Saturday, December 22, 2007

Happy Holidays and a Happy New Year to All; The Rest of the Story Will Return on Monday, January 7

I wish all of my readers a very happy holiday season and a Happy New Year. The Rest of the Story will return on Monday, January 7. On that day, I hope to have an exciting announcement. Happy Holidays to All.

Los Angeles Times Retracts and Corrects Story on Roger Clemens' Use of Steroids and Apologizes: Tobacco Control Groups Should Take Note

The Los Angeles Times yesterday retracted its October 1, 2006 story which had reported that pitcher Jason Grimsley named former teammate Roger Clemens as someone who had used performance-enhancing drugs. In the actual affidavit, which was unsealed Thursday, Grimsley did not, in fact, name Clemens.

In response to the unsealing of the affidavit, the Los Angeles Times immediately retracted its original story, corrected it, and apologized. In fact, the paper ran its corrected story on the front page.

This retraction in no way clears Clemens of wrongdoing, since he is named in former Senator George Mitchell's report as a player who at one point used illegal steroids to enhance his performance. Clemens has vehemently denied that allegation.

The Rest of the Story

In many ways, this is an appropriate way for me to bring the 2007 year of The Rest of the Story to an end. This story has a very simple message: organizations do, from time to time, make mistakes. They do occasionally make inaccurate statements. But when that happens and the truth is brought to their attention, they do -- if they are responsible, are concerned about their credibility, and have some integrity -- retract the inaccurate information, correct it, and apologize for the error.

In 2007, The Rest of the Story has brought to the attention of many anti-smoking groups a large number of inaccurate, deceptive, or highly misleading scientific statements. With just a few exceptions, the anti-smoking groups and prominent researchers and advocates have not only ignored the truth and failed to correct their mis-statements, but in some cases they have instead attacked me and questioned my character.

I hope that the New Year is a time of reflection for the anti-smoking groups, and that they will come out in 2008 by following the lead set by the Los Angeles Times in the Clemens case: acknowledge their mistakes, correct them, and apologize for deceiving and misleading the public.

The problem is that what motivates organizations to act in this ethical way is: (1) a sense of public responsibility; (2) a concern for their credibility in the future; and (3) a degree of scientific integrity.

So far, the failure of anti-smoking groups to respond appropriately to the mistakes they have made suggests, unfortunately, the absence of these qualities.

In the pages of The Rest of the Story, the affidavit has been unsealed: many anti-smoking organizations have been named in the unethical (although not illegal) use of deceptive and misleading propaganda in order to pursue their (in some cases fanatical) policy agenda.

Just as this is now the time for Major League Baseball to respond to the Mitchell report in order to save itself, its reputation, and its integrity, this is now the time for tobacco control to respond to The Rest of the Story in order to preserve its own reputation and integrity.

Will 2008 represent a year of change, a year in which the anti-smoking groups come to terms with this unethical and inappropriate behavior? Or will it simply be more of the same: do not address the substance of the "Siegel report," just attack him, his credibility, his character, and his motives?

Based on the actions of anti-smoking groups and leaders in 2007, I have a little more hope that Major League Baseball will address its rampant steroid problem than that tobacco control will address its scientific integrity problem.

But this is the turn of a new year, and I am willing to forget the past and give the anti-smoking groups a new opportunity to make amends for their actions of the past. To do that, however, they need to turn a new leaf.

Wednesday, December 19, 2007

Another Day, Another 340 Young People Die From Smoking

According to Breathe California of Sacramento-Emigrant Trails, 340 young people will die today from smoking. Added together over a year, this amounts to 124,000 deaths of young people due to smoking. Since there are approximately 420,000 smoking-related deaths, this means that 30% of smoking-related deaths occur among young people.

I'm quite serious when I say that if smoking actually did kill 124,000 young people each year, it should simply be prohibited. The only reason why I think society tolerates 420,000 deaths from this product each year is that most of the deaths occur among people who are older. If 124,000 young people were dying each year from any product, I have no doubt that public health advocacy groups would be calling for an outright ban on that product.

So why isn't Breathe California of Sacramento-Emigrant Trails calling for a ban on smoking? I think the answer is simple: they know that 124,000 young people do not die from smoking each year.

In other words, it is quite apparent that Breathe California of Sacramento-Emigrant Trails knows that its website contains a statement that is blatantly false. It is almost impossible for me to imagine that they would not realize that their statement is false.

To me, this means that they are essentially lying on their web site. It may not have been a lie initially (in the sense that it is at least theoretically possible that this was some sort of very bad mistake). However, now they are aware of it and so it has changed from simply a mistake to a known lie.

The organization's excuse for not retracting what is now a lie is apparently that the web developer is no where to be found. I find that very hard to believe.

What I question is the organization's priorities. If I had a web site up and I knew that there was a blatantly false statement on the site, I would change it immediately. If only my web developer had control over the site, I would call him or her and demand that the web site be fixed right away. Not in 2 months. Right away.

