ClearWay Minnesota Removes Contentious Secondhand Smoke Health Claims from Web Site in Response to The Rest of the Story Post

Apparently in response to a number of posts on The Rest of the Story which pointed out the inaccuracy of several secondhand smoke health claims made on the ClearWay Minnesota web site (post 1; post 2; post 3; post 4), the organization has removed the contentious claims from the site. The inaccurate claims appeared in a manual for local advocates working on clean indoor air ordinances.

The two claims in question, along with the reasons why I questioned their accuracy, are as follows:

Claim #1: "Blood flow in the coronary arteries is decreased in healthy young adults exposed to secondhand smoke."

Why It is Misleading: In fact, the study that is being used as the basis for this claim revealed that coronary blood flow in healthy young adults exposed to secondhand smoke was not decreased. What was decreased was the coronary flow velocity reserve, which has no clinical meaning for these young adults in the absence of sustained or repeated exposure. The clear impression of the statement is that a healthy young person exposed to secondhand smoke for 30 minutes will suffer a reduction in coronary artery blood flow. This is untrue.

I think that a normal person reading the claim would have gotten the impression that any exposure to secondhand smoke, even brief exposure, leads to a reduction in coronary blood flow in a healthy young person, such that the individual could be at risk of a heart attack (since most people correctly identify reduced coronary blood flow with heart attacks).

I had expressed the opinion that is it not appropriate to scare healthy young people into thinking that they may suffer a heart attack due to a short-term secondhand smoke exposure.

Claim #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."

Why It is Misleading: There are no scientific data which show that eating in a smoky restaurant can cause a heart attack. But more importantly, it is impossible that eating in a smoky restaurant could increase the risk of cardiac events by 30%, since being exposed to secondhand smoke for a lifetime only increases the risk of cardiac events by about 30%.

These two inaccurate claims appeared in a toolkit that is designed to be used by many local anti-smoking groups to promote smoking bans. Failure to correct these "facts" would have resulted in the widespread dissemination of false health claims by anti-smoking groups.

ClearWay corrected the first claim by changing it to state that coronary "flow reserve" is decreased in healthy young adults exposed to secondhand smoke and that this indicates that "passive smoking can cause endothelial dysfunction in the coronary circulation."

ClearWay corrected the second claim by deleting the assertion that eating in a smoky restaurant increase heart attack risk by 30% and by simply stating that "exposure to secondhand smoke" increases that risk by 30%.

The Rest of the Story

I congratulate ClearWay Minnesota for showing the concern and taking the time to address my concerns and correct these claims in its smoking ban manual. This is an unusual occurrence, as most of the other anti-smoking groups to which I have communicated my concerns have ignored them or indicated that they do not really care.

I wish all the anti-smoking groups which are making misleading or inaccurate claims about the acute cardiovascular health effects of secondhand smoke would follow ClearWay Minnesota's lead and delete or correct them.

20 Minutes of Secondhand Smoke Exposure Puts You at Risk of Stroke, Says Anti-Smoking Group

According to a statement by Smokefree Air for Everyone (Columbia, MO) published in the Columbia Business Times, being exposed to secondhand smoke for just 20 minutes puts you at risk of having a stroke due to the formation of blood clots:

"After 20 minutes, blood platelets look like a pack-a-day smoker’s, making your blood “sticky” and contributing to stroke causing blood clots."

The Rest of the Story

I consider this statement to be inaccurate, and I think it might unnecessarily scare people into thinking that if they are exposed to secondhand smoke for just 20 minutes, they might develop a blood clot and suffer a stroke.

The good news is that the statement is not accurate. If you are an otherwise healthy person -- or in fact, even if you are unhealthy but as long as you do not have severe pre-existing cerebrovascular disease (atherosclerosis of the arteries supplying the brain), you are not at risk of suffering a stroke from 20 minutes of secondhand smoke exposure.

While it is true that chronic exposure to secondhand smoke can cause atherosclerosis and put an individual at increased risk of a stroke, a mere 20 minutes of exposure cannot cause a stroke in anyone who does not already have severe cerebrovascular disease and who is already basically a stroke waiting to happen.

In other words, if someone has cerebrovascular disease that is so severe that any temporary increase in platelet activation may be enough to trigger life-threatening clot formation, then that individual is at severe risk of suffering a stroke, from secondhand smoke exposure, eating a high-fat meal (which can also activate platelets), or any of a large number of other exposures.

The important point here is that the claim is not qualified as applying only to people with extremely severe, pre-existing cerebrovascular disease. The way I read the statement, it is applying to anyone. After all, it states that 20 minutes of secondhand smoke makes "your" blood sticky, putting you at increased risk of a stroke. Thus, it seems intended to apply to any reader, meaning that it is a general statement of increased risk for the entire exposed public.

While I agree wholeheartedly with the goals of the SAFE coalition and support the Columbia smoke-free workplace law, I am uncomfortable with the idea of using exaggerated, misleading, and fallacious health claims in order to support those goals and that law.

I think the actual effects of secondhand smoke are enough; we do not need to go beyond the truth in order to promote our policy goals.

Statement of John L. Kirkwood, President and CEO, American Lung Association

Dear Dr. Siegel:

Thank you for bringing the “Abuse” spot to my attention. The spot was produced by an advertising agency for one of our local lung associations who was attempting to increase public awareness about the dangers of second hand smoke. Unfortunately the spot tries to accomplish this objective with a child abuse theme that is both inappropriate and extremely offensive. The spot is disgraceful and it is something that would have never been condoned by the American Lung Association if my office had been aware of it. We have taken immediate action to remove it from You Tube and to halt any further distribution. We extend our profound apologies to everyone for this grievous error.

John L. Kirkwood
President & CEO
American Lung Association
61 Broadway, New York, NY 10006
Tel: 212-315-8701 Fax: 212-315-8800
www.lungusa.org

American Lung Association Pulls "Abuse" Television Ad and Expresses Disgust; Apologizes to the Public

The American Lung Association, upon being informed of the "Abuse" television advertisement that is circulating on YouTube, has immediately pulled the spot and ceased its circulation on YouTube and all other sources.

Apparently, the spot was produced by an ALA-affiliate and the national office was not aware of, and did not approve, the ad. Immediately upon being informed about the ad, the American Lung Association's national office, under the direction of CEO and President John Kirkwood, pulled the ad and expressed its apologies.

I applaud Mr. Kirkwood and the American Lung Association for responding immediately and definitively, and for expressing their thoughtful sentiments and apology.

I will post a statement from Mr. Kirkwood momentarily.

Rest of the Story Calls for Immediate Retraction of American Lung Association Ad and for a Public Apology to the Nation's Physical Abuse Victims

The Rest of the Story is today calling on the American Lung Association to immediately retract and remove from the airwaves its "Abuse" anti-smoking television advertisement and to issue a public apology to all victims of physical abuse for extreme insensitivity and offensiveness (ad also discussed here).

The television commercial begins by showing the exterior of a house with the door open. Through the door, you can hear a father yelling viciously at a child. The child is obviously in great peril and terribly fearful.

"No, daddy, no. Stop it!" the child screams. Clearly, the child is being physically beaten and abused.

The camera pans in on the living room, where to the viewer's surprise, there is no beating going on. Instead, a father is smoking while his children sit calmly watching television.

The narrator then states: "Exposing your children to the dangers of secondhand smoke is in fact abuse. A message from the American Lung Association."

The Rest of the Story

I find this to be an extremely disturbing spot. It is almost unbearable for me to watch, but terribly upsetting to find out at the end that the piece is actually making a mockery out of child abuse, rather than treating the issue with sensitivity and respect.

How dare the American Lung Association compare the horrors of child abuse and the severe, immediate, and irreversible physical and emotional damage that it does to the increased risk of ear and lower respiratory tract infections in children.

Does the American Lung Association not appreciate the difference between risk and harm. Physically beating a child is child abuse because it invariably causes harm. The harm is intentional, it is immediate, it is severe, and it is irreversible. You cannot physically abuse a child without causing harm.

In contrast, exposing a child to secondhand smoke does not necessarily cause harm. What it does is increase the risk of certain health problems. In all but very rare cases, the infliction of any harm is not intentional. In most cases, any harm done is reversible and not particularly severe (although it can be in some cases). But the most important point is that with smoking around a child we are talking about increasing that child's risk, by a relatively modest degree, of certain health conditions.

With physical child abuse, we are talking about inevitable, severe, irreversible harm.

To compare the two in this way is a profound disservice to physical abuse victims. It shows an overwhelming disrespect and insensitivity to these individuals. After all, if smoking around children is equivalent to child abuse, then the message being sent is that being physically abused is no more serious than merely being exposed to a little secondhand smoke.

The commercial does not present a very specific situation of a child with asthma, for example, whose asthma is severely exacerbated by secondhand smoke, and whose parents continually smoke around that child despite clearly being warned about the consequences. This is one situation where smoking around a child could be considered abuse because in this specific (and in my experience as a physician - extremely unusual) situation, the harm is definite and can be viewed as being intentional.

