarding who is or is not fit to be a parent? As long as ASH is willing to impose its distorted sense of morals on all of us, why not make ASH the clearinghouse for all decisions regarding fitness for parenthood?

It is also quite ironic that the pronouncement that anyone who is desperate to adopt a child should be willing and able to quit smoking comes from the self-proclaimed "mastermind" behind the tobacco litigation - which rests largely on the basic premise that smokers are unable to quit smoking because of an intractable addiction. Apparently, it is highly difficult to quit smoking when you are a plaintiff in a tobacco lawsuit, but easy to do so if you are not looking to win money from Big Tobacco, and instead, are a smoker in the path of ASH's hurricane of intolerance and hatred.

At least some groups in the anti-smoking movement should be with me in condemning this latest statement by Action on Smoking and Health. Sadly, I doubt a single group will join me in speaking out for the idea of treating smokers as human beings deserving of any autonomy or respect.

Frankly, the anti-smoking movement is becoming dangerous in its narrow-mindedness, intolerance, and complete obliviousness to the decency and respect with which public health should be practiced. While only one anti-smoking group is leading the charge in this particular crusade against the rights and citizenship status of smokers, other groups that are silent in the wake of this story may one day end up being viewed as complicit in this crusade.

Anti-Smoking Advocate Claims that Secondhand Smoke Causes Radiation Poisoning

An Indianapolis anti-smoking advocate has publicly claimed that chronic radiation poisoning from Polonium-210 is common in individuals exposed to secondhand smoke. This revelation adds to the growing and alarming risks of secondhand smoke, coming on the heels of anti-smoking groups' statements that secondhand smoke causes heart disease within 30 minutes, devastates coronary artery function in 30 seconds, causes heart attacks within seconds, contains radioactive plutonium, and causes cyanosis in children.

The advocate, who chairs the Department of Public Health at a university in Indianapolis, claimed in a letter to the editor published in the Indianapolis Star that:

"a form of chronic poisoning with polonium 210 is common in those who ... inhale secondhand smoke."

The Rest of the Story

If one assumes, conservatively, that by "common" the advocate means that at least 10% of people exposed have the condition, then he is apparently claiming that there are about 10 million nonsmokers in the United States with chronic polonium-210 poisoning. Even if "common" means that only 1% of people exposed have the condition, then he is claiming that 1 million nonsmokers have chronic radiation poisoning from polonium-210.

No matter how you slice it, this is one of the most absurd and most misleading claims being made by the tobacco control movement about the health effects of secondhand smoke.

In some ways, this is a much more misleading claim than the St. Louis University Tobacco Prevention Center's assertion that secondhand smoke contains plutonium. At least the Tobacco Prevention Center didn't actually claim that millions of nonsmokers throughout the country have chronic plutonium poisoning.

Here, the claim could easily mislead nonsmokers into believing that somehow they have clinically significant radiation poisoning from polonium-210 in tobacco smoke.

To be clear, there is no evidence that nonsmokers exposed to secondhand smoke have chronic poisoning from polonium-210.

As has previously been the case, this fallacious and misleading claim is completely unnecessary. The truth should be enough. There is enough bad stuff in tobacco smoke, including polonium-210, that simply making people aware of the constituents and health effects of the smoke should be enough. But to exaggerate and distort the truth so much that it actually misleads people into believing something that is untrue is unfortunate, inappropriate, unnecessary, and by my account - unethical.

If the advocate had merely pointed out that tobacco smoke contains polonium-210, it would have been enough.

Had he pointed out that tobacco smoke contains polonium-210 and that smokers may have elevated levels of polonium-210, putting them at possible risk of cancers such as acute leukemia, that would have been enough.

Had he pointed out that tobacco smoke contains polonium-210 and that smokers may have elevated levels of polonium-210 that puts them at possible risk of cancers and that nonsmokers may also be exposed to polonium-210, that would have been enough.

But to add on that nonsmokers are chronically poisoned by polonium-210 is going too far. It is the difference between scientific accuracy and widespread deception of the public. It is the difference between responsible public health advocacy and irresponsible health communication. And it is the difference between ethical public health practice and unethical tactics.

It is undoubtedly true that smokers inhale polonium-210 and it is also true that some have speculated that this polonium exposure could be associated with an increased risk for certain cancers (especially acute myeloid leukemia). In fact, I myself was the first to report a conclusive link between active smoking and acute myeloid leukemia and I myself speculated that the polonium-210 contained in cigarette smoke could be a contributing factor (see: Siegel M. Smoking and leukemia: Evaluation of a causal hypothesis. American Journal of Epidemiology 1993; 138:1-9).

But to claim that nonsmokers exposed to secondhand smoke are chronically poisoned by polonium-210 is an errant and unscientific extrapolation.

Again, I think any short-term gains to be obtained by scaring people and creating a more emotional and shocking public appeal are going to be far outweighed by the long-term loss of credibility of the tobacco control movement if these types of absurd claims continue.

Action on Smoking and Health Admits that Malpractice Lawsuits Against Physicians are a Longshot, But Encourages Tying Up the Courts Anyway

In response to my letter to the editor arguing that the idea of filing malpractice lawsuits against physicians for failing to adhere to the Public Health Service smoking cessation guidelines is legally unsound, Action on Smoking and Health (ASH) submitted a letter outlining a differing viewpoint.