I don't usually offer money on this blog, but today I am offering up a $1,000 prize for whoever is the first to find the web developer for Scene Smoking. Since Scene Smoking itself is having such a hard time finding the guy, I suggest that we here at this site do our part and initiate a national (no, an international) search for this guy. We've got readers from all over the world, so we should be able to track him down.

I'm not sure if I have any readers from Tortola. That could be a problem. Maybe I'll go down there over New Year's and try to track him down myself. If anyone has any leads, please let all of us know.

Tuesday, December 18, 2007

IN MY VIEW: Burbank Smoking Ordinance Goes Too Far and Gives Anti-Smoking Movement a Bad Name

Claiming that businesses in downtown Burbank are losing customers because of harsh penalties for smoking on sidewalks or other outdoors areas in the downtown, a group of business owners is attempting to overturn the six-month old smoking ordinance which essentially bans smoking throughout the downtown -- outdoors.

According to Chapter 17, Article 7 of the city's municipal code: "Smoking is prohibited on all non-enclosed sidewalks, paseos, and other pedestrian areas in Downtown Burbank accessible to the general public, except within smoking areas designated pursuant to Section 17-705.
1. For the purposes of this Section, Downtown Burbank means the area bounded by Angeleno Avenue, Third Street, Magnolia Boulevard, and First Street; and the area commonly known as the Burbank Town Center and bounded by Magnolia Boulevard, Third Street, Burbank Boulevard, and the Golden State Freeway.
2. This prohibition applies to the sidewalks along public and private streets within and around the perimeter of the area defined in Subsection 1, pedestrian alleys, pedestrian paseos and plazas including but not limited to the paseo along the former Palm Avenue between First Street and San Fernando Boulevard, walkways providing access from parking lots and structures to stores or sidewalks, and all other pedestrian paths or areas that are accessible to the general public."

Essentially, this means that when you enter downtown Burbank, you cannot smoke anywhere outdoors.

The Rest of the Story

This ordinance is far broader than what would be needed to achieve the purpose of addressing the public health problem of secondhand smoke exposure. While banning smoking inside the buildings in downtown Burbank, as well as in any outdoor areas where people cannot move about freely, makes sense, it serves no significant and legitimate public health purpose to declare all of downtown Burbank a smoke-free zone.

If someone is smoking in a parking lot, how does that endanger the public's health by creating substantial, unavoidable exposure to secondhand smoke? If someone is smoking in an alleyway behind a building, how does that endanger the public's health?

Apparently, the ordinance has become somewhat of a money maker for the city, as the LA Daily News article reports that more than 250 citations have been issued at $200 a pop.

It is also a violation of the ordinance to aid or permit someone to smoke in downtown Burbank. So technically, if you light up a cigarette for another person, you are guilty of violating the law. And if someone asks you if you mind if they smoke and you say "No, go ahead," you are violating the law.

These violations are no small matter. The law is enforced by the police department and apparently, a court appearance is required even for a first violation. The article reports that one woman who received a citation for smoking in a parking lot and then forgot about her court appearance ended up having a citation issued for her arrest. That seems like a large price to pay for lighting up in a parking lot.

Ironically, the ordinance allows (forces, if you will) people to light up in their own cars, where they will expose their children and other family members to high concentrations of secondhand smoke. Better that mom should step outside into the parking lot and smoke her cigarette than smoke in the car. But not so under the terms of this ordinance.

This ordinance is more than simply nonsensical and unjustified on public health grounds. It is dangerous. It threatens to undermine the smoke-free movement by giving a bad name to those of us who are working to legitimately protect people from a serious health hazard. Smoke-free advocates are going to be viewed as fanatics who are trying to simply get rid of smoking everywhere.

In my testimony in favor of smoke-free workplaces, bars, and restaurants, one of the most common arguments used by opponents was that this was just the first step and that soon we would be trying to ban smoking everywhere - even outdoors. I argued that this wasn't the case - that we were concerned with the high levels of secondhand smoke indoors and the very substantial and devastating health effects caused to large numbers of people.

Unfortunately, it appears that I was wrong.

Monday, December 17, 2007

New Poll Shows Waning Support for Anti-Smoking Groups' Agenda of Employer Discrimination Against Smokers

A Wall Street Journal Online/Harris Interactive poll conducted earlier this year revealed waning public support for policies - favored by many anti-smoking groups - by which employers fire or otherwise discriminate against workers, including smokers, who have unhealthy lifestyles.

While 53% of respondents in 2006 supported higher insurance premiums for those with unhealthy lifestyles, only 37% of respondents expressed such support in 2007. Similarly, the proportion of respondents supporting higher deductibles or co-payments for people with unhealthy lifestyles fell from 53% in 2006 to 35% in 2007.

In the 2007 poll, only 7% of respondents agreed that "employers should be able to fire an employee who is unwilling to quit smoking." Only 29% agreed that employers should be able to force a worker who smokes to take part in smoking cessation programs. The majority of respondents - 65% - believe that employers should neither be able to fire smokers nor require them to take part in smoking cessation programs.