Instead, the commercial makes a very general statement about smoking around your children.

It is important to recognize that in the majority of cases, smoking around children does not have any severe health consequences. It is not an issue of harm, but of risk. And thus, the categorization of smoking around a child as child abuse fails definitively.

This advertisement is so offensive that I call for its immediate retraction and removal from the airwaves. I also call on the American Lung Association to publicly apologize to all victims of true child abuse for minimizing and trivializing the pain, suffering, and emotional havoc that their being physically abused has wrought in their lives.

There's no question that childhood exposure to secondhand smoke is a significant public health problem. But characterizing parents who smoke around their children as child abusers is not an appropriate way to address the problem. Perhaps we could start by providing adequate smoking cessation services and health insurance coverage of these programs for those smokers who want to quit. Then perhaps we could provide more education to parents so that they are aware of the health effects of smoking on young children.

But to address the problem by rubbing salt in the wounds of physical abuse victims is disgraceful.

These ads cannot be retracted soon enough.


(Thanks to JustTheFacts for the tip).


UPDATE: May 25, 2007; 3:45 p.m. -- The American Lung Association, upon being informed of the "Abuse" television advertisement that is circulating on YouTube, has immediately pulled the spot and ceased its circulation on YouTube and all other sources. Apparently, the spot was produced by an ALA-affiliate and the national office was not aware of, and did not approve, the ad. Immediately upon being informed about the ad, the American Lung Association's national office, under the direction of CEO and President John Kirkwood, pulled the ad and expressed its apologies. I applaud Mr. Kirkwood and the American Lung Association for responding immediately and definitively, and for expressing their thoughtful sentiments and apology. The statement from Mr. Kirkwood is posted here.

A Tale of Two Press Releases: R.J. Reynolds and Campaign for Tobacco-Free Kids Battle Over Alleged Violation of 2006 Settlement Agreement

In a press release issued yesterday, the Campaign for Tobacco-Free Kids alleges that R.J. Reynolds is violating the terms of a 2006 settlement the company reached with 40 state attorneys general regarding the marketing of flavored cigarettes. In a press release in response, R.J. Reynolds denied the allegations, arguing that the Campaign for Tobacco-Free Kids is plain wrong and is misrepresenting facts in order to promote the FDA tobacco legislation which it is championing.

According to the Campaign for Tobacco-Free Kids' complaint: "In October 2006, the R.J. Reynolds Tobacco Company entered into a settlement with state attorneys general to stop marketing candy, fruit and alcohol-flavored cigarettes. The states had asserted that RJR's marketing of flavored cigarettes violated the 1998 state tobacco settlement's prohibition on targeting youth. Now, barely seven months later, RJR is already trying to circumvent the settlement by introducing new flavored cigarettes in yet another marketing scheme that is likely to appeal to children. RJR has taken out a lavish ad in Cosmopolitan, a magazine with a high youth readership, to introduce its Camel Signature Blends cigarettes that come in Robust, Mellow, Frost and Infused flavors. RJR's web site describes Robust as "similar to notes found on cocoa and espresso"; Mellow as "accented with toasted honey"; Frost as "Fine Asian Mint ... while the creamy finish delivers a smooth, buttery aftertaste"; and Infused as offering "notes of Citrus" and "a sweet apple-like flavor." These products are also being advertised and sold in stores. While RJR claims its web site is age-restricted, kids will be fully exposed to the magazine and store ads that highlight the tempting new cigarette names and claims of "distinctive flavor."

According to R.J. Reynolds' statement: "The Campaign for Tobacco-Free Kids' press release today alleging R.J. Reynolds Tobacco Company is "circumventing" its 2006 agreement with state attorneys general is grossly inaccurate. The company requests that the Campaign for Tobacco-Free Kids retract its statement. "Voicing an opinion is one thing; ignoring the facts to achieve your goals is just plain wrong," said Tommy Payne, executive vice president - public affairs for Reynolds American Inc. "These misrepresentations perpetuate an atmosphere of mistrust and conflict, and prevent any reasonable dialogue to resolve the issues that surround the tobacco industry." The agreement signed by 40 state attorneys general permits the marketing of specialty blends, like R.J. Reynolds Tobacco Company's Camel Signature styles, while restricting the use of fruit, candy and alcohol descriptors in brand names or in non-age-restricted communications. Camel Signature is in full compliance with this agreement. "The Campaign for Tobacco-Free Kids seizes every opportunity to criticize tobacco manufacturers as part of their effort to advocate FDA regulatory authority over tobacco products," Payne said. "We support their right to do so but believe it requires full and fair disclosure of the facts so that people can draw their own objective conclusions."

The Rest of the Story

If this were 5 years ago, I probably would have assumed that in a battle between R.J. Reynolds and an anti-smoking group for the truth, the anti-smoking group would win hands down, so I would have concluded that the Campaign for Tobacco-Free Kids was right without any further thought.

Today, however, after seeing the degree of deception and misrepresentation that the Campaign for Tobacco-Free Kids is capable of in promoting the FDA legislation, I thought this conflict warranted my own careful examination of the facts so that I could draw my own conclusion.

The first thing that became clear is that the Campaign for Tobacco-Free Kids press release is inaccurate. The 2006 settlement between R.J. Reynolds and the attorneys general does not require the company "to stop marketing candy, fruit and alcohol-flavored cigarettes." What it requires is for the company to not use any candy, fruit, or alcohol terminology in brand names and not to use any such terminology or imagery in advertising that is accessible to minors. Thus, fruit terminology and imagery can be used on internet advertising if the site requires that users are adults.

For someone who relies solely on the Campaign for Tobacco-Free Kids press release for her information, it will seem like a slam-dunk case against RJR. The company agreed not to market fruit-flavored cigarettes, its "Infused" brand style advertises a citrus and apple flavor; thus, it is indeed marketing fruit-flavored cigarettes in violation of the settlement agreement.

However, the settlement does not ban the marketing of fruit-flavored cigarettes. Nor does it even ban the marketing of fruit-flavored cigarettes in venues in which youths may be exposed to that advertising. What it bans is the use of fruit names, terminology, and imagery in advertising to which youths may be exposed.

Let's examine the actual language of the settlement. The relevant clause is the following:

"In the event that Reynolds manufactures, markets, distributes, or sells Flavored Cigarettes specifically intended by Reynolds for distribution or sale in the United States, Reynolds agrees that with respect to its marketing of such Flavored Cigarettes:

(1) It will not use in the name of a brand style, (i) a Fruit or Candy, or (ii) the words “fruit,” “candy,” “sweet,” “sugar,” “citrus,” “tart,” “tangy,” or “cream,” or any extensions or variations of such words (e.g., “fruity,” “sweetened,” “creamy”).

(2) It will not use on the packaging visible to consumers before purchase, in print advertising, in point of sale advertising not located in an Adult-Only Facility, in direct mail or email promotions to individuals Reynolds has not reasonably determined to be an Adult, or in web-based advertising (excluding web-based advertising which is accessible to individuals Reynolds has reasonably determined to be an Adult), (i) a Fruit or a Candy, (ii) the words “fruit,” “candy,” “sweet,” “sugar,” “citrus,” “tart,” “tangy,” or “cream,” or any extensions or variations of these words, or (iii) images of a Fruit, a Candy, or other sweet desserts."

The advertisement in Cosmopolitan magazine which the Campaign for Tobacco-Free Kids alleges is in violation of this agreement uses the following names and language/imagery to describe the four advertised brand styles:

Robust - Camel Signature Robust is a lively blend with distinctive flavor.
Mellow - Camel Signature Mellow is deliciously smooth with sun-cured tobacco taste.
Frost - Camel Signature Frost is extremely cooling with a crisp, clean taste.
Infused - Camel Signature Infused is smooth and intriguing.

In terms of part 1 of the above clause, there is clearly no violation. The words “fruit,” “candy,” “sweet,” “sugar,” “citrus,” “tart,” “tangy,” or “cream,” or any extensions or variations of such words are not used, nor is there any fruit or candy used.

In terms of part 2 of the above clause, there is also no violation. The words “fruit,” “candy,” “sweet,” “sugar,” “citrus,” “tart,” “tangy,” or “cream,” or any extensions or variations of these words are not used, nor is there any fruit or candy used, nor is there any imagery relating to a fruit, candy, or other sweet desserts.

The words robust, mellow, frost, and infused are not fruits or candies, nor do they convey imagery of fruits or candies or other sweet desserts. The Campaign for Tobacco-Free Kids might have a case if RJR used the word "frosting" and imagery related to frosting, since that could be construed as a sweet dessert.