The response begins, not surprisingly, by insulting me and presenting a self-aggrandizing testimonial to ASH's executive director:

"Dr. Siegel makes some interesting observations but, as a physician rather than an attorney, he appears to be out of his field, and - with all due respect - perhaps out of his depth (despite his participation in some tobacco litigation), in bluntly stating that the "“legal reasoning in [the] malpractice article is not sound."” As someone with almost 40 years of experience with anti-tobacco litigation -– and who has been called the "Ralph Nader of the Tobacco Industry," an "Entrepreneur of Litigation, [and] a Trial Lawyer's Trial Lawyer,"” "a Driving Force Behind the Lawsuits That Have Cost Tobacco Companies Billions of Dollars," and "The Law Professor Who Masterminded Litigation Against the Tobacco Industry," let me speak frankly in suggesting from a lawyer'’s perspective why the legal reasoning is sound and why the legal threat is very real."

Then, ASH goes on to acknowledge my basic point that it is "true that the plaintiff must prove ... that he would have quit if only the physician has warned him and assisted him in doing so."

However, rather than presenting sound scientific evidence to support the contention that physician advice to quit smoking is the critical factor in the failure of most smokers to quit smoking, ASH instead argues that if you flood the courts with enough cases, eventually the heartstrings of a jury, somewhere, will be touched enough to side with the plaintiff. And by doing so, the threat of this litigation will be enough to get doctors to implement the PHS guidelines, regardless of the apparent weakness of the legal principle upon which these lawsuits are based.

For example, ASH argues that: "The question of whether the plaintiff would have heeded the advice and assistance of the physician if he or she had given it is a factual issue for the jury to decide, and the issue must be left to them if reasonably people could possibly differ as they obviously can on this question. Experience clearly suggests that, faced with a sympathetic and very ill plaintiff who swears that he would have heeded a warning if it had been given, and a physician who (as his lawyer will argue) "“thumbed his nose at his professional obligation, ignored the simple guidelines of a governmental commission and the unanimous advice of his peers,"” the jury'’s sympathy for the plaintiff will incline them to award him some damages, even if empirical evidence as well as common experience suggests how hard it often is to quit."

ASH further argues that: "The same is true with regard to the burden on the plaintiff to prove that, had he quit, he would not have had the medical problem of which he now complains. Sympathy may well be more important in a jury'’s consideration of this issue than dry empirical and statistical evidence and related arguments put forth by "“rich doctors and their greedy insurance company lawyers."” ...

And ASH tops off its argument by stating that: "Antismoking lawyers do not have to win every case, most cases, or even one out of every ten cases to put strong pressure on hospitals, medical organizations, insurance companies, and ultimately on individual physicians to begin complying with the guidelines to avoid the risk of being sued and the possibility -– however large or small it may appear -– of losing such a law suit."

The Rest of the Story

First of all, by ASH's own logic, ASH is completely out of its field in commenting on this issue because its executive director, unlike me, is not a trained epidemiologist who is skilled and experienced at interpreting the data on the effectiveness of smoking cessation interventions. ASH is apparently out of its depth in claiming expertise on the epidemiologic research on the effectiveness of physician-centered and pharmaceutical-centered smoking cessation interventions. And by its own logic, ASH is out of its field in commenting at all on what is appropriate or inappropriate for physicians to do since its executive director, unlike myself, is not a physician and has never so much as treated a patient. I would not descend to that level in responding to a colleague, but it is worth pointing out how ASH shoots itself in the foot by sinking to this level.

Second, ASH never addresses the substantive issue of my letter: that it would be difficult if not impossible to prove that a smoker would have quit had only a physician advised him to because the success rate of physician-centered and pharmaceutical-based smoking cessation interventions is dismally low and it would be easy for the defense to present compelling evidence that more likely than not, a smoker would not have been successful in quitting even if he had received advice and a prescription from the physician.

In fact, ASH readily admits that this is one of the key showings that would have to be made.

Instead, what ASH essentially argues is that despite the scientific evidence -- the "empirical and scientific evidence" which clearly shows that the overwhelming majority of smokers do not quit when advised to by a physician and given NRT treatment -- it is prudent to tie up the courts with these malpractice lawsuits, threaten the well-being of physicians, and significantly jack up health insurance rates because of the off-chance that a sympathetic jury somewhere might ignore the statistical evidence and be swayed, instead, by emotion.

Friends - this is exactly the opposite of what I think the justice system is supposed to be about. I don't view it as a crapshoot, where you threaten as many doctors as you can in order to exact one non-science-based, purely emotional success in order to scare physicians so that they have no choice but to do what a couple of fanatical anti-smoking advocates and groups want them to do.

I don't believe that you threaten people with million dollar lawsuits based on admittedly frivolous grounds, just hoping to convince a jury here or there to put science and statistical evidence and reason aside and reach a verdict based solely on emotion and spin (the portrayal of doctors and insurance companies as being greedy).

I don't believe that you use the justice system to scare people into your own preferred course of action in the absence of a solid and defensible legal principle that is reasonable and not a crapshoot that relies upon dismissal of science and reliance on emotion.

In many ways, ASH's response to my letter is more disturbing than the original article. While I disagree with the legal premise of the original article and think it would be a travesty to tie up the courts with frivolous lawsuits that lead to increased health care costs, at least the authors of the original article can simply be faulted with having produced a poor argument. In contrast, ASH actually makes the argument that the legal soundness of a lawsuit is of no consequence - the only thing that really matters is whether the litigation is effective in putting enough of a scare into the targeted group so that it changes its behavior out of fear. Thus, while the authors of the original article may simply have produced a poor argument, the group authoring the response to my letter is actually promoting what I view as the destruction of the integrity of the justice system.