The Rest of the Story

This poll reveals that the agenda of many anti-smoking groups, which includes discriminating against smokers in employment decisions, is not in line with public opinion. A measly 7% of the public expressed support for employers being able to fire employees because they smoke. Only a little over one-third of the public supports the idea of charging higher health insurance premiums for people with unhealthy lifestyles, such as smokers.

While public opinion is not necessarily a measure of the validity or appropriateness of a public policy, I am presenting these data in order to show that the extremist faction of the tobacco control movement - which is supporting employment discrimination against smokers - is so far out of touch with public opinion that it risks alienating the public if it continues to pursue this agenda.

My fear is when that alienation occurs, it will not be specific to the smoker discrimination movement. I'm afraid it will carry over to the entire anti-smoking agenda, including the movement to provide smoke-free environments for workers and the public.

Once the anti-smoking movement is associated with fanaticism, all aspects of the movement will be viewed in that way. The public will not, I believe, discriminate between the various parts of the tobacco control agenda.

In fact, I wonder whether the extreme actions of companies like Weyco, which have fired smokers who refused or failed to quit smoking, are behind the waning of public support for far less intrusive policies such as requiring higher health insurance premiums for smokers.

The animal rights movement went by the wayside largely because it came to be viewed by the public as a fanatical movement. It completely lost touch with public opinion. This is the exact path that I see the anti-smoking movement taking right now. I am speaking out because I want to prevent the movement from going down that road. Unfortunately, my words are largely falling upon deaf ears, or at least ears that don't want to listen, and therefore, I don't see my actions having any effect. I think it is too late for the extremist element within tobacco control to be restrained. And it is not going to happen with the current groupthink mentality in the movement. It is not going to happen when those who dissent are attacked and ostracized. This is precisely why dissent is important in a social movement. Without it, the tobacco control movement is going to eventually become what the animal rights movement is today.

Friday, December 14, 2007

FDA Tobacco Legislation Would Solidify Philip Morris' Financial Position By Shielding it from Liability; Why Would Health Groups Want to Do That?

With enemies like the Campaign for Tobacco-Free Kids, American Cancer Society, and American Medical Association, Philip Morris - the nation's largest cigarette manufacturer - doesn't need friends. Its enemies are about to do it the biggest favor imaginable: to solidify its financial well-being by taking care of, once and for all, the significant liability threat that is hanging over the company.

According to a new report issued by Zacks financial analysts, the chief obstacle to Philip Morris' financial stability is the continuing litigation threat - especially, the threat of large punitive damage awards. "Zacks senior consumer industry analyst Steven Ralston, CFA is keeping the shares of cigarette manufacturer Altria Group, Inc. a Sell, especially as its price has crept up in recent weeks. Here are some of the reasons why: Altria Group is the leading domestic tobacco company. The company generates significant cash flow and has a high dividend yield. However, the company is engaged in numerous tobacco liability suits. Several large punitive damage awards have been upheld by appellate courts, especially the $50-million judgment paid out in the Boeken case after the U.S. Supreme Court refused to hear the case. ... The stock has maintained a low P/E due to tobacco-related litigation issues, and has been pressured down to a single digit P/E during times of court case losses."

The Rest of the Story

The FDA tobacco legislation being promoted by the Campaign for Tobacco-Free Kids, American Cancer Society, American Heart Association, American Lung Association, American Medical Association, and many other health and anti-smoking groups would end, once and for all, the significant litigation threat that hangs over Philip Morris and its financial well-being.

While the legislation itself does not directly affect litigation, its effect would be to definitively end the litigation threat by virtually destroying the possibility of large punitive damage awards in pending and future legal cases against the company. Philip Morris could successfully (and correctly) argue that there is no need for punitive damages because the FDA now has full jurisdiction over the company's marketing practices, the sale of cigarettes, and even the ingredients, components, and design of the cigarette. Thus, there is no need to award huge punitive damages to deter future fraudulent activity.

I have testified before many of the juries in these cases, and I can tell you that this argument will be very compelling. Philip Morris tried to use this type of argument with the Engle jury, but it didn't work because expert witnesses like me testified that the Master Settlement Agreement didn't actually regulate the companies or effectively deter future fraudulent actions. In contrast, it would be all too easy to convince jurors that granting the FDA jurisdiction over the manufacture, sale, safety, and marketing of tobacco products is sufficient to prevent future legal violations.

The companies will be able to successfully use the argument that they are already regulated to stave off injunctive relief and substantial punitive damages in litigation by appealing to jurors' perceptions that the problem is "taken care of." The highly exaggerated claims of the positive public health impacts of this legislation that the health organizations are making are only contributing to this perception.