The descriptions of these brand styles in the Cosmopolitan ad also fail to use any type of fruit, candy or dessert terminology or imagery. A lively blend with distinctive flavor is not a reference to a fruit, candy, or dessert. Neither is deliciously smooth with sun-cured tobacco taste. Neither is extremely cooling with a crisp taste. And neither is smooth and intriguing.

The other imagery used in the advertisement does not appear to represent or invoke any fruit, candy, or sweet dessert. There is a camel, leaves, and what appears to be smoke, but nothing that I can discern to be a fruit, candy, or dessert.

So it seems quite clear to me that the Cosmopolitan advertisement does not represent a violation of the 2006 settlement agreement. Let's turn to the store advertising.

The store advertising cited by the Campaign for Tobacco-Free Kids as violating the settlement consists of pictures of the cigarette packaging for each of the 4 brand styles, with the words "Frost," "Infused," "Robust," and "Mellow." There is no additional terminology used. There is imagery on the packaging, but it does not appear to represent any fruit, candy, or sweet dessert. As above, the brand style descriptors themselves do not use or invoke fruit, candy, or dessert terminology or imagery. Therefore, the store advertising does not appear to represent a violation of the 2006 settlement agreement.

That leaves us with the RJR web site. The web site clearly does use fruit terminology and imagery, as it refers to notes of citrus and an apple-like flavor. This advertising would most clearly be in violation of the settlement agreement if it were to appear in a non-adult-restricted site. However, the settlement clearly states that this type of advertising is allowable on an adult-restricted web site: "excluding web-based advertising which is accessible to individuals Reynolds has reasonably determined to be an Adult."

The web site requires the user to certify that he or she is of legal age, and RJR claims to verify that the user is of legal age before granting access to the site; a username and password are required.

The certification states: "Certification: I certify that I am a legal age tobacco consumer; and that I want to receive in the mail offers, premiums, and/or coupons, as well as tobacco products that I may purchase. I understand that giving false information in order to accept these offers may constitute a violation of law. (Required)"

It certainly appears to me that this represents a reasonable determination that the user is an adult. Thus, the use of fruit terminology and imagery in this web-based advertising does not constitute a violation of the 2006 settlement agreement.

Perhaps the misunderstanding on the Campaign for Tobacco-Free Kids' part is its apparent interpretation of the 2006 settlement as banning the advertising, in venues accessible to minors, of fruit-flavored cigarettes. What the settlement does is to ban the use of fruit terminology and imagery in advertising that is accessible to minors; it does not ban the advertising of such brands in venues accessible to minors as long as that advertising does not include any fruit terminology or imagery. I see nothing in the settlement which indicates that if a brand contains fruit flavoring, it cannot be advertised in youth-accessible venues even if no fruit terminology is used in that advertising.

Based on my analysis, I do not see any violation of the 2006 settlement.

I agree with R.J. Reynolds that the Campaign for Tobacco-Free Kids is inaccurate in its assessment and wrong in its accusation. I also agree that the Campaign for Tobacco-Free Kids has a tendency to go to great deceptive lengths to promote the FDA tobacco legislation, and that it is consistently failing to provide a full and fair disclosure of the facts so that people can draw their own objective conclusions.

New Study Concludes that Bowling Green Smoking Ban Reduced Heart Disease Admissions by 47%; Unfortunately, Science is Weak and Conclusions Unjustified

A new study published online ahead of publication in the journal Preventive Medicine concludes that a smoking ban in Bowling Green, Ohio resulted in a 47% decline in hospital admissions for heart disease. The study compared the standardized monthly rates of hospital admissions for heart disease in Bowling Green (which implemented a smoking ban in March 2002) and Kent (which did not implement a smoking ban) from January 1999 through June 2005 (Khuder SA, Milz S, Jordan T, Price J, Silvestri K, Butler P. The impact of a smoking ban on hospital admissions for coronary heart disease. Preventive Medicine 2007 [in press]).

The study concludes: "A reduction in admission rates for smoking-related diseases was achieved in Bowling Green compared to the control city. The largest reduction was for coronary heart disease, where rates were decreased significantly by 39% after 1 year and by 47% after 3 years following the implementation of the ordinance. ... The findings of this study suggest that clean indoor air ordinances lead to a reduction in hospital admissions for coronary heart disease, thus reducing health care costs."

The Bowling Green ordinance eliminated smoking in public places, including restaurants, but exempted free-standing bars. Bar areas of restaurants were also exempted, as long as they were isolated in an enclosed room.

The Rest of the Story

Unfortunately, the study conclusions are, in my view, unsupported by the data, and the science backing up the study is quite poor. Like the other studies which have claimed to have found a drastic reduction in heart attack admissions attributable to a smoking ban, this one is yet another example of shoddy science making its way into tobacco control research.

The chief flaw of the study is that it is unable to rule out the very likely possibility that the observed changes in heart disease admission in Bowling Green during the study period are due primarily to random variation, rather than to the smoking ban.

To see what I mean, let's look at the actual data. Here are the annual standardized heart disease admission rates for Bowling Green during the study period. Note that the ordinance went into effect in March 2002:

1999: 35
2000: 24
2001: 24
2002: 36
2003: 22
2004: 26

The paper presents data for 2005, but since only the first six-month period of data are available, it is not valid to compare the 2005 data with the preceding year. The paper simply doubles the admission rates from the first six months, but that is invalid due to the well-established seasonal variation in these rates.

You can see several important things by examining these data.

First, there is tremendous natural (random) variation in the heart disease admission rates in Bowling Green. Because we are dealing with such small numbers of admissions, the percentage change in admissions from one year to the next is very high, even without any smoking ban. For example, from 1999 to 2000, there was a 31% decline in admissions. From 2001 to 2002, there was a 50% increase in admissions. Clearly, these changes were not due to the smoking ban. They reflect, at least in part, the underlying random variation in these data.

Given the fact that annual changes in heart attack admission rates of between 30% and 50% are common in Bowling Green, it is completely unjustified to conclude that the observed 39% decline in the first year following the smoking ban was attributable to the smoking ban.

More likely, it was simply random variation that led to an "abnormally" high heart disease admission rate in 2002. The rate was bound to fall in 2003 due simply to this pattern of random variation.

Does the study conclude that the absence of a smoking ban in Bowling Green caused the 31% decline in admissions in Bowling Green from 1999 to 2000? Of course not. That "drastic" decline was due to absolutely nothing. Just random variation in the data.

Does the study conclude that the whopping 50% increase in heart disease admissions between 2001 and 2002 was due to the implementation of the smoking ban? Of course not. That would be an unfounded conclusion given the high degree of random variation in these data.

The second very important thing to notice is that the rate of heart disease admissions in Bowling Green was exactly the same before the smoking ban as after the smoking ban. In 2001, the year prior to the smoking ban, the rate was 24. In 2003, the year after the ban, the rate was 22. In 2004, two years after the smoking ban, the rate was 26. Thus, the average rate in the first two years following the smoking ban was 24 - exactly the same as it was prior to the ban.

How can one possibly conclude that the Bowling Green smoking ban decreased heart disease admissions by 47% when the rate in 2000 and 2001 (prior to the ban) was 24, and the rate in 2004 (after the ban) was 26?

The conclusion of the study, it turns out, is based heavily upon the low admissions rate during the first six months of 2005. You can't possibly draw any valid conclusion until the full 2005 data are in. And you certainly don't want to just double the 2005 early-year data in order to present the appearance of a very low annual rate for the entire year.

The study findings are also largely dependent on whether you categorize the "abnormally" high rate of 36 observed in 2002 to pre-ban or post-ban. If you call the heart attacks in 2002 mostly post-ban observations, then the high rate in 2002 is attributed mainly to post-ban, and thus there is the appearance of an increase, not a decrease in heart disease admissions immediately following the ban.

On the other hand, if you call the heart attacks in 2002 mostly pre-ban observations, then the high rate in 2002 suddenly becomes attributed to pre-ban, and thus there is created an appearance of a decrease, not increase in heart disease admissions following the ban.

It is quite interesting, then, to note how the paper treated the 2002 data. Although the smoking ban went into effect early in 2002, the study treats the 2002 data as being pre-ban. In reporting the change in heart disease admissions rates during the first year of the ban, the study compares the rate of 36 in 2002 (which it considers pre-ban) with the rate of 22 in 2003 (post-ban). This yields an estimate of a 39% decline in admissions.

The problem is that most of that rate of 36 in 2002 is actually post-ban, since it went into effect in March of that year. If you want a true idea of the pre-ban rate, go back to 2001 which is unequivocally pre-ban. The rate in 2001 was 24. The rate in 2003, which is unequivocally post-ban, was 22. That represents a decrease of 8%, not 39%.

It seems odd that the paper uses the rate of 36 in 2002 as the pre-ban rate to compare both the one-year change and three-year change (for which the paper reports a drop of 47% - from 36 to 19). The reason I say it is odd is because this rate was actually a post-ban rate, for the most part.