There are two other arguments made in ASH's response that deserve comment.

First, ASH argues that juries in the proposed malpractice cases will be instructed to assume that patients would have quit smoking if their physicians had warned them of the need to quit. "In most jurisdictions, a judge will charge the jury that there is a legal presumption that the plaintiff would have heeded a warning, and this jury charge is usually given even regarding small-print routine warnings on tools, drugs, etc. which were merely inadequate rather than nonexistent. This presumption - which in effect shifts the burden on this issue onto the defendant - is likely to be far stronger where the specific face-to-face warning from a physician mandated by the guidelines was not even given, since judges as well as jurors know that warnings from authority figures in white coats are likely to be far more effective that tiny-print warnings on jars or packages."

Unfortunately, ASH is mixing up consumer product safety law with malpractice law. The issue is not whether some company should have put a warning on its product - tools, drugs, etc. - but whether or not a patient has suffered damages that were directly caused by physician negligence, and would not have occurred had the physician taken the action that the plaintiff claims was not done out of negligence. It may be convenient to mix up these two situations as the lay public may be misled about the legal soundness of these cases; however, in the courtroom, no judge in one of these cases will give the jury an instruction which basically forces it to accept as fact the key legal question in the case.

Second, ASH criticizes my argument that these proposed cases will be difficult to win because plaintiffs must show that they would more likely than not have quit had the physician followed the PHS guidelines and since this intervention is successful less than 50% of the time, it is more likely than not that it would not have been effective. ASH criticizes this argument on the grounds that in malpractice cases, physicians are often found to be negligent even if the patient most likely would not have survived anyway, and the negligent action merely increases the odds of non-survival.

ASH argues: "Dr. Siegel seems to suggest that any malpractice action based upon a physician's failure to warn a patient of a potential risk, or to suggest a treatment (medication, operation, or other course of action), is doomed to failure if the proposed treatment is less than 50% effective: Until such time as there is a truly effective treatment for smoking cessation (one that works most of the time), there really can be no basis for establishing a causal relationship between the breach of duty and the incurred injury. In other words, by this reasoning, it would appear that the medical community would have no legally enforceable duty to do anything at all (including refraining from negligence) where the chance of success - much less the patient's ultimate chance of survival - is less than 50%. But several courts have ruled directly to the contrary, finding that even plaintiffs whose conditions were so grave that their chance of survival was less than 50% still have a valid cause of action against a physician whose negligence decreases those already poor odds."

ASH's argument fails because the analogy is not valid. It is true that an intervention to treat a patient for a disease does not have to be more than 50% effective for it to represent negligence not to implement that treatment. However, this is true for the treatment of a disease. Smoking is not a disease. It is a behavior. And the importance of the effectiveness of advice to quit smoking is therefore not relevant to the determination of whether the action was negligent, but instead, it is relevant to the issues of damages and causation.

It could, potentially, be considered negligent for a physician not to warn his or her patient to quit smoking. However, the plaintiff cannot win such a malpractice case unless he shows that the failure to give the advice was what caused the injury. The injury is not the smoking, but the illness or disease that allegedly resulted from the smoking.

In the case of a severely ill patient, for example, who is not put on life support and ultimately dies, it is still malpractice even if the patient likely would not have survived. It is clearly negligent because any reasonable physician would provide life support in such a situation. And there is direct causation between the negligent action and the injury, because in this case, the injury is the damage that was caused by the failure to put the patient on life support. Without question, that failure harms the patient, regardless of the fact that the patient may have died anyway. The patient invariably died more quickly because of the negligent action. Thus, there are damages and those damages were caused directly by the negligent action. The risk of death is inherently and directly tied to the provision of life support. The odds of death may not go from 49% to 100%, but even if they go from 90% to 100% there is a documentable, significant harm done by the negligent action.

In a "smoking" malpractice case, however, the only damage that can be claimed is the disease that was allegedly caused by the smoking. And the risk of that disease is not inherently and directly related to the provision of advice to quit smoking. Instead, it is inherently and directly related to the patient's behavior - smoking. Thus, the damages are directly tied only to the patient's actions, not the physician's actions.

The connection between the purported damages and the physician's action are indirect. The postulated link is that the physician's action could have changed the patient's behavior, which in turn could have prevented the injury. Thus, to support both of the links in this purported causal chain, the plaintiff would have to show that the physician's action would, more likely than not, have changed the patient's behavior.

After reading the response of one prominent anti-smoking group to my comments, I am led to ask the question, "Is this really what we as a tobacco control movement want to be doing?" The rest of the story, then, is that the anti-smoking movement is, as I have repeatedly warned, spiraling quickly out of control and beyond any sense of reason.

Massachusetts Man Who Was Fired for Smoking Off-the-Job Files Lawsuit Under Massachusetts Privacy Statute

According to an Associated Press article, a Massachusetts man who was fired by the Scotts lawn and garden company after having cotinine (a break-down product of nicotine) detected in a urine sample he was forced to submit has filed a lawsuit against the company, claiming that the company unduly violated his privacy and civil rights. The suit was filed primarily under Massachusetts privacy law, which "bars the unreasonable, substantial or serious interference of privacy."