Moreover, the FDA tobacco legislation would bail out Philip Morris from what I feel is the most threatening potential litigation to the industry in the future and the one about which I believe the industry is most concerned -- claims related to potentially reduced exposure products (PREPS). Ultimately, I argue, as bad as people think the status quo might be, the FDA legislation would be far worse.

It is the status quo -- specifically, the absence of FDA regulation of tobacco products -- that is actually the limiting factor in the inability or reluctance of tobacco companies to proceed wholeheartedly with the development, introduction, and marketing of PREPS.

This is because of the fear that cigarette companies might face litigation based on claims that they made misleading or unproven health claims about these potentially reduced exposure products. Because it would take years of epidemiologic research after the introduction of these products to provide any meaningful evidence that there is a health benefit from these products compared to existing cigarettes, it is virtually impossible for the cigarette companies to make any health claims regarding PREPS without facing the risk of litigation based on a claim that they are making misleading or unproven health claims.

After all, if they can't prove a health claim until they market and study a cigarette for 10-20 years, and they can't market a PREP until they can prove the health claims, then they are in a complete bind.

But the FDA legislation would bail them out. How? By regulating the introduction and marketing of PREPS, including the conditions regarding the cigarette companies' ability to make various types of health claims, the proposed FDA legislation would preempt any claims against the industry related to PREPS, and would therefore effectively provide immunity for them, allowing them to proceed with the widespread introduction of PREPS into the market, both nationally and internationally.

In essence, not only is the Campaign for Tobacco-Free Kids working to open up global markets to the introduction of a new cigarette innovation that kills people, but does so by making them think they are protecting their health, but it is also working to take away the legal rights of American citizens to hold corporations accountable for damages suffered as a result of using their products.

With "enemies" like the Campaign for Tobacco-Free Kids, the major cigarette companies do not really need friends - the Campaign is doing their bidding for them in the halls of Congress.

And the result of that bidding, if successful, would be the global expansion of the cigarette market, the third major cigarette product innovation by the industry in the past half a century, the provision of immunity to cigarette companies to introduce and market a broad new class of deadly products with no fear of liability, the widespread introduction and sanctioning by the government of unproven and undocumented health claims that are sure to mislead millions of smokers, and ultimately, needless deaths due to the undermining of public health efforts to encourage smoking cessation, emphasize the deadly effects of cigarette smoking, and ensure that the public is not led to believe that there is any safe cigarette.

The real question is why would these health groups want to do such a favor for Philip Morris?

Perhaps it's because they feel, subconsciously, that they will be getting something in return.

Thursday, December 13, 2007

Breathe California of Sacramento-Emigrant Trails Still Claiming that Smoking Kills 340 Young People Every Day

Despite having been made aware of the absurdity of its claim nearly two months ago, Breathe California of Sacramento-Emigrant Trails is still stating publicly on its web site that smoking kills 340 young people a day, or 124,000 young people each year.

As of this morning, the web site continues to state: "Smoking Kills About 340 Young People A Day."

This statement appears inside a warning box, similar to movie ratings, which states: "SK-340 - Viewers Strongly Cautioned."

The SK-340 is apparently a rating that Breathe California of Sacramento-Emigrant Trails devised to warn movie viewers that smoking kills 124,000 young people each year.

The Rest of the Story

That smoking kills 124,000 young people a year should come as a great comfort to smokers in their 40's, 50's, 60's, and 70s. Since the total death toll from smoking is estimated to be about 420,000 per year, this means that only about 300,000 of those deaths occur among these older folks, as opposed to more than 400,000 as previously believed.

I don't see any way that Breathe California of Sacramento-Emigrant Trails can defend this statement. It is not just misleading, it is blatantly false.

If the tobacco industry were making such a blatantly false statement, anti-smoking groups would be calling on the offending companies to immediately retract it. Should anti-smoking groups not also be terribly concerned about untruthful statements that they themselves are making?

The organization has claimed that it has to wait until the web developer is available before any change can be made. Interestingly, however, it seems to me that a fancy introduction was added to the web site in recent days. If I'm right about that, then why was a web developer available to make that change, but not the change in the apparent lie on the web site?

Where is the web developer, and where has he or she been for the past 7 weeks? Vacationing in Tortola?

The story is beginning to sound a little fishy. Although I'm still open to the possibility that the web developer has been lying on the beaches of Cane Garden Bay for the past 7 weeks, sipping Coronas, doesn't it at least seem like Breathe California of Sacramento-Emigrant Trails has failed to make this a priority?

If I had an untruthful statement on my web site of which I was aware, I would remove it immediately - like...within minutes. OK - let's suppose that I didn't have access to the web page but had to work through an off-site web service. I would demand that the change be made right away. It's hard to imagine that I would allow the false statement to remain for 7 weeks.

By the way, when I informed Dr. Glantz about this statement (since it is apparently based on his data), his response was that he advised the group to ignore me. In other words, he apparently had no problem with the use of a false statement for a "good" purpose.