The paper justifies its characterization of the 2002 data as pre-ban by arguing that a full six months of enforcement are necessary before health effects from reduction in secondhand smoke exposure or reduction in smoking prevalence or smoking intensity would be observed: "Due to the novelty of the ban, initial resistance by its opponents and legal wrangling over its enforcement, we believed that several months of consistent enforcement would be needed before citizens would actually change their behavior."

It sounds to me like this is more of a convenient excuse for treating the high observed post-ban heart disease admission rate in 2002 as pre-ban than it is an objective way to conduct this analysis. I'm not suggesting that this was intentionally done to try to make it appear that there was a decline in heart disease rates; I'm just pointing out that this type of manipulation is highly subjective, and given the actual data in question, is unacceptable. It basically throws the entire analysis into question.

Given the question about what points exactly should be considered pre-ban versus post-ban, the most objective way to handle this would be to use the 2001 data as pre-ban and the 2003 data as post-ban. These categorizations are unequivocal. And if you do that, you find a drop from 24 to 22 -- hardly evidence of any substantial effect of the smoking ban.

And if you go to the second year post-ban, you find an increase from 24 to 26. Again, this is hardly evidence of a decline in heart disease admissions due to the smoking ban.

I should also point out that the assumption that it takes several months of consistent enforcement before people change their behavior is unsupported. The data I have published from Boston's smoking ban demonstrates that within the first few days of the ban, there was basically 100% compliance. The change in secondhand smoke exposure was almost immediate.

There are several other serious flaws in the study.

The study provides no evidence to support its assertion that there was a drastic drop in secondhand smoke exposure, cigarette consumption, and smoking prevalence in Bowling Green in response to the smoking ban. If you are going to conclude that the smoking ban is what was responsible for the observed changes in heart disease rates, you ought to document that there actually was a dramatic reduction in secondhand smoke exposure, cigarette consumption, and smoking prevalence. The paper does none of these things.

The study also makes another serious mistake. It uses a fancy statistical model (an ARIMA - or autoregressive integrated moving average model) to estimate the change in monthly heart disease admission rates in those months in which the smoking ban was in force. It finds that in Bowling Green, the rate was 1.7 lower per month when the ban was in force, and that estimate is statistically significant. In Kent, the comparison community, the rate was 1.1 lower per month when the ban was in force, and that estimate was not statistically significant.

The paper then concludes that since the 1.1 per month decline in admission rate in Kent was not statistically significant, these data do not show a parallel significant change in heart disease admission rates in Kent following the implementation of the smoking ban in Bowling Green.

However, this is not the appropriate way to conduct this analysis. The proper way to compare these estimates is to statistically determine whether the observed decline of 1.7 per month in Bowling Green is different from the observed decline of 1.1 per month in Kent. Since we know the standard errors of each of these estimates, we can determine whether these estimates are statistically different from each other.

Since the paper does not provide the standard errors, I cannot conduct that analysis. However, given the levels of statistical significance for these estimates in the paper, I was able to make a rough estimate of what the standard errors likely were. Based on my calculations, it is highly likely that the decline in heart disease admission rate of 1.7 per month in Bowling Green is not statistically different from the decline of 1.1 per month in Kent. In other words, it is likely that the actual analysis in the paper confirms that there was no significant decline in heart disease admission rates in Bowling Green due to the smoking ban.

I recognize that this may be a difficult point to understand, so let me give an example to illustrate it. Suppose that I want to determine whether the smoking ban in Massachusetts resulted in an increase in average temperatures in Massachusetts compared to temperatures in New Hampshire. We want to therefore compare the change in annual mean temperatures in Massachusetts with the change in annual mean temperatures in New Hampshire. We find that in Massachusetts, the average mean temperature increased by an average of 0.5 degrees per year, with a standard error of 0.1. Thus the increase was statistically significant. In New Hampshire, the average mean temperature also increased by an average of 0.5 degrees per year, but with a standard error of 0.3, so that the increase was not statistically significant.

By the reasoning provided in the paper, one would conclude that there was no parallel significant increase in temperatures in New Hampshire; thus, the change in Massachusetts must have been due to the smoking ban. However, it is readily apparent from these data that there was exactly the same observed increase in temperature in the two states. The correct way to do this analysis is to compare the two estimates of the average annual decline in temperatures and see if they are statistically different. In this case, the two estimates are 0.5 and 0.5, which are clearly not different. This shows how one can draw the wrong conclusion if one conducts the analysis in the wrong way.

The final point that deserves mention is that the smoking ban in Bowling Green was a partial smoking ban. It exempted free-standing bars and bars within restaurants. Thus, it is much less plausible that such a ban would have had a dramatic effect on smoking prevalence. Smokers likely chose to go out to restaurants or bars that continued to allow smoking. There is little evidence that partial smoking bans result in significant smoking cessation.

The rest of the story is that upon closer examination, the study which purports to demonstrate that a smoking ban in Bowling Green resulted in a massive decline in heart disease admissions demonstrated nothing of the sort, and possibly demonstrated that there was no significant decline in admissions attributable to the smoking ban. Like its predecessors (e.g., Helena and Pueblo), this is another example of shoddy science that apparently now passes as acceptable in tobacco control research.

American Lung Association Using Deception to Promote FDA Tobacco Legislation

Apparently not to be outdone by the Campaign for Tobacco-Free Kids and the American Cancer Society, the American Lung Association has joined the fray by waging its own campaign of deception to promote the proposed FDA tobacco legislation.

In an email sent to its constituents yesterday trying to entice them to write their Congressmembers in support of the FDA tobacco legislation, the American Lung Association stated: "As you know, the legislation pending before Congress would restrict tobacco marketing and sales to kids, require changes in tobacco products to make them less toxic and less addictive, stop tobacco companies from misleading the public about the health consequences of using their products. These are common-sense consumer protections that should have been passed a long time ago."

The statement in question is that: "the legislation pending before Congress would ... require changes in tobacco products to make them less toxic and less addictive."

The Rest of the Story

The truth is that the legislation would not require changes in tobacco products to make them less toxic and less addictive. It would merely give the FDA the authority to require changes that might make tobacco products less toxic and less addictive. But the bill requires no such changes.

This is a critical difference. The bill merely gives FDA the ability to require changes in cigarettes, but it doesn't require that FDA mandate any such changes, nor does it give the FDA any guidance in suggesting what changes would make cigarettes less toxic and less addictive. Nor is there any evidence that simply by reducing levels of various constituents, a cigarette could be made that is less toxic and/or less addictive.

In fact, the bill gives the tobacco companies the opportunity to use their tremendous political power to block any attempt by the FDA to require the reduction or removal of constituents, especially nicotine. An escape clause in the legislation essentially requires Congressional approval of FDA action (by allowing the industry to use its political power to get Congress to exercise its veto power that the bill specifically provides).

It seems like outright deception for the American Lung Association to tell its constituents, falsely, that the proposed legislation would require cigarette companies to make changes to their cigarettes to make them less toxic and less addictive.

Is there some sort of requirement I am not aware of that forces groups advocating for the FDA tobacco legislation to deceive the public?

Is there some sort of law requiring anti-smoking groups which promote the FDA legislation to hide the truth about what the bill does and does not do?

Are the arguments in favor of this legislation so weak that the groups supporting the bill cannot rely on the truth, but instead must wage a campaign of deception?

Is it not mildly ironic that deception is the basis of a campaign for a bill whose very purpose is supposedly to prevent the tobacco companies from deceiving the public?

Is there some rule that in order to join the coalition with the Campaign for Tobacco-Free Kids, you too need to deceive the public in your communications about the legislation?,

Do any of these groups think for themselves, or do they simply copy the deceptive rhetoric from the Campaign for Tobacco-Free Kids without paying attention to what they are saying?

American Cancer Society Claims Big Tobacco is Lying About Cigarette Ingredients, But Provides No Evidence; Truth Can't Be Used to Support FDA Bill?

This week's theme of the American Cancer Society's web site promoting the proposed FDA tobacco legislation is "Stop Big Tobacco from Lying About Their Ingredients."

The American Cancer Society's main FDA campaign web page explains it as follows:

"Cigarette smoke contains more than 4,000 chemicals, including at least 69 that cause cancer. These dangerous chemicals include arsenic, formaldehyde, ammonia and radioactive Polonium-210. Yet most Americans don’t know what’s really in a cigarette because tobacco companies are not required to disclose the contents of their products or to remove dangerous ingredients. Despite all the death and disease they cause, tobacco products are exempt from basic health regulations that apply to other products such as food, drugs and even dog food. All of these products have a list of ingredients somewhere on the label but not on a pack of cigarettes. It’s time to Stop Big Tobacco from Lying About Their Ingredients! You CAN help us show Congress that it needs to put lives ahead of Big Tobacco’s profits."

Then, the page states: "Read our talking points about how Big Tobacco is lying about their ingredients," and links to this page.