As I revealed here in The Rest of the Story last December, Scotts Miracle-Gro implemented a policy of firing smokers, even if they smoke only off-the-job in the privacy of their own homes, in order to reduce health care costs. At the time the policy was announced, employees were given one year to quit smoking completely or be fired.

Scott Rodrigues of Bourne claims that he was fired from a job with Scotts that he held for just a few weeks after a required urine cotinine test turned up positive for cotinine.

According to the article: "The lawsuit asks for unspecified damages and lawyer's fees. "In more general terms, this case challenges the right of an employer to control employees' personal lives and activities by prohibiting legal private conduct the employer finds to be dangerous, distasteful or disagreeable," the lawsuit said."

"The Scotts Co., a subsidiary of Scotts-Miracle Gro Co. of Marysville, Ohio, instituted a policy early this year forbidding smoking to promote healthy lifestyles and hold down insurance costs. In the 20 states that allow it -- including Massachusetts -- the company refuses to hire smokers and tests all new employees for nicotine, said Jim King, Scotts' vice president for corporate communications and investor relations. King refused to comment specifically on Rodrigues' case because the company's lawyers hadn't reviewed it, but said all new employees are told they must be tobacco-free and are told they will be tested for nicotine." ...

"Rodrigues' lawyer, Harvey Schwartz, said companies can require drug tests if they believe their employees are using the substances at work or if drug use would seriously interfere with the job. Neither of those are true in this case to justify a test for nicotine, he said. "Being compelled to provide a urine sample and the information that the sample contains is a violation of his privacy, where it has no relation to his job," Schwartz said. Schwartz also said the case goes beyond smokers' rights. If this practice stands, employers could dictate other aspects of their workers' lives, he said. "They can say you don't exercise enough. We want every employee to attend a health club, and we're going to check your attendance record there," Schwartz said."

The Rest of the Story

This is potentially an important case for two reasons. First, it is the first case I am aware of that specifically addresses whether a company can intrude into the privacy of an individual's lawful off-the-job behavior in the employee's home by requiring invasive biological testing. Previous cases have established the right of employers to implement a smoker-free workplace, but this may be the first lawsuit since the recent proliferation of these policies and the expansion of the scope off these policies to include firing existing employees and requiring invasive biological testing of bodily fluids.

Second, this case is filed not simply under employment law, but under a specific state privacy statute. Thus, the lawsuit asks not merely whether or not employment law allows an employer to hire and fire at will (as long as anti-discrimination statutes are not violated), but whether monitoring of an employee's urine for cotinine (to detect lawful smoking off-the-job) represents an undue intrusion of privacy that is barred under the state's privacy statute.

I want to make it clear that I strongly condemn these type of employment discrimination policies against smokers, whether they are legal or not. The fact that discrimination against smokers in hiring and firing may be legal does not make it right. Anti-smoking groups, in my view, should loudly oppose such policies in no uncertain terms. Of course, so far not a single U.S. anti-smoking group has done so, and several groups have actually expressed strong support for these policies.

Nevertheless, if the policy is found to violate privacy law, it will have a huge dampening effect on the widespread proliferation of these discriminatory policies. It may also help to bring national attention to this problem, and may help garner public opposition to these policies, which would make it more difficult for employers to implement this form of discrimination.

Furthermore, it may ultimately convince a number of states to enact statutes that specifically protect the rights of employees against discriminatory hiring practices that are not currently protected by anti-discrimination statutes.

Regardless of the outcome of this case and whether or not it inhibits the spread of these type of policies, there is one sure-fire way to stop this nonsense. And that is for anti-smoking groups to condemn the practice.

That's not going to happen, both because I don't think anti-smoking groups really care about the welfare of smokers and because those that do are afraid to speak out because of the McCarthyist nature of the current anti-tobacco movement.

Anti-Smoking Group Claims that Secondhand Smoke Causes Reduced Oxygen Flow in Children Comparable to Cyanotic Heart Disease

An anti-smoking group - Physicians for a Smoke-Free Canada - is claiming that exposure to secondhand smoke can cause children to turn blue.

I'm not kidding. The group states that secondhand smoke exposure among children can cause them to suffer reduced oxygen delivery to their body, similar as to what might occur with cyanotic heart disease.

For those who are not familiar with it, cyanotic heart disease is a condition, usually caused by a congenital abnormality of the heart in which oxygenated and non-oxygenated blood mix in the heart, causing the oxygen level of the blood to be very low, and these children literally can turn blue. Physicians for a Smoke-Free Canada is claiming that secondhand smoke exposure causes the same thing.

According to its fact sheet on the health impacts of secondhand smoke on children's health: "ETS is causally linked with a number of adverse health effects in children (under 18), including ... reduced oxygen flow to tissues, comparable to children with anemia, cyanotic heart disease or chronic lung disease."

The Rest of the Story

I've seen it happen all the time. Children are playing in their homes; their parents are smoking in the other room and then all of the sudden, the kids turn blue. This cyanosis - which is typically seen in severe congenital abnormalities such as cyanotic heart disease - is apparently causally linked to secondhand smoke exposure, according to Physicians for a Smoke-Free Canada.

While it may sound absurd, it is apparently not so absurd to stop a prominent anti-smoking group from publicly making the claim on its web site.

Unfortunately (actually, quite fortunately), this is a completely fallacious claim. There is no evidence that secondhand smoke exposure reduces oxygen flow to tissues comparable to the cyanosis seen in children with cyanotic heart disease.