I suspect that there's something more going on here than simply a long-vacationing web design service. But if I'm wrong, please tell me how I can get a job with them. I'd love to spend two consecutive months in Tortola during this time of year.

Wednesday, December 12, 2007

Anti-Smoking Groups Using Misleading Scientific Statements to Support Smoking Bans

Not only have more than 100 anti-smoking groups made misleading scientific claims about the acute effects of secondhand smoke, but these deceptive statements are being used to support the need for smoking bans. Today's example comes from Missouri, where Smoke-Free St. Louis is citing, in support of a smoking ban, a statement that 30 minutes of secondhand smoke causes heart damage similar to that of active smokers and that it reduces the ability of the heart to get life-giving blood.

The misleading health claim comes not from Smoke-Free St. Louis itself, but from the national anti-smoking group Americans for Nonsmokers' Rights (ANR), which is arguably the leading source of information for anti-smoking advocates throughout the nation who are promoting smoking bans.

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

The Rest of the Story

First of all, I support the efforts of Smoke-Free St. Louis to promote a smoking ban for workplaces, bars, and restaurants in St. Louis. However, I do not support the use of misleading and deceptive scientific statements in order to promote such a ban. The ultimate blame, of course, lies at the door of ANR, which exaggerated the results of the Otsuka et al. study so much that they turned an important scientific finding into a blatant misrepresentation of the truth.

It is not true that 30 minutes of secondhand smoke exposure causes any heart damage, much less damage that is similar to that sustained after many years of active smoking. It is also not true that the hearts of nonsmokers exposed to secondhand smoke for 30 minutes are impaired in their ability to get life-giving blood.

In fact, the Otsuka et al. study, which is the one being relied upon for this statement, actually demonstrated that there is no impairment of basal coronary artery blood flow in subjects exposed to high levels of secondhand smoke for 30 minutes. The study itself documents that there was not any reduced ability of the heart to get life-giving blood!

Thus, the statement is contradicted by the very study which ANR claims supports it.

There is, in fact, no evidence that 30 minutes of secondhand smoke causes any heart damage. Does it impair the function of the cells lining the coronary arteries? Yes. But does that cause heart damage? No.

If sustained over many years, the endothelial dysfunction caused by tobacco smoke exposure could result in atherosclerosis. However, this is not going to occur from a 30-minute exposure. So it is massively deceptive to suggest that a 30 minute exposure causes heart damage, much less that it causes heart damage that is similar to that observed in long-term active smokers, who may have developed severe coronary artery stenosis and suffered heart attacks which destroyed heart muscle.

The Smoke-Free St. Louis web site also cites the invalid conclusions from the Helena and Pueblo studies, which I have already discussed in great detail.

But my chief concern is the citation of ANR's highly deceptive statements about the acute effects of brief secondhand smoke exposure on the heart.

Given the real scientific evidence about the hazardous effects of secondhand smoke exposure, why does ANR need to exaggerate and distort the truth? And why do anti-smoking groups around the country have to cite this garbage, when they could be relying strictly on valid science?

Tuesday, December 11, 2007

Canadian Medical Association Encourages Policy Makers to Enact Ban on Smoking in Cars, But Not in Homes

A press release issued by the Canadian Medical Association last Friday urges policy makers throughout Canada to protect children from secondhand smoke by banning smoking in cars, but not to protect those same children by eliminating tobacco smoke exposure in the home.

According to the press release: "The Canadian Medical Association (CMA) urges all levels of government to move now to make it illegal to smoke in vehicles carrying children. ... 'By banning smoking in cars carrying children, governments would be removing a substantial threat to health of Canada's children', said Dr. Brian Day, President of the CMA. 'We all strive to make our children's health the best possible, a Canada-wide ban would be a step toward achieving that goal.' Over 260 physician-delegates from across the country who attended the CMA's annual meeting in August in Vancouver recognized the importance of such legislation when they adopted the following resolution: 'The Canadian Medical Association urges all levels of government to implement a Canada-wide ban on smoking in vehicles carrying children.' Infants and children are more severely affected by the exposure of second-hand smoke than adults because they are smaller, have immature immune systems and have higher respiratory rates. ... 'Canada's doctors see the harmful effects of smoking every day in our practices. We encourage all the Canadian legislatures to play a leadership role and send an unequivocal message to smokers not to smoke in the presence of children', said Dr. Day."

The Rest of the Story

The rest of the story is that if Canada's physicians are so concerned about protecting infants and children from secondhand smoke exposure, since they have "immature immune systems" and "higher respiratory rates," then why are they apparently content to allow parents to continue to smoke around children in their homes? Why only ban smoking in cars, when we know that secondhand smoke exposure in the home is the primary source of infection and respiratory problems in infants and children, dominating the effects of tobacco smoke exposure in cars.

While the CMA mentions that it wants to send an unequivocal message that smokers shouldn't smoke in the presence of their children, it is instead sending the opposite message: smoking around children is not OK in cars, but it's OK in your home.