However, the "talking points" page about how Big Tobacco is lying about their ingredients does not say anything about how Big Tobacco is lying about their ingredients. It merely points out that consumers are largely unaware of the ingredients because there is no requirement that these ingredients be disclosed. It also mentions that the tobacco companies are deceiving consumers by marketing products with terms such as "low-tar," which imply some degree of health benefit.

The Rest of the Story

Despite all of the fanfare from the American Cancer Society, I'm still waiting to hear exactly how Big Tobacco is lying about the ingredients in their products.

I'd really like to know because I testify in lawsuits all the time against Big Tobacco, and this would be dynamite evidence to present to a jury. In my previous testimony, I've been able to testify that the tobacco companies have misled the public into thinking that cigarettes are safer than they actually are by undermining the public health messages that have been disseminated regarding the risks of smoking. However, I have never before been able to testify that Big Tobacco is actually lying about what the ingredients of their products are. That's because I was previously unaware of this fact.

So I would love for the American Cancer Society to reveal exactly how the tobacco companies are lying about the ingredients in their products. Is the ACS claiming that there are ingredients in Big Tobacco's products which the companies claim actually aren't in there? Or is the ACS claiming that tobacco companies have stated that their products don't contain certain ingredients which actually are in there?

This would be extremely damning evidence to present to a jury, because it would demonstrate that even in 2007, the tobacco companies continue to lie to the public about their products, and in this case, with factual misrepresentation about the ingredients in the products, not merely with a misleading framing of the information.

I'm aware that the cigarette companies have claimed that there are certain levels of tar and nicotine in their products, as required by the Federal Trade Commission. Beyond that, I'm not aware of claims about the ingredients of cigarettes that the companies are making, so I am anxious to find out about these claims.

Unfortunately, the evidence that the ACS provides in its "talking points" does not demonstrate any lying about any ingredients.

First, failing to disclose the ingredients does not represent "lying" about the ingredients. Lying about the ingredients would mean claiming that something is present which is not actually there, or that something isn't there which actually is. The fact that cigarette companies don't disclose all the ingredients of their products may be improper (I actually don't think it is - frankly, what does it matter what's in there as long as people know the product contains thousands of chemicals, many of which are toxic and/or carcinogenic), but it is certainly not lying.

Second, while marketing products as "low-tar" may be misleading because it implies a safer product, it does not represent "lying" about the ingredients in the product. In fact, the cigarettes are "low-tar" as defined by the Federal Trade Commission. So the tobacco companies aren't lying; they're just misleading people.

So that leaves us with nothing. No evidence whatsoever that the tobacco companies are lying about their ingredients.

Perhaps the American Cancer Society is just keeping this all hushed because they don't want to give anything away. But a more likely possibility is that the American Cancer Society is full of it, and that this is yet another sleazy ploy to promote passage of the FDA tobacco legislation.

By suggesting to its constituents that Big Tobacco is lying about the ingredients in its products, it certainly does make it appealing to support legislation that would require disclosure of these ingredients. The problem, however, is that Big Tobacco (at least to the best of my knowledge) is not lying about the ingredients - it is just not required to disclose them.

The one attempt to require cigarette companies to disclose the ingredients of their products (by the state of Massachusetts) was struck down by the First Circuit U.S. Court of Appeals. It is therefore unclear whether the ingredient disclosure requirements of the proposed legislation will survive legal challenge in the first place.

But the point is - simply - that the American Cancer Society appears to be once again deceiving the public in order to generate support for the FDA legislation.

Is not the American Cancer Society capable of using factual information to argue in support of the FDA legislation?

Is the bill so awful that the ACS needs to resort to the consistent use of deception to support it?

If the ACS cannot use the truth to argue in support of the bill, then might it perhaps want to re-think its position on the bill?

As a sidenote, I should mention that disclosure of the ingredients in cigarettes will do nothing to protect the public's health. We already know that cigarettes kill - knowing the specific ingredients in the cigarettes, beyond the more than 4,000 chemicals that have already been identified - is not going to help out substantially. After all, what is there that we are going to find out from disclosure of all ingredients that we don't already know from the identification of the thousands and thousands of ingredients that we have known about for the past 30 years or so? The cigarette additives have already been disclosed and that long list hasn't been of any use to protecting the public's health.

But that's neither here nor there. The point is that the American Cancer Society is once again using deceit to support the FDA bill. Either that or they are keeping one of the juiciest secrets of all time.

The truth be told, the only entity I'm aware of that is "lying" to the public about the "ingredients" in cigarette smoke is the anti-smoking movement. After all, weren't we the ones who claimed that cigarette smoke contains asbestos; and then retracted that claim when called on it, only to claim - again falsely - that cigarette smoke contains plutonium?

If you are going to publicly accuse the tobacco industry of lying, I think it is only appropriate that you provide evidence and documentation to support your claim. The American Cancer Society has failed to do that.

I'm left, therefore, with the impression that the ACS is being somewhat disingenuous. I guess it just isn't fashionable to be honest when you are promoting the FDA legislation.

Berkeley Proposes Use of Expanded Outdoor Smoking Ban to Keep Homeless People Away from Stores

In order to protect local businesses by ridding their outdoor environments of congregating homeless people, the city of Berkeley is considering expanding its outdoor smoking ordinance and using that law to keep the homeless off the streets in its retail districts.

According to an article in the Berkeley Daily Planet, Mayor Tom Bates is attempting to get the homeless off the streets, and he's doing it in part by proposing a new law that would ban sitting on the street for a prolonged period of time and in part by proposing to expand the existing ban on smoking outside of buildings by extending the smoke-free boundary from 20 to 25 feet and enforcing that law against homeless persons who might not be able to be approached by police for any other legitimate reason.

These changes are part of a broader proposal by the mayor - entitled "Public Commons for Everyone." While the proposal apparently calls for increased services for homeless persons hanging out on the streets in front of Berkeley's crowded retail district in the area south of its UC campus, it has been criticized by advocates for the poor and the homeless who say the proposed ordinance could be misused, may violate people's civil rights, and fails to address the underlying reasons for the widespread homelessness problem in Berkeley, including the lack of affordable housing.

According to the article: "Dan McMullan of Disabled People Outside, told the Daily Planet he feared that even something as popular as a no-smoking ordinance could be misused. Storeowners who come outside to smoke won’t get cited, but homeless people will, McMullan said. ... Speaking to the committee on behalf of the Berkeley Community Coalition, which mostly represents service providers, boona cheema, executive director of Building Opportunities for Self-Sufficiency, called on the mayor and city manager to meet directly with homeless people to have 'open and honest dialogue as to the total purpose of the Public Commons for Everyone initiative and with their input find ways to influence street behavior without creating new laws.' ...

"'The religious community says ‘love thy neighbor as thyself.’ I feel this is the antithesis,' said Sally Hindman, a member of the coalition and director of Young Aspirations, Young Artists (YAYA). The mayor has said in previous meetings that this initiative is important to force 'service-resistant' people into getting services. But Hindman, who describes herself as a strong supporter of Mayor Tom Bates said, 'It’s not right to talk about service-resistant people when there are not enough services.' What needs to happen is that the community should support adequate services for those in need, including building adequate housing, she said.”

See San Francisco Chronicle commentary by Matier & Ross here.
See The Daily Californian article here.
See Oakland Tribune article here.
See Jacob Sullum's commentary on Reason Online here.

The Rest of the Story

How ironic that the proposal is called "Public Commons for Everyone." For everyone but homeless smokers. After all, they have two slams against them. As if it isn't bad enough that they are discriminated against because they are homeless, now they will be additionally discriminated against by virtue of the fact that they smoke.

Apparently, a 20-foot border zone around store entrances isn't big enough to allow police to harass the homeless. They need an extra 5 feet to get fully rid of these undesirables.

One thing is clear. This isn't about health. It's about economics. The expansion of the no-smoking zone around public buildings is not being considered because it is needed to protect the health of nonsmokers; it is being proposed because it will help the city to get rid of the presence of homeless people around stores on Telegraph and Shattuck, and therefore to appease business owners and help protect profits of these stores. It's clearly about money and not health.

Apparently, there doesn't appear to be much opposition on the City Council to the expansion of the outdoor non-smoking areas. If I still lived in Berkeley, I would be vehemently opposing the proposal. I would hope that local anti-smoking groups would express their opposition; I doubt they will, however.

Sally Hindman is exactly right. If you want to get rid of the homeless, then build adequate affordable housing. Provide adequate services and social support, including substance abuse and mental health services. Harassing these individuals, criminalizing them, and changing the law specifically to take away their civil liberties is not going to solve the problem, although it may well be successful in protecting local businesses.

I worked with the homeless in Berkeley for two years, so I am quite familiar with this population and the "problem" of homeless persons hanging out on the streets in the downtown area. What I can say from my own experience is that the services for this population were hideously inadequate. Basic social services were unavailable, and there was a concerted effort on the part of the County to try to deny these people services in order to protect the County budget. To now take it out on that very population which was systematically denied services which helped to keep them without shelter and in poverty is despicable.