To be honest with you, if it were shown to be true that secondhand smoke could cause cyanosis in children, I would be the first to immediately demand a prohibition of all smoking. Such extreme health effects, in which kids become blue from tobacco smoke, could simply not be tolerated.

If the effects of secondhand smoke on children were actually as severe as the effects of cyanotic heart disease, I don't think there would be any justification for Physicians for a Smoke-Free Canada not to call for the immediate prohibition of the sale of tobacco products in Canada (instead, this group has called for the government to take over the sale of these products, so that the government, rather than the tobacco companies, profit from killing people).

Readers should be rest assured that secondhand smoke exposure does not cause kids to become blue. Physicians for a Smoke-Free Canada appears to be pulling this one out of the woodwork. Frankly, I have no idea where they came up with this one.

The group does provide a scientific citation to support its statement: a review article by Dr. Jon Samet on the health effects of secondhand smoke among children. However, nowhere in the article does it mention that secondhand smoke has been found to be a cause of cyanosis among children.

It is true that secondhand smoke may have some effects on oxygen transport. This is particularly true in the fetus when the mother smokes. But among children, these effects are not known to even cause hypoxemia (reduced oxygen levels), much less cyanosis (turning blue). The effect is essentially a sub-clinical one.

To state that any reduced oxygen transport caused by secondhand smoke exposure is comparable to the reduced oxygen levels (caused by mixing oxygenated and non-oxygenated blood) in cyanotic heart disease is more than just an exaggeration; it's a blatant inaccuracy.

Now I should mention that secondhand smoke can cause asthma and pneumonia, both of which, if severe enough, could result in cyanosis. But this is not what the fact sheet is talking about. Separately, it mentions both pneumonia and asthma as health effects of secondhand smoke exposure. The fact sheet is clearly implying that secondhand smoke is a direct cause of reduced oxygen delivery and cyanosis.

I can think of no reason why this group would make such a claim other than to try to scare people and increase the emotional appeal of the message. But the shame of this all is that it isn't even necessary. The group already points out that secondhand smoke exposure can cause upper respiratory tract infections, lower respiratory tract infections (such as pneumonia), middle ear infections, asthma, and asthma exacerbation. Why do they need to distort and misrepresent the science and mislead people into thinking that it also causes cyanosis? Aren't these other health effects bad enough?

As I'm rapidly learning, no - they are not bad enough. We apparently need to sensationalize the science - the truth is no longer enough. It's not enough to state that chronic exposure to secondhand smoke can cause lung cancer and heart disease. Now we have to state that 30 minutes of exposure can cause these outcomes. And I guess it's not enough to state that secondhand smoke exposure can cause upper respiratory tract infections, otitis media, pneumonia, and asthma. Now we have to state that it can cause a child to turn blue.

It will be interesting to see whether the group corrects this claim. It will also be interesting to see whether any other anti-smoking groups will acknowledge that the claim is fallacious.

Just when I thought we had reached the lowest level of scientific quality - claiming that 30 seconds of secondhand smoke exposure causes coronary artery dysfunction equal to that seen in active smokers - I was shown to be wrong. Secondhand smoke exposure causes children to turn blue. That one is going to be hard to beat.

Rest of the Story Author's Rapid Response Letter Published in Response to Malpractice Article

The rapid response letter to the editor which I submitted to Tobacco Control in response to the article suggesting that malpractice lawsuits against physicians be filed if they fail to follow the Public Health Service smoking cessation guidelines was published today.

The letter, entitled "Legal Reasoning in Malpractice Article is Not Sound," stated the following:

"I find the argument provided in the paper to be non-compelling because it fails to provide any reasonable argument for how the 3rd showing in a medical malpractice case - that there is a causal relationship between the breach of duty and the incurred injury - could possibly be met in a smoking malpractice case. This would require proving to the jury that the physician's failure to warn the patient to quit smoking was the cause of the injury sustained by the patient.

This would imply that 3 things would have to be shown: (1) that the patient would have quit smoking if only the physician had advised them to quit and followed the PHS guidelines; and (2) that the reason the patient did not quit smoking was that the physician failed to advise them to quit and failed to follow the PHS guidelines; and (3) that if the patient had quit smoking, he would not have developed the injury.

These seem to be unreasonable, if not impossible, points to prove. How can we possibly know that a patient would have successfully quit smoking if only the physician had followed the guidelines? Unfortunately, the overwhelming scientific evidence cited in the paper supports a conclusion that the patient would most likely not have quit smoking, even if the physician had followed the guidelines. The data demonstrate that the cessation success rate, even with physician treatment, is dismal. The success rate does not even come close to approaching 50%; thus, it is more likely than not that even with physician advice to quit smoking, the patient would not have been successful in quitting smoking.

The success rates reported in the PHS guideline itself are generally below 20%. This means that it is much more likely than not (in fact 4 times out of 5) that a patient who goes through the suggested intervention will fail to quit smoking. I view this as an intractable problem in the use of the PHS CPG in medical malpractice lawsuits for failure to properly treat tobacco dependence. Until such time as there is a truly effective treatment for smoking cessation (one that works most of the time), there really can be no basis for establishing a causal relationship between the breach of duty and the incurred injury.

Finally, it is important to note that one would not only have to show that the plaintiff would have quit smoking had only the physician advised them to quit; one would also have to show that had the person quit smoking, they would not have developed the injury. However, we know that many former smokers still develop smoking-related injuries. It is not clear that one could show that the plaintiff wouldn't have developed the disease even if they had successfully quit smoking, especially for a disease such as lung cancer where risk decreases slowly following smoking cessation."