How does the CMA justify its support of banning smoking in cars, but its apparent unwillingness to support banning smoking around children and infants in the home? According to the CMA itself, such a step would "be removing a substantial threat to health of Canada's children."

I'm very curious to hear how the CMA, or other health and anti-smoking groups which want to send a message that smoking around children is unacceptable in cars, but acceptable in homes, would justify this position.

I don't think it can be justified, and thus I oppose car smoking bans. If anyone can offer a justification for arguing that smoking around children is acceptable in a home, but not acceptable in a car, please let me know. I'd love to be able to change my position so that it is in accord with the anti-smoking groups.

Monday, December 10, 2007

Another Policy Maker Says Smoking Around Children is Child Abuse

According to a Fox News article, an Arizona state lawmaker has publicly stated that smoking in the vicinity of a child is child abuse. He offered that comparison as justification for a bill he has proposed which would ban smoking in cars with children.

According to the article: "An Arizona lawmaker has proposed making smoking in a vehicle with anyone 17 and younger a crime that can get drivers pulled over and lead to fines of $50 or more per child. 'We already protect children from child abuse,' said Rep. David Schapira, who is proposing the new law, the first bill filed in the House of Representatives in anticipation of the upcoming legislative session. 'I think if you are smoking in a vehicle, to me that is child abuse.'"

The Rest of the Story

While I have dealt with this issue in detail before, let me summarize the two main reasons why smoking around a child is not, and should not be considered, child abuse.

First, child abuse generally refers to actions that directly harm a child. While secondhand smoke increases the risk of adverse health outcomes, it does not directly and necessarily cause harm. There is an important difference between risk and harm. There are many behaviors that increase a child's risk for adverse health outcomes. However, we do not consider these to be child abuse because they do not directly and necessarily cause harm.

For example, feeding a child large portions of high-fat, greasy foods increases the child's risk of developing adverse health outcomes, such as obesity and its sequelae. Feeding a child large quantities of food containing trans-fats increases the risk for later cardiovascular disease. Allowing a child to play hockey increases that child's risk for severe head and neck injuries. Allowing a child to ride in a lawn tractor greatly increases the child's risk for loss of limbs.

But none of these behaviors are considered to be child abuse because they only increase risk. They do not directly and necessarily cause harm to the child.

In some rare circumstances, exposing a child to secondhand smoke could be construed as necessarily causing direct harm. For example, if a child has severe asthma that is known to be triggered by secondhand smoke, then exposing that child to secondhand smoke could reasonably be construed as causing harm. However, this is not the argument that Rep. Schapira is making. He is not restricting his definition of child abuse to such cases.

Second, child abuse is an act of volition. It occurs intentionally. You cannot really back into child abuse. The parent who beats their child is intentionally inflicting harm. It is intentional, by definition. If a child accidentally drops their child while playing with them, that is not child abuse. If the same parent drops the child intentionally, that is child abuse. The difference is intention, and that's perhaps the key element of child abuse.

The overwhelming majority of parents who expose their children to secondhand smoke are not intentionally trying to harm their kids. Many of them do not know that secondhand smoke is harmful. Many of them do not believe that secondhand smoke is harmful, even if they are aware of public health statements to the contrary. Others may understand that it can be harmful, but simply don't think that it will harm their particular children. Still others may have observed that it doesn't appear to cause health problems in their children based on exposure experiences in the past.

Again, smoking around a child who is known to have asthma which is triggered by secondhand smoke could be an exception to this. If a parent knows that smoking around their child is likely to trigger an asthma attack, then doing so can be reasonably considered to be an intentional act of abuse. But again, there is no restriction of Rep. Schapira's definition of child abuse to such a situation.

The rest of the story is that in order to be considered child abuse, smoking around children would have to: (1) necessarily and directly cause harm to all children who are exposed; and (2) be an intentional act conducted with awareness that the behavior will cause harm.

Neither of these two essential conditions is met. Thus, smoking around children is not and should not be considered to be child abuse.

I would like to close by suggesting that the failure of some lawmakers and a number of anti-smoking groups and advocates to appreciate this distinction not only results in a flawed definition of child abuse, but it is also dangerous. We cannot afford to lose our ability to differentiate between parental behaviors that intentionally vs. unintentionally cause harm to children. The actions of these lawmakers and advocates is working towards blurring that distinction and undermining our ability to make this differentiation.

I can only hope that some anti-smoking group - somewhere - will publicly condemn these efforts to define child abuse in a way that includes smoking around children -- other than the rare situation where a parent knows his or her child is an asthmatic who will suffer an attack if exposed to tobacco smoke.

I have not the slightest bit of hope that a U.S. anti-smoking group will do this, however. I believe that the thinking in tobacco control is so narrow that groups are unable to see any aspect of child welfare or any societal values other than whether or not kids are exposed to tobacco smoke.