American Cancer Society Continues Campaign of Deception Promoting FDA Legislation; This Time, Taking Advantage of Racial/Ethnic Minority Groups

This week, the American Cancer Society is enticing its constituents to write letters to Congress supporting the proposed FDA tobacco legislation by falsely implying that the bill currently before Congress would stop Big Tobacco from marketing its products to "minorities" (i.e., racial/ethnic minority groups).

This week's campaign is entitled "Stop Big Tobacco From Targeting Minorities."

The lead web page states: "Big Tobacco’s expenditures for magazine advertising of mentholated cigarettes, popular with African-Americans, increased from 13% of total ad expenditures in 1998 to 49 % in 2005. And without fail, an estimated 1.6 million African-Americans Americans alive today, who are now under the age of 18, will become regular smokers, and about 500,000 of these will die prematurely from a tobacco-related disease. ... It’s time to Stop Big Tobacco from Marketing to Minorities! You CAN help us show Congress that it needs to put the lives of African-Americans and Hispanics ahead of Big Tobacco’s profits."

The web site then features a link that readers can click; it provides them with a prepared letter to Congress urging passage of the FDA tobacco legislation in order to stop Big Tobacco from targeting "minorities" (racial/ethnic minority groups).

The Rest of the Story

This is truly disturbing to me. The American Cancer Society is blatantly deceiving its constituents into believing that the proposed legislation would stop Big Tobacco from marketing their products to racial/ethnic minority groups. The ACS is clearly implying that the proposed legislation would stop Big Tobacco from marketing to these groups, but the bill does nothing of the sort.

The truth is that the bill does not give the FDA the authority to stop tobacco companies from marketing products to racial/ethnic minority groups. As long as cigarettes are a legal product and adults of racial/ethnic minority groups are legal consumers of those products, the FDA simply cannot stop that marketing. Prohibiting the marketing of tobacco products to racial/ethnic minority groups - as long as that marketing is targeting adults - would clearly be unconstitutional because it would violate the First Amendment to the Constitution.

It is questionable whether even restrictions on advertising designed to protect youths from exposure will be deemed constitutional by the Supreme Court (in light of its ruling in Lorillard v. Massachusetts). But clearly, banning advertising to adults is not constitutional. In fact, the Supreme Court clearly stated: "The First Amendment ... constrains state efforts to limit advertising of tobacco products, because so long as the sale and use of tobacco is lawful for adults, the tobacco industry has a protected interest in communicating information about its products and adult customers have an interest in receiving that information."

Since tobacco use is lawful for all adults - whether they are members of a racial/ethnic minority group or not - restricting tobacco marketing to racial/ethnic minority groups is not allowable under the First Amendment. Thus, the American Cancer Society is not being truthful in telling its constituents that the proposed legislation would stop tobacco companies from marketing to "minorities".

The best the legislation could do is to stop the marketing of tobacco products to youths, and even the extent to which that could be done is not clear. Based on the Supreme Court's previous decision, much of the advertising restriction in the FDA legislation would probably be overturned.

I find it disturbing not only that the American Cancer Society is being untruthful to its constituents, but also that the ACS is taking advantage of racial/ethnic minority groups to try to garner support for its political agenda. The ACS is giving members of racial/ethnic minority groups false hope that the legislation will stop tobacco companies from marketing their deadly products to these groups, and through that false hope, trying to take advantage of the emotions of racial/ethnic minority group constituents (who naturally don't like the idea of being a tobacco industry target) to entice them to support the legislation. But this enticement is being done under false premises.

Essentially, what is going on is that the ACS is manipulating its racial/ethnic minority constituents, playing on their emotions, but doing so in a false and deceptive manner. Little do their constituents realize it, but they are being taken advantage of. They are being used merely as pawns in a political game. To treat racial/ethnic minority group constituents in this way is simply appalling.

Just because an individual is a member of a racial/ethnic minority group doesn't mean that person is any less entitled to be informed about public health policies that affect them. The American Cancer Society has no business trying to get the racial/ethnic minority community to support a piece of legislation without informing the community what the legislation would and would not actually do.

Bemoaning the advertising of mentholated cigarettes, the ACS implies to its African American constituents (and others concerned about the health of African Americans) that the FDA legislation would get rid of the addition of menthol to cigarettes. However, quite the opposite is the truth. The bill would preclude the FDA from eliminating menthol from cigarettes.

Section 907(a)(1) of the proposed legislation states: "A cigarette or any of its component parts (including the tobacco, filter, or paper) shall not contain, as a constituent (including a smoke constituent) or additive, an artificial or natural flavor (other than tobacco or menthol) or an herb or spice, including strawberry, grape, orange, clove, cinnamon, pineapple, vanilla, coconut, licorice, cocoa, chocolate, cherry, or coffee, that is a characterizing flavor of the tobacco product or tobacco smoke."

The bill, then, eliminates all kinds of flavorings from cigarettes, but it leaves the one flavoring that is most responsible for the targeting of African Americans - menthol - alone.

Thus, what the bill actually does is institutionalize the targeting of racial/ethnic minority groups. It ensures that menthol would forever remain a constituent of cigarettes. It ensures that there will always be cigarette brands that are targeted at African-Americans.

The ACS is doing a huge disservice to the African-American community by supporting a bill that would preclude the elimination of menthol from cigarettes. But it is doing an even greater disservice by falsely implying that the bill would stop the marketing of tobacco products to racial/ethnic minority groups when the bill does nothing of the sort.

Last week, the ACS took advantage of women to support the legislation. This week, they are taking advantage of racial/ethnic minority groups. Who will they take advantage of next week?

I do not call on the American Cancer Society to immediately withdraw its support from the FDA legislation. It is the right of the ACS to support whatever legislation it wants to, even if that legislation is clearly not in the best interests of African-Americans, as it would institutionalize the use of menthol to target this group and ensure the continuation of a disproportionate number of tobacco-related deaths among African-Americans.

However, I do call on the American Cancer Society to immediately end its deceptive, inappropriate, and disturbing campaign in support of this legislation.

Chicago Tribune Column Criticizes Health Groups' Movie Smoking Demands

A column by Steve Chapman in yesterday's Chicago Tribune takes issue with the demand of many anti-smoking groups that any movie that depicts non-historical smoking be automatically given an R rating.

Chapman makes a number of arguments, starting with the contention that the research linking exposure to smoking in movies with smoking initiation is perhaps not as strong as anti-smoking groups have made it out to be. Specifically, Chapman suggests that the observed relationship between seeing smokers in movies and starting to smoke may be due to an increased propensity to smoke among the kinds of youths that tend to view movies that show lots of smoking: "it may be that teens who are inclined to smoke anyway are also inclined to see the sort of movies that feature smoking."

Chapman then quotes me, noting my argument that this research cannot possibly isolate a specific effect of movie smoking, as opposed to exposure to smoking in a variety of media: "Michael Siegel, a physician and professor at the Boston University School of Public Health, believes the studies greatly exaggerate the impact of tobacco in films. 'It is simply one of a large number of ways in which youths are exposed to positive images of smoking (which includes advertisements, television movies, television shows, DVDs, Internet, music videos and a variety of other sources),' he told me in an e-mail interview. 'To single out smoking in movies as the cause of youth smoking initiation for a large percentage of kids is ridiculous.'"

The column then cites my argument that a mandatory R rating for any smoking in movies could undermine the ratings system and ironically lead to more exposure to smoking: "Siegel points out that applying R ratings to films just because they feature full-frontal shots of cigarettes may backfire. Parents anxious about sex and violence may stop paying attention to the rating system once it factors in smoking. So you could end up with more kids seeing films with smoking."

Finally, Chapman makes the interesting point that requiring an R rating of movies that depict smoking may not be particularly effective in preventing youth exposure to smoking in movies, since data show that 84% of kids in grades 5 through 8 (pre-teens and young teenagers) view R-rated movies. The percentage must be even higher among older teenagers.

The Rest of the Story

The point this column makes about the extremely high percentage of adolescents who view R-rated movies is a very important one. Even if we accept, for the sake of argument, that smoking in movies is responsible for 38% of youth smoking, as asserted by some anti-smoking researchers, it is not necessarily the case that requiring an R rating for movies that depict smoking would lead to any substantial reduction in youth smoking.

The reason is that the overwhelming majority of adolescents are exposed to smoking in R-rated movies. It is not clear whether the anti-smoking groups' proposed policy would actually prevent youths from being exposed to smoking in movies.

In fact, it is possible that the exposure to smoking in movies might not be reduced substantially. First of all, smoking depictions would tend to be heavily concentrated among R-rated movies. Movies that previously might have limited smoking would no longer have any incentive to do so. Since a single smoking depiction would generate an R rating anyway, the film might as well depict as much smoking as desired. Thus, the R-rated films that youths see anyway could well be packed with smoking depictions.