I will continue to alert readers as subsequent rapid responses to this troublesome, though important, article are published.

Tobacco Control Research and Education Center Suggests Malpractice Lawsuits as a Way to Get Physicians to Prescribe Pharmaceuticals to Smokers

In an article in this month's issue of Tobacco Control, two tobacco control researchers from the University of California, San Francisco's Center for Tobacco Control Research and Education suggest malpractice lawsuits against physicians as an appropriate approach to get doctors to follow smoking cessation guidelines put out by the U.S. Public Health Service. Those guidelines call for pharmaceutical treatment of all smokers who are willing to quit, except in cases where there are medical contraindications to pharmaceutical use. Patients who state that they are not interested in quitting must be given a motivational intervention.

(See: Torrijos RM, Glantz SA. The US Public Health Service "treating tobacco use and dependence clinical practice guidelines" as a legal standard of care. Tobacco Control 2006;15:447-451).

According to the article: "a court could have sufficient basis to find that the failure to adequately treat the main cause of preventable disease and death in the US qualifies as a violation of the legal duty that doctors and hospitals owe to patients habituated to tobacco use and dependence. ... The PHS Treating Tobacco Use and Dependence CPG forms a strong basis for a legal duty, whether it is used as a tool to support expert witness testimony in traditional litigation or as a judicially noticed presumptive standard of care under a litigation reform model. Given the PHS guideline'’s straightforward recommendations, the broad agreement regarding the efficacy of its treatments, its cost effectiveness and the recognised ability of smoking cessation to prevent serious disease, a doctor or hospital might be hard pressed to defend against a failure to properly treat tobacco use dependence."

The guidelines that are suggested to represent a legal standard of care call for the use of pharmaceuticals on all patients who are willing to try quitting smoking: "Numerous effective pharmacotherapies for smoking cessation now exist. Except in the presence of contraindications, these should be used with all patients attempting to quit smoking."

For patients unwilling to try quitting or simply uninterested in quitting, the guidelines require physicians to implement a motivational intervention to try to persuade the patient to quit smoking. The motivational intervention must be repeated every time the patient visits the clinic, regardless of whether they indicate a desire to quit smoking at that time.

For patients who have quit smoking, even if years earlier, the guidelines require physicians to engage in relapse prevention interventions even if the patients "no longer consider themselves actively engaged in the quitting process."

The Rest of the Story

The first part of the rest of the story is that the chair of the panel which developed the guideline is a pharmaceutical collaborator, consultant, and grant recipient. Dr. Michael Fiore, the panel chair, collaborated with Glaxo Wellcome and received research funding from Glaxo at the time the CPG was released in 2000.

In addition, as of 2001, Dr. Fiore had "served as a consultant for, given lectures sponsored by, or ... conducted research sponsored by Ciba-Geigy, SmithKline Beecham, Lederle Laboratories, McNeil Consumer Products, Elan Pharmaceutical, Pharmacia, and Glaxo Wellcome."

In other words, the head of the panel that produced this clinical practice guideline had an extensive financial interest in the pharmaceutical industry and had in fact a financial relationship with most, if not all, of the pharmaceutical companies that manufacture drugs whose use is recommended in the guideline.

Moreover, 11 of the 18 panel members who developed the guideline acknowledged financial relationships with one or more pharmaceutical companies (see page 173 and 174 of the guideline). Three out of the five project consultants had financial relationships with Big Pharma. To make matters even worse, one of the peer reviewers of the report was the head of Psychiatry Clinical Development at Glaxo Wellcome (see page 159).

Thus, the guideline is anything but an independent review of the evidence and an objective assessment of the most effective approaches to smoking cessation in the population. It is a strategy that was put together largely by individuals with a vested financial interest in promoting pharmacotherapeutic treatment (and not cold-turkey treatment) of smoking cessation.

Essentially, what it comes down to is that this article is promoting a very specific form of treatment for smokers -- pharmaceutical treatment -- and suggesting using the force of malpractice lawsuits to coerce physicians into following this pharmaceutical-influenced and pharmaceutical-based guideline rather than any other of a multitude of approaches that could be taken to encourage and assist smoking cessation among one's patients.

Personally, I have found in my experience that pharmaceutical treatment for smoking cessation is ineffective. The most success I have had or seen is lifestyle change, with or without a spiritual element. In fact, I would go so far as to note that in my experience, the use of pharmaceuticals tends to obscure for the patient the most important and pressing issues they will have to deal with in sustaining cessation and becoming free of the addictive power of smoking. In the long run, I believe this makes it more difficult for patients to achieve a long-term success.

By the argument presented in this article, I should be charged with malpractice for adhering to an approach which I believe (and can document, for my own patients) worked far better than the use of drugs.

Before actually dealing with the issue of malpractice itself, I need to dispense with another troubling aspect of this article. One of the things that the article suggests (in addition to the prescription of pharmaceutical treatment for cessation under the threat of malpractice lawsuits) is the disrespect for the expressed desires of one's patient, even if those desires are expressed uniformly, definitively, and consistently. And again, this disrespect for patient autonomy is required at the threat of a massive lawsuit.

If a patient makes it clear to the physician that he or she is fully aware of the risks of smoking but has made an informed decision that he doesn't wish to quit, must the physician not respect that decision and continue to badger the patient with a prescribed motivational intervention at every visit? Even if the patient is definitive and consistent in her expressed desires and decision?

