Thursday, February 23, 2006

IN MY VIEW: Why ASH's Recent Actions Are an Example of Fanaticism, Rather than Science-Based Advocacy

I have been appropriately challenged by a number of readers to defend my use of the term "fanaticism" to describe the recent actions of Action on Smoking and Health (ASH), which is now pushing for broad bans on smoking in virtually all outdoors places, including in sidewalks, streets, and parking lots, has now publicly boasted that they are going to break down the barriers to banning smoking in the final frontier - the private home, and is promoting policies to fire all smokers from their jobs and to refuse to hire any smoker.

I want to make it clear, up front, that it is not simply the draconian nature of what ASH is promoting - firing all smokers, making it impossible for smokers to get jobs, and banning smoking just about everywhere - that leads me to term what they are doing as being an example of fanaticism, rather than science-based policy advocacy.

Rather, it is the complete lack of critical judgment and the fact that ASH appears to have lost the ability to exercise critical thinking and judgment, and therefore to responsibly act as a public health advocacy group, that leads me to this conclusion.

The Rest of the Story

Fanaticism is not defined as "extreme enthusiasm or zeal." I do not think, and I'm not arguing that ASH is fanatical because they are so zealous that they are supporting policies that would ban smoking just about everywhere and would make it nearly impossible for any smoker to get a job.

Instead, fanaticism is defined as "extreme, uncritical enthusiasm or zeal." So the hallmark of fanaticism is not just excessive zeal, but the lack of careful evaluation and judgment in acting on that enthusiasm.

So let's look at how careful ASH is in its evaluation and judgment in its public campaigns to promote its agenda, which I think it is fair to say is quite zealous.

ASH is publicly claiming, in an effort to promote its agenda, that: "Even for people without such respiratory conditions, breathing drifting tobacco smoke for even brief periods can be deadly. For example, the Centers for Disease Controls [CDC] has warned that breathing drifting tobacco smoke for as little as 30 minutes (less than the time one might be exposed outdoors on a beach, sitting on a park bench, listening to a concert in a park, etc.) can raise a nonsmoker'’s risk of suffering a fatal heart attack to that of a smoker."

They actually go further than this and warn cities that there is a good chance that nonsmokers may keel over from a heart attack if they are exposed to secondhand smoke in wide-open outdoors places like beaches or parks and that these cities can then be held liable for the heart attack deaths of these nonsmokers:

"In cases where drifting tobacco smoke was present and a nonsmoker suffered a heart attack, ... the municipality which owns and operates the beach, park, playground, etc. could be liable since it was on notice of the known health dangers but failed to take the 'reasonable' step of banning smoking as taken by many other outdoor areas."

So let's get this straight. ASH is supporting its agenda - which is apparently to try to ban smoking almost everywhere - by claiming to the public and policy makers that an otherwise healthy nonsmoker who is exposed to secondhand smoke for just 30 minutes is at risk of a fatal heart attack, and moreover, that their risk is equivalent to that of a smoker.

In science and medicine, we have a technical term that can be used to describe such a contention: a bunch of crap.

This contention is completely fallacious. How often do you walk down a street and see a healthy nonsmoker keel over from a heart attack because they were exposed to smoke for a half hour? Does ASH really believe that a nonsmoker can develop coronary artery disease severe enough to cause a heart attack in 30 minutes?

It actually takes years to develop coronary artery disease, and the risk of an otherwise healthy nonsmoker developing atherosclerosis, stenosis of the coronary arteries, and complete compromise of the coronary circulation such that it precipitates a myocardial infarction in 30 minutes is ZERO.

And it's completely irresponsible to scare nonsmokers, the public, and policy makers into thinking that otherwise healthy people walking down a street and being exposed to secondhand smoke for 30 minutes are going to drop dead of a heart attack.

Even if one were to accept the contention that 30 minutes of exposure to secondhand smoke in an otherwise healthy nonsmoker could, theoretically, have a greater than zero (perhaps a 0.0000000001) chance of causing a heart attack, it is obviously completely fallacious to claim that the risk of that person having a heart attack is the same as that of a smoker, who may have smoked 2 packs a day for 40 years.

Actually, if you think about it, what ASH is really saying could be devastating to anti-smoking efforts and destructively misleading to smokers.

If I were a smoker, and I was told that my risk of a heart attack was equivalent to that of an otherwise healthy nonsmoker exposed to secondhand smoke for 30 minutes, you know what I would do? I'd keep smoking and forget about any significant risk of a heart attack, because I know that the risk of a healthy nonsmoker keeling over after 30 minutes in a bar is basically nil.

So ASH's public claim is not only fallacious, but it is devastatingly misleading to smokers and could well cause them to conclude that they are at essentially minimal risk of a heart attack.

I can't emphasize enough how irresponsible and potentially damaging this public propaganda is that ASH is disseminating to the public and policy makers.