Second, the rating of any film with any smoking depiction as an R-rated film could well undermine the ratings system. Parents might become more lax about their children viewing R-rated films. Or it might give kids an excuse to convince their parents to let them watch such movies ("Awe mom. It's only rated R because one of the characters lights up a cigarette once.")

Third, youths would continue to see smoking in many other media, including advertisements, television movies, television shows, DVDs, the internet, music videos and a variety of other sources.

Things are a lot more complex than the anti-smoking groups are making them out to be. The world is not black and white. It is not as simple as concluding that exposure to smoking in non-R rated movies is the cause of more than a third of youth smoking. And we are deceiving ourselves if we think that requiring an R-rating of any movie with any smoking depiction is going to save countless lives.

Nicotine-Free Cigarettes May Increase Heart Disease Risks for Smokers; New Study Reveals Another Potential Contraindication to FDA Tobacco Legislation

In a previous post, I argued that the proposed FDA tobacco legislation – which is being supported by health groups in part on the grounds that reducing the nicotine levels in cigarettes will improve the public’s health by making cigarettes less addictive – may actually harm the public’s health because smokers may compensate (i.e., smoke more) in response to nicotine reductions, thus increasing the delivery of tar and the consequent carcinogenic and pulmonary effects.

Today, I reveal an additional way in which severe reductions in the nicotine content of cigarettes could harm smokers: by increasing the cardiovascular health risks of smoking due to a reduction in the platelet activation modifying activity of nicotine.

The new research, presented yesterday at the Sixth Scientific Symposium of the Flight Attendant Medical Research Institute (FAMRI), studied the effect of nicotine-free cigarettes on cardiovascular disease risk in smokers, as measured by levels of platelet activity in the blood (higher levels of platelet activity indicate a more thrombotic state – a state more conducive to clot formation and therefore to the development of cardiovascular disease) (Girdhar G, Xu S, Jesty J, Bluestein D. Abstract – Nicotine reduction and elimination in cigarettes – its effect on cardiovascular risk in smokers, and in non-smokers exposed to secondhand smoke).

The researchers, from the State University of New York at Stony Brook, examined the effect on platelet activity of switching smokers from a low-nicotine to a zero-nicotine cigarette. They found that platelet activation increased significantly more among smokers who switched to zero-nicotine cigarettes than among those who continued to smoke low-nicotine cigarettes. In other words, nicotine did appear to suppress to some extent the platelet activating effect of cigarette smoking. Thus, the absence of nicotine led to higher levels of platelet activation, which would be expected to yield a more thrombotic state, and a higher cardiovascular disease risk.

The researchers wrote: “With regard to platelet activation – a clear marker of cardiovascular risk – we conclude that these [zero-nicotine] cigarettes may be substantially more pro-thrombotic than nicotine-containing cigarettes. … Nicotine in tobacco smoke of low-nicotine cigarettes significantly protects platelets against activation by non-nicotine smoke components. Accordingly, the reduction or elimination of nicotine from cigarettes may render them more harmful.”

The researchers concluded: “Removal of nicotine from cigarettes is dangerous for smokers and may increase risk of cardiovascular disease.”

The Rest of the Story

This new research is quite intriguing and it has some important implications for consideration of the proposed FDA tobacco legislation being promoted by Philip Morris and by a number of major anti-smoking groups. The results of the research are not intuitive; in fact, they may seem unexpected to those who were not previously familiar with the existing research showing in vitro, nicotine exhibits some suppressive effects on platelet activity. These new findings, which demonstrate this effect in vivo, suggest that the proposed FDA legislation may end up harming the public’s health not only because a reduction in nicotine levels may lead to increased tar delivery due to compensation, but also because greatly reduced nicotine cigarettes may be more pro-thrombotic and therefore more dangerous.

The purpose of this research was apparently to evaluate the health effects of new low- and zero-nicotine cigarettes being marketed by Vector Group (Quest cigarettes). The research shows that despite having very low or no nicotine, these cigarettes may not be safer for smokers, and that they may in fact be more hazardous due to reduction of the platelet activation suppression function of nicotine.

Although not the primary purpose of the research, it also has important implications for the evaluation of a government-mandated reduction in nicotine levels in cigarettes. The research cautions us that a strategy of mandating reductions in the nicotine content of cigarettes could be harmful to smokers, and therefore in conflict with the goal of protecting the public’s health.

This adds to the concern that I expressed previously about the potential for compensation by smokers in order to maintain a constant nicotine dose in the face of mandatory reductions in nicotine content of cigarettes.

It also adds to the concern over increased carbon monoxide levels produced by very low nicotine cigarettes, which would also be expected to increase disease risk.

The bottom line is this: we simply do not know what the effect of reduction of particular components of cigarettes – including nicotine – would be. Therefore, it is completely unwarranted to make a claim that the proposed legislation will protect the public’s health and/or save lives, as several of the major anti-smoking groups have asserted.

It is just as likely that the proposed regulation by the FDA could lead to changes that increase the health risks of cigarettes and kill people, rather than save lives.

Anti-Smoking Groups Demand Complete Removal of Historically Incorrect Smoking from Non-R Rated Films; An Exercise in Hypocrisy

Not content with the MPAA's historic announcement last week that for the first time, it will consider smoking in films as a factor in the rating of films, a number of anti-smoking groups are calling the MPAA's policy a mere "placebo" and are demanding that any film with any depiction of smoking be automatically given an R rating, unless the smoking depicted is historically correct (i.e., the person depicted actually smoked in real life).

These health groups issued a strongly worded statement yesterday which declares that: "each time a member of the industry releases another movie that depicts smoking, it does so with the full knowledge of the harm it will bring to children who watch it."

Describing what happened last week, the statement said: "With much fanfare, the MPAA announces that it will “consider” tobacco imagery in the ratings starting immediately. However, for the goal of eliminating tobacco content in movies accessible to young people, it substitutes another: merely informing parents — the sort of “fig leaf” that Harvard had specifically warned against. Leading health organizations quickly denounce the MPAA’s placebo policy. They pledge to keep pressing for the “R” rating and other measures that can substantially and permanently reduce adolescent exposure. (The statements from the American Medical Association, American Heart Association, American Legacy Foundation, and Campaign for Tobacco Free Kids were typical.) What happened? The major studios that make up the MPAA failed to reach consensus on the recommendations that the MPAA had itself invited. Unable to respond to the substance of the AGs’ letter, it has tried PR razzle-dazzle instead, recycling old and debunked ideas. It is now clear that the studios are not yet willing, for whatever reason, to break themselves free from Hollywood’s history of collaboration with the tobacco industry."

The groups are now calling on the parent companies of the film studios to force the studios to accept the recommendation of an automatic R-rating for any film that depicts any smoking that is not historically accurate.

The Rest of the Story

I think there are 2 aspects to the hypocrisy being displayed by these health groups.

First, I find it hypocritical to take such a principled stand against any smoking in movies - claiming that any smoking depiction in a movie (even a single, short depiction of someone smoking in the background) represents knowingly causing harm to children watching the film - and then to go ahead and argue that films which depict smoking which is historically accurate, even if the smoking is pervasive and glamorized, are perfectly OK for children to view and there is no need to protect children from exposure to these films by increasing their rating.

If the health groups were simply calling for an end to all depiction of smoking in movies, I would have a lot more respect for the proposal. I just don't see how you can take such a supposedly principled stand against any depiction of smoking, and then argue that some depiction of smoking is acceptable. It seems to me that once you start drawing a line and casting your own judgment on what smoking depictions are acceptable, then you've conceded the argument that there is a responsibility to protect children from any exposure that may increase their propensity to start smoking.

If the health groups' reasoning is correct, then by depicting historically accurate smoking, are not movie studios depicting smoking with the full knowledge of the harm it will bring to children who watch it?

The second aspect of the hypocrisy of some of these groups - in particular, the Campaign for Tobacco-Free Kids, the American Medical Association, and the American Heart Association - is that at the same time they are supposedly standing up against the tobacco industry and demanding that Hollywood end its historical collaboration with Big Tobacco, they are teaming up with the largest tobacco company - Philip Morris - and promoting legislation that is the chief legislative priority of this cigarette company.

I'm sorry, but if you are going to march shoulder-to-shoulder with Philip Morris through the halls of Congress, jointly promoting a piece of legislation that was negotiated directly with Philip Morris and which contains provisions inserted specifically to protect Big Tobacco profits, then you have lost the pedestal upon which you can proclaim to Hollywood that it needs to end its own collaboration with the tobacco companies.

To make matters worse, I think the implication that by depicting smoking in movies, the studios are continuing their collaboration with the tobacco industry is false. There is no evidence I am aware of that in 2007, the depiction of smoking in movies represents a collaboration with the tobacco industry, or that the tobacco companies are in any way influencing the depiction of smoking in movies. I understand that historically, this was the case. But the statement implies that the collaboration continues and that the influence of the industry is the reason why films are depicting smoking today. If you are going to make such a claim, I think it is your obligation to back it up. I am not aware of any such documentation, however.