And is a malpractice lawsuit the appropriate strategy to deal with this issue, even if it were legally justified (and we'll get to that in a minute). Smoking is the only behavior for which I have ever heard it suggested that physicians should be charged with malpractice if they fail to put their patient through a specific prescribed set of interventions that include drugs and badgering the patient consistently even after a clear and consistent expression of a lack of desire to alter the behavior.

There are a fair number of my patients who liked to eat eggs for breakfast, and while cutting eggs out of the diet is a tried and true way to reduce cholesterol, I never heard it suggested that I should face a malpractice lawsuit if I didn't put my patient through a de-eggification intervention.

And if I did an intervention and the patient told me that they loved eggs and despite knowing the risks, wanted to continue eating them, it never would have occurred to anyone that I might face a malpractice lawsuit if I didn't repeatedly institute a motivational intervention at every patient visit, repeatedly going over the cholesterol-enhancing effects of fried eggs, Egg McMuffins, and eggs benedict.

This leads us to the practical problem of requiring physicians to intervene on a preventive basis for a host of individual behaviors in order to avoid a malpractice lawsuit. What if I fail to prescribe an exercise program for my overweight patient? Does that mean I'll have to face him in the courtroom if he has a heart attack due, in part, to persistent obesity that I failed to solve for him?

But most importantly, what kind of mishegas is this?

Is this really the way we want to practice tobacco control and public health? Do we really want to encourage hundreds of lawsuits against physicians and hospitals for what is intrinsically a personal behavior choice that these patients have made? Do we want to clog our courtrooms with these frivolous lawsuits and tie up the court system even further for no good reason? Do we want to start out down the slippery slope that could logically lead to malpractice suits against physicians for failing to solve a host of other health-related behavioral problems of their patients?

And we haven't even gotten to the legal foundations of the article yet.

The Legal Basis for Failure to Follow PHS Cessation Guidelines as Medical Malpractice

The article points out that there are four essential showings in a medical malpractice case: "As in all negligence torts, a plaintiff claiming medical malpractice must show: (1) a legal duty owed to the plaintiff by the defendant; (2) a breach of that duty; (3) a causal relationship between the breach of duty and the incurred injury; and (4) damages."

I find the argument provided in the paper to be non-compelling. The primary reason for this is that the paper fails to provide any reasonable argument for how the 3rd showing in a medical malpractice case - that there is a causal relationship between the breach of duty and the incurred injury - could possibly be met in a smoking malpractice case. This would require proving to the jury that the physician's failure to warn the patient to quit smoking was the cause of the injury sustained by the patient.

This would imply that 2 things would have to be shown: (1) that the patient would have quit smoking if only the physician had advised them to quit and followed the PHS guidelines; and (2) that the reason the patient did not quit smoking was that the physician failed to advise them to quit and failed to follow the PHS guidelines.

This seems an unreasonable, if not impossible, point to prove. How can we possibly know that a patient would have successfully quit smoking if only the physician had followed the guidelines? Unfortunately, the overwhelming scientific evidence cited in the paper supports a conclusion that the patient would most likely NOT have quit smoking, even if the physician had followed the guidelines. The data demonstrate that the cessation success rate, even with physician treatment, is dismal. The success rate does not even come close to approaching 50%; thus, it is more likely than not that even with physician advice to quit smoking, the patient would not have been successful in quitting smoking.

The success rates reported in the guideline itself are generally below 20%. This means that it is much more likely than not (in fact 4 times out of 5) that a patient who goes through the suggested intervention will fail to quit smoking.

I view this as an intractable problem in the use of the PHS CPG in medical malpractice lawsuits for failure to properly treat tobacco dependence. Until such time as there is a truly effective treatment for smoking cessation (one that works most of the time), there really can be no basis for establishing a causal relationship between the breach of duty and the incurred injury. Sure, one could successfully argue that there is a legal duty to the plaintiff to advise her to quit, that the physician breached that legal duty, and that there were damages incurred. But one could not hope to establish that the incurred injury was a direct result of the physician's failure to follow the guidelines, and thus that the damages stemmed from the negligent act. Even had the guidelines been followed, it is most likely the case that the patient would still have suffered the injury because more likely than not, they would have failed to quit smoking.

The situation is quite different in cases where there is a direct connection between the breach of duty and the incurred injury. If a physician fails to diagnose a person's heart disease because they fail to order an EKG or stress test when a patient presents with exertional chest pain, and the patient goes on to have a heart attack, it is reasonable to expect that one could show that the failure to diagnose the heart disease caused the injury - in other words, that the heart attack would not have occurred if the heart disease had been diagnosed and treated. But if a patient who smokes sees a doctor and a month later has a heart attack, it is not reasonable to expect that one could prove that the failure to advise the patient to quit smoking caused the heart attack - in other words, that the heart attack would not have occurred if the patient had been advised to quit smoking. The important point is that one must prove not that the heart attack would not have occurred if the patient had quit smoking (which is difficult enough), but that the heart attack would not have occurred if the patient had been advised to quit smoking.

Conclusion

Ultimately, what troubles me the most about this article is not the fact that it is devoid of any real legal substance or that it is inappropriate in a number of ways, but the fact that it is indicative of a larger problem in tobacco control: that we're headed in the wrong direction, spinning out of control, going off the deep end, losing our sense of reason, and becoming so narrow-minded that we are blind to everything other than smoking.