Moreover, ASH has failed to correct its public statement, even though it has been out there for several weeks and they've had plenty of time to more carefully scrutinize their work and make any necessary corrections or clarifications. I'll be the first to admit that sometimes we are just careless and we don't catch our mistakes. But ASH has now had at least 3 1/2 weeks to critically review and check its claims and the fallacious claims are still out there as we speak (as of the writing of this post).

By the way, what the CDC did say, and what the relevant research does say, is that 30 minutes of exposure to secondhand smoke can cause endothelial dysfunction, as measured by coronary flow velocity reserve (CFVR), in nonsmokers to the same degree as seen in smokers (see Otsuka R, Watanabe H, Hirata K, et al. Acute effects of passive smoking on the coronary circulation in healthy young adults. JAMA 2001; 286:436-441 and Pechacek TF, Babb S. How acute and reversible are the cardiovascular risks of secondhand smoke. BMJ 2004; 328:980-983).

But endothelial dysfunction is a far cry from a heart attack!!!

In fact, what endothelial dysfunction measures is the early process of atherosclerosis. As the authors (Otsuka et al.) concluded: "The present findings suggest that reduction of CFVR after passive smoking may be caused by endothelial dysfunction of the coronary circulation, an early process of atherosclerosis, and that this change may be one reason why passive smoking is a risk factor for cardiac disease morbidity and mortality in nonsmokers."

What this means is that acute exposure to secondhand smoke can result in endothelial dysfunction in nonsmokers that if prolonged and repeated over a long time, could eventually result in atherosclerosis and heart disease.

In other words, this study provides a potential mechanism for the observed increase in heart disease risk among passive smokers. It provides biologic plausibility for a causal relationship between exposure to secondhand smoke and heart disease. But it does not suggest that an otherwise healthy nonsmoker could suffer a heart attack as a result of a 30 minute exposure to secondhand smoke, and it certainly does not mean that a nonsmoker's risk of a heart attack approaches that of a smoker's after 30 minutes of exposure to secondhand smoke.

The only possible acute risk of secondhand smoke exposure in terms of heart attack risk is the slight possibility that in people with existing severe coronary artery disease, the endothelial dysfunction triggered by acute exposure to secondhand smoke might be enough to trigger a coronary event (i.e., a heart attack). There is very little evidence that this is the case, but it is possible, and I would agree with recommending that nonsmokers with coronary artery disease should try to minimize or eliminate their exposure to secondhand smoke.

By the way, eating a single high-fat meal can cause significant endothelial dysfunction. Plotnick et al., writing in the Journal of the American Medical Association, reported that: "A single high-fat meal transiently reduces endothelial function for up to 4 hours in healthy, normocholesterolemic subjects, probably through the accumulation of triglyceride-rich lipoproteins." (see Plotnick GD, Corretti MC, Vogel RA. Effect of antioxidant vitamins on the transient impairment of endothelium-dependent brachial artery vasoactivity following a single high-fat meal. JAMA 1997; 278:1682-86).

Is ASH also going to claim that eating a single high-fat meal raises the risk of a heart attack in an otherwise healthy individual? The reasoning is identical. This example shows how meaningless the relevant study is in terms of documenting any acute heart attack risk in healthy individuals. It is simply measuring endothelial dysfunction, which can be caused by eating too many tater tots. It is not measuring acute heart attack risk.

So I think what we have here, apparently, is a group that is so overly zealous and enthusiastic that they have lost any semblance of scientific credibility or critical judgment. They are making a completely fallacious public claim, coupled with a severe litigation threat to cities throughout the country (warning them that nonsmokers may drop dead from heart attacks on a beach because of small amounts of exposure to secondhand smoke and that the city will be held liable because it knew about the risk of this heart attack [I guess thanks to ASH] and failed to act.

This, friends, is uncritical, irrational zeal.

Look - even if ASH had just claimed that nonsmokers could walk down a street, be exposed to secondhand smoke for 30 minutes, and drop dead from a heart attack, you might persuade me that it is an example of being naive or unquestioning. But if you're going to go to the extent of making a public threat to cities throughout the country, trying to scare them into action by making them think that by allowing smoking in a park, they are putting nonsmokers at significant risk of keeling over from heart attacks, I think that has to go beyond just simple lack of questioning.

ASH is intentionally promoting these policies, and they are apparently intentionally using these unfounded, fallacious, and irrational public claims and warnings (i.e., scare tactics) to try to promote their agenda. And they are in what should be the responsible position of a science-based public health advocacy organization.

I won't even begin to go into the extreme hypocrisy of ASH's actions, and the fact that despite yet another overzealous justification for its support of banning smoking everywhere outdoors (to prevent kids from having to see smokers), ASH actually supported and promoted legislation that specifically allows and promotes smoking at outdoors areas of crowded shopping malls!

The rest of the story is that ASH's recent actions are an example not of rational, critical, science-based advocacy, but of extreme uncritical zeal - in other words, of fanaticism.

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