Perhaps most importantly, I find this stand by the health groups to be quite narrow-minded and inconsistent from a broader public health perspective. There are a lot of ways in which movies influence unhealthy behaviors among adolescents: depiction of drunk driving, fast driving, alcohol misuse, illicit drug use, violence, sex, sexual violence, racism, gang violence, firearms, and so forth. For any of these depictions, one could state just as accurately that they are done with with the full knowledge of the harm it will bring to children who watch them.

Why, then, are these health groups not calling for an R-rating for any film that depicts any of these other behaviors. If anything, many of these behaviors could be considered worse, because unlike smoking, many of them are illegal. If we are going to have a zero-tolerance policy for smoking in movies, should we not also have a zero-tolerance policy for these other exposures which cause great harm to our nation's children?

Again, I could respect the health groups' position a lot more if they were taking a broad public health perspective and calling for an overhaul of the ratings system such that we protect our children from exposure to the wide range of depictions that may lead them to adopt unhealthy or harmful behaviors. To single out smoking and treat it differently seems narrow-minded to me.

If a single depiction of smoking in a film warrants an R-rating, then certainly we would want to give an R rating to a film that depicts racism, would we not? Or violence against women?

While I am obviously an anti-smoking advocate, I more than anything consider myself to be a public health practitioner. I try to see the world with a wider lens than merely a filter for smoking depictions. There is a whole world of unhealthy influences of media out there. It seems we are missing much of it because the smoke has gotten in our eyes.

IN MY VIEW: American Cancer Society Misusing Cancer Victims and Now Taking Advantage of Women

In Friday's post, I revealed that the American Cancer Society (ACS) has joined the Campaign for Tobacco-Free Kids in a campaign of deception, trying to elicit support for the proposed FDA legislation from its constituents, but hiding from them the critical fact that the bill is supported by none other than the nation's leading tobacco company - Philip Morris.

Today, I explain why I think this is doing a disservice to the nation's cancer victims and why I think the American Cancer Society is actually misusing these individuals.

The Rest of the Story

I have treated a large number of cancer patients in my career and have gotten to know them and their families extremely well. Many of them developed cancer because of smoking and I have had occasion to discuss with these patients and their families their view about the cigarette companies. And I can tell you that a huge proportion of these people would never support any legislation being actively pursued by Philip Morris.

It really isn't too much more complicated than that.

These folks don't trust Philip Morris for one second. They don't believe that Philip Morris would support a bill that puts public health ahead of tobacco company profits. They don't believe that Philip Morris would support legislation that would result in a significant decline in cigarette consumption. They don't believe that any bill which was negotiated with Philip Morris and which contains specific provision to appease the interests of Philip Morris can possibly be a public health policy worth pursuing.

Now comes the American Cancer Society and tells these folks - many of whom have lost loved ones to smoking-related cancers - that we can save millions of lives if only we convince Congress to allow the FDA to regulate tobacco products. Just email your Congressmembers and tell them to support the proposed FDA tobacco legislation. It will help stop Big Tobacco.

The cancer victims or their family members think this sounds great. Who wouldn't be in support of the idea of fighting Big Tobacco?

So they go ahead and email their Congressmembers.

But little do they know that they have just helped Philip Morris to promote its legislative dream come true. Little do they know that they have just supported a bill which is being actively promoted by Philip Morris. Little do they know that they have just supported a bill which contains special provisions negotiated by Philip Morris - provisions which sacrifice health protection in order to protect Big Tobacco profits. Little do they realize that their American Cancer Society is marching shoulder-to-shoulder with Philip Morris through the halls of Congress to promote this legislation.

Talk about misusing cancer victims and their families.

Don't you think that we could have a little bit of respect for these folks and have the human decency to let them know what it is that they are supporting?

If the American Cancer Society wants to try to convince cancer victims and their families and other constituents that Philip Morris has been outsmarted and that the bill will in reality reduce cigarette consumption and reduce the company's profits, then that's fine. The Cancer Society is free to do that. If the ACS wants to try to convince its constituents that the bill is worthy of our support despite the fact that it is Philip Morris' chief legislative priority, that's fine. If the ACS wants to argue to its constituents that despite their innate mistrust of anything that Philip Morris supports, this bill represents a surprising but important exception to the rule for certain well-articulated reasons, then they can go ahead and do that.

But to try to sneak this one by its constituents without ever informing them of the truth - without ever having the decency to give the constituents the ability to make their own informed decision about whether to promote the legislation - is misusing cancer victims and their families for political purposes.

Even if a constituent navigates around the web site, trying to see if there is any fine print or important information they should know about prior to signing away on their support of the legislation, they will be unable to find any mention of the bill's support by the leading tobacco company, nor will they be able to find any mention of the numerous loopholes in the bill, inserted by - and to protect the interests of - Philip Morris. Nor will they be able to find any mention of the critical fact that the bill resulted from a direct negotiation with Philip Morris.

It's not that the important details are in the fine print. There isn't even any fine print. It's what I would call blatant deception.

Of course people who are or have been affected by cancer are going to be a somewhat vulnerable position. Why would they ever fail to support a measure that they are told is going to prevent cancer? So to fail to inform these individuals of a fact as important as that Philip Morris is sponsoring this legislation is completely unfair, inappropriate, and bordering on abusive.

The rest of the story, then, is that the American Cancer Society is misusing its own constituents for its own political purposes.

My readers are familiar with the fact that I happen to believe that the proposed FDA legislation would be a public health disaster and that it would result in increased deaths from smoking, not in the saving of countless lives. But this is actually besides the point. It doesn't even matter. The ACS could be right about the impact of the legislation or wrong about it, and they are still misusing their constituents.

Have the human decency to tell these people exactly what it is that they are supporting. Give them an opportunity to make their own informed decision. Don't make that decision for them without giving them the chance to exercise their own informed judgment. Don't misuse them for your own political purposes -- especially when these are cancer victims and families you are misusing and the political purposes you are supporting happen to coincide with those of the very tobacco company whose products were the ones that caused many of them to be affected by cancer in the first place.

Taking Advantage of Women

The American Cancer Society last week ran a campaign under the theme of "Stop Big Tobacco from Marketing to Women." Constituents, like me, were given the opportunity to send Mother's Day messages to loved ones or friends urging them to help protect mothers from the deadly marketing practices of Big Tobacco.

That message states: "Happy Mother's Day! This Mother's Day, we have a chance to protect all mothers and children from the deadly practices of Big Tobacco. ... For decades, tobacco companies have successfully targeted women and girls with their products, appealing to their sense of fashion and independence. ... As an easy Mother's Day gift to yourself and others, please join me in helping Stop Big Tobacco. Together, we can Stop Big Tobacco."

Enticed by the possibility of taking an action that would stop tobacco companies from marketing to women, constituents who send an email actually end up sending an email that states the following:

"As a volunteer for the American Cancer Society Cancer Action Network, I am asking you honor women this Mother's Day by supporting S. 625 and H.R. 1108 ... It's time we stop tobacco companies from killing our mothers, our sisters, our daughters, and our wives by marketing their deadly and addictive products to women."

What the ACS is doing here, then, is enticing constituents to send Mother's Day messages to friends and loved ones - thinking that they are doing something to address the problem of tobacco industry marketing to women. Instead, possibly unbeknownst to them (unless they scrutinize the scam by first sending a message to themselves, like I did), they are actually being used to promote the FDA tobacco legislation, which does nothing to stop tobacco companies from "killing our mothers, our sisters, our daughters, and our wives by marketing their deadly and addictive products to women."

There is nothing in the FDA legislation that prohibits or in any way regulates the marketing of tobacco products to women. The legislation does allow the FDA to regulate cigarette marketing, but it can only do so in accordance with the First Amendment to the Constitution, and there are no Constitutional grounds upon which the FDA could prohibit the marketing of cigarettes to women (who are, after all, legal age consumers or potential consumers of legal tobacco products).

Essentially, this is a scam.

It is deceiving constituents into thinking that they are stopping tobacco companies from marketing to women. But the bill they are enticed (perhaps unknowingly) into supporting does nothing of the sort.

Moreover, constituents are told nothing about the other critical things that the bill does. They are told nothing about the fact that Philip Morris supports the bill, etc. If someone simply is concerned about the marketing of tobacco products to women, they would have no reason not to send this email along, and thereby support the FDA regulation.

I feel sorry for the potentially thousands of cancer victims and family members who may have been deceived by this political lobbying scam into supporting legislation that they may well not actually support because of its sponsorship by Philip Morris and which does not do the things they were told it will do. It is truly a disservice to the American Cancer Society's volunteers (of which I am one).

I hope that the ACS will put an end to these deceptive tactics immediately.