Challenge Issued to Association of Nonsmokers - Minnesota to Retract Fallacious Claim and Apologize; Similar Challenge Issued to ClearWay Minnesota

Today I am issuing a challenge to the Association of Nonsmokers - Minnesota to retract its fallacious and absurd public claim that 30 seconds of secondhand smoke exposure can cause as much deterioration of coronary artery function as that seen in chronic active smokers.

According to an article in the St. Paul Pioneer Press, a Minnesota anti-smoking group publicly claimed that 30 seconds of secondhand smoke is as bad as a lifetime of active smoking in terms of coronary artery function. The group - Association for Nonsmokers (Minnesota) - issued a press release which declared that a mere 30 seconds of secondhand smoke exposure results in coronary artery damage that is indistinguishable from the damage suffered by active smokers (many of whom have smoked for decades).

According to the article, the Association for Nonsmokers press release claimed that: "Just 30 seconds of exposure can make coronary artery function of nonsmokers indistinguishable from smokers."

The Rest of the Story obtained a copy of the press release, dated August 30, which indeed stated:

"Research studies have shown that even just thirty seconds of exposure to secondhand smoke can make coronary artery function of non-smokers indistinguishable from smokers."

The challenge, being issued today and the result to be reported on Thursday, is simple. The Association of Nonsmokers - Minnesota is being challenged to simply publicly acknowledge that the claim was fallacious, retract it, and apologize.

A similar challenge is simultaneously being issued to ClearWay Minnesota regarding its public claim that eating in a smoky restaurant increases the risk of a fatal or non-fatal heart attack by 30%.

As I revealed in September, ClearWay Minnesota is actively deceiving the public about important information regarding secondhand smoke. Specifically, I believe they are deceiving the public about the acute cardiovascular effects of secondhand smoke. In their smoking ban manual on their web site, they claim that a brief exposure to secondhand smoke decreases coronary blood flow in young, healthy individuals:

"Blood flow in the coronary arteries is decreased in healthy young adults exposed to secondhand smoke."

I think this claim is wildly misleading and deceptive. The truth is that exposure to secondhand smoke has been found not to affect basal coronary blood flow in healthy adults. In fact, the same study upon which this statement is based is the one that actually reports no difference in the blood flow in the coronary arteries of exposed adults.

Sure, the coronary reserve flow is reduced in exposed nonsmokers, but this reserve flow reduction is simply an indication of endothelial dysfunction, and it has no acute clinical significance.

I think it is irresponsible to mislead healthy young adults and to scare them by thinking that if they are exposed to secondhand smoke, the blood flow in their coronary arteries is going to decrease. It is not, and the claim is therefore wildly misleading.

Unfortunately, this is not the worst of it. Elsewhere in the same manual, ClearWay claims that eating in a smoky restaurant increases your risk of heart disease by 30%. Not eating in a smoky restaurant every day of your life, I might add. Just eating (presumably once) in a smoky restaurant:

"Current scientific data suggest that eating in a smoky restaurant can precipitate myocardial infarctions in nonsmokers and increase the risk of fatal and non-fatal cardiac events in nonsmokers by about 30 percent."

There is no evidence that eating in a smoky restaurant causes heart attacks in nonsmokers, but that's not the part of the claim that I'm most concerned about. The part I'm concerned most about is the claim that eating in a smoky restaurant increases your heart disease risk by 30%. Because that's not just a misleading or deceptive claim, it's completely fallacious.

The scientific evidence shows that chronic exposure (over many years) may increase your risk of heart disease by 30%. But eating once in a smoky restaurant? Obviously, this claim is false.

The challenge issued today to ClearWay Minnesota is to publicly acknowledge these mistakes, correct these two misleading claims, and apologize.

The Rest of the Story

While there are a large number of fallacious claims that are being made by anti-smoking groups, the claim made by Association for Nonsmokers - Minnesota is probably the most important because it is so absurd that it is obviously false on its face. There is absolutely no scientific documentation to support a claim that 30 seconds of secondhand smoke exposure causes as much damage to the coronary artery function of nonsmokers as chronic active smoking causes to the coronary artery function of smokers. Yet this claim was made in a press release disseminated to the media.

I am willing to give the group the benefit of the doubt and assume that it was just an innocent mistake. However, if this were the case, it is imperative, for the scientific integrity of the tobacco control movement and the reputation of all of us, that the group publicly acknowledge the mistake, retract or correct its claim, and issue some sort of apology for the mistake.

The same is true of ClearWay Minnesota's claims. I'm willing to give them the benefit of the doubt and assume that the 30% increased heart attack risk from eating in a smoky restaurant was meant to refer to chronic secondhand smoke exposure rather than a single acute exposure. However, it is again imperative for the scientific integrity of the tobacco control movement and all of our reputations that the group publicly acknowledge the mistake, correct it (since the manual is still widely available on the internet and intended to serve as a guidebook for many anti-smoking organizations), and apologize.

I will be the first to admit that it is easy to make mistakes when you are reporting lots of scientific data. I would be lying if I said that I had never made such a mistake myself. However, when I have and it has been called to my attention, I have immediately acknowledged the mistake, corrected it, and apologized. I will not hold tobacco control groups responsible for making mistakes; but it is quite another thing to refuse to acknowledge, correct, and apologize for the mistake.

On Thursday, I will report back on the response to this challenge, which is being communicated directly to the two organizations. So check back here on Thursday for the rest of the story.