Sunday, December 09, 2007

GOING TOO FAR: Nova Scotia Town Proposes to Ban Smoking in All Outdoor Public Places, Including Streets, Sidewalks, and Parks

If a bylaw being considered by the town council is enacted, the only outdoors location where residents of Bridgewater, Nova Scotia will be able to smoke is outside their own homes (but not in the street or on the sidewalk). If not on private property, smokers will be in violation of the law, which was approved 3-2 on an initial vote, but which must be agreed to in a final vote (two councillors were absent for the initial vote).

According to an article from a CBC News site, the proposed bylaw "would ban smoking on all town property, including streets, sidewalks and parks."

This was confirmed by a CNEWS article, which wrote that the bylaw "would make it illegal to smoke in almost all [outdoors] public places within the town's limits."

The impetus for the new law? Apparently, someone complained about a person smoking in front of a school.

Yesterday, dozens of smokers lit up on the two bridges in Bridgewater which cross the LaHave river to protest the proposed bylaw. These would be the only public outdoors locations where smoking would be allowed under the proposal, since the bridges are owned by the province and are not subject to the regulation.

A number of the protesters were not opposed to the idea of indoor smoking bans, but thought this proposal was going too far. For example, according to CBC News: "Protester Bob Lewis said he can understand the current rules against smoking in bars and restaurants, but finds the latest proposal goes too far."

The Rest of the Story

I agree completely with the sentiments expressed by protester Bob Lewis. The latest proposal does go too far. Smoking on streets and sidewalks and in parks does not represent such a substantial threat to the public's health that it needs to be banned. An all-out ban on smoking in outdoors public places goes too far and divorces the tobacco control movement from any kind of rational science base. It also threatens to cast those of us who support workplace smoking bans as being fanatics who are simply trying to achieve prohibition through the back door.

Why should the sight of a smoker outside a school prompt an effort to ban smoking throughout the town? If the intent is simply to protect nonsmokers from health damage caused by secondhand smoke exposure, then there is no need to go this far. Instead, it seems that the real impetus for this proposal is a distaste for the idea that young people might see people smoking.

If you are going to regulate smoking in public places, I think you do so in order to protect people from secondhand smoke. I don't think you regulate smoking in public places in order to keep kids from seeing people smoking. The former is justified on public health grounds. The latter is not.

More disturbingly, the latter intent (to protect kids from seeing smokers) casts a negative moral value on smoking. It becomes more than simply a health issue. It now becomes a moral issue. I think that is a mistake, because I don't think we want to mix up lifestyle choices with morality. It could have devastating consequences in a number of ways.

If I happened to be a resident of Bridgewater, Nova Scotia, I would have joined the group of protesters on the bridges over the LaHave river yesterday. Not lighting up myself, of course, but standing with them in their opposition to an over-reactive policy proposal that paints tobacco control advocates as being fanatics. The Bridgewater town council should throw this idea where it belongs - right into the LaHave river.

(Thanks to Kevin for the tip).

Friday, December 07, 2007

IN MY VIEW: Campaign for Tobacco-Free Kids is Degrading Scientific Integrity of Tobacco Control with Its "Pick a Number Out of a Hat" Science

Yesterday, I revealed that the Campaign for Tobacco-Free Kids is disseminating very specific estimates about the number of lives that would be saved by enacting the proposed FDA tobacco legislation that are based on complete junk science. The Campaign based its entire series of projections of health care cost savings on an undocumented and unsupported estimate made in a Congressional Budget Office (CBO) report that there would be a 12.5% reduction in youth smoking if this legislation were to be enacted. However, neither the CBO nor the Campaign for Tobacco-Free Kids provides any scientific evidence to support their claim that the legislation would reduce smoking rates among youths by 12.5%. This is pure speculation. It is essentially picking a number out of a hat.

Neither the CBO nor the Campaign offers any explanation for exactly how the legislation would reduce smoking rates. Neither consider any of the many ways in which this legislation would likely increase smoking rates. There is no sensitivity analysis, in which projections are provided given a range of assumptions, rather than a single assumption. This is not science. It is junk science.

Here, I discuss the implications of this kind of junk science for the tobacco control movement.

The Rest of the Story

In my view, this kind of junk science seriously harms the tobacco control movement. It works towards undermining the movement's scientific integrity and credibility.

What is the point of researchers in tobacco control doing serious research and policy analysis if the leading anti-smoking group is simply going to make up the facts, picking a number out of a hat and drawing sweeping conclusions that have no basis in any evidence base?

Suppose a researcher wanted to do a proper analysis of the potential effects of the FDA legislation on smoking rates and health care costs. What would be the point of doing so? The Campaign has already disseminated its undocumented and unsupported sweeping conclusions. It is too late for anyone to conduct real science. The bogus information has already been disseminated. The valid research question is essentially moot.

This, by the way, is one of the reasons why I gave up my position as a statistical and methodological editor with the journal Tobacco Control. I just don't see the value of carefully conducted and stringently reviewed science in tobacco control anymore. If groups like the Campaign for Tobacco-Free Kids are going to engage in "pick a number from a hat junk science," then what is the need for solid science? If groups like the Campaign are going to widely disseminate junk science findings and lobby for legislation based on that junk science, then what role does solid science play in the movement? To prove the Campaign was wrong after it's too late and the legislation has already been enacted? I don't see the point.

Even worse, the effects on the scientific credibility of the movement could be severe. In some ways, the movement is only as strong as its weakest link. Even if 95% of the science being conducted is solid, if the public sees a small proportion of science that is complete junk, the credibility of the movement could be completely destroyed. People do not calculate the proportion of science that is solid vs. junk. If they see junk, they dismiss the credibility of the movement altogether.

And perhaps worst of all, the Campaign for Tobacco-Free Kids is destroying the difference in scientific quality between the tobacco control movement and the tobacco industry. It used to be that I could tell people that the tobacco industry produces junk science and that if you want to know the real science, you have to listen to what tobacco control groups are saying. Now, I can't tell people that. Based on the latest junk science from the Campaign for Tobacco-Free Kids, I can't honestly say that the tobacco control groups have any more of an evidence-base for their statements than the tobacco industry does.

Thursday, December 06, 2007

Campaign for Tobacco-Free Kids Disseminating Complete Junk Science in Support of FDA Tobacco Legislation

A report recently released by the Campaign for Tobacco-Free Kids (TFK) presents claims of the specific amount of money that will be saved because of reduced health care costs due to lowered smoking rates if the FDA tobacco legislation is enacted. The report goes so far as to estimate the specific amount of money that would be saved in each state. The Campaign for Tobacco-Free Kids is now issuing press releases in various states, making claims about how much money each state will save from reduced smoking rates due to the legislation (for example: Utah; Virginia). The report claims that exactly 2,502,000 fewer kids who are alive today will become future addicted adult smokers if the legislation is enacted, that there will be exactly 797,700 deaths prevented, and that the future health care savings will be exactly $44.4 billion. These numbers are based on a Congressional Budget Office estimate that the legislation would reduce youth smoking by 12.5% over five years.

The Rest of the Story

Before saying anything else, let me first say that in my opinion, this is the absolute worst piece of junk science I have ever seen in my entire career.

When you see a sweeping claim like this of the exact number of lives that will be saved due to a complex piece of legislation and you do not see any sensitivity analysis (meaning an estimate of the range of savings under various assumptions), you know you are dealing with complete crap.

What should tip people off that this is complete crap is are two things:

1. The fact that although the report devotes page after page to an accounting of the lives saved and reduced health care costs, it does not specify exactly what policies are going to reduce youth smoking and how they are going to accomplish that, nor does it provide any research to back up the contention that these policies will reduce youth smoking by exactly 12.5% over 5 years; and

2. The fact that the report does not take into consideration any of the potential adverse effects of the legislation, including the probable increase in cigarette consumption due to the implied FDA seal of approval for cigarettes, which would greatly undermine the public's appreciation of the health hazards of smoking.

If this were a cost-benefit analysis submitted for a class that I teach, it would receive failing marks. And I'm actually an easy grader (ask any of my students). It is exceedingly difficult to fail one of my classes, but TFK would fail, without question, if it submitted this report.

Actually, this is a highly partisan, one-sided view of the impact of the FDA tobacco legislation. It considers only the possibility that youth smoking would decline due to marketing restrictions and user fees. However, it does not even consider the possibility that smoking would increase due to a complete undermining of public health efforts for the past four decades to impress upon smokers the severity of the risks of cigarettes. It does not account for the implications of the FDA's seal of approval on cigarettes. It does not account for possible increases in cigarette consumption if nicotine levels are reduced. It does not account for cigarette company response to the legislation. It does not account for the very likely possibility that many of the marketing restrictions will be overturned by the Supreme Court. It does not account for the also likely possibility that Philip Morris will be able to greatly increase cigarette consumption by successfully marketing a reduced exposure product.

In fact, the report provides no analysis (zero) of the effects of the legislation. It simply assumes that the bill would reduce smoking by 12.5%.

Look - I could just as easily assume that the bill will increase smoking by 12.5% and come up with estimates of my own of the increased costs of this legislation. I could, but I wouldn't do that, because it is junk science.

The 12.5% estimate comes from the Congressional Budget Office (CBO) report, but that report simply assumes that youth smoking will decline by 12.5% because the intention of the legislation was to reduce youth smoking. The CBO offers absolutely no (zero) explanation for how the legislation will reduce youth smoking rates. It provides no scientific evidence to back up the assumption that this legislation will reduce youth smoking. It also fails to consider the adverse impact of the legislation, especially in terms of increased smoking due to a reduced perceived risk of smoking.

This is as low as I've ever seen the science get in the tobacco control movement.

The rest of the story is that the claims being made by the Campaign for Tobacco-Free Kids are based on junk science. The report, in my opinion, is complete crap.

Wednesday, December 05, 2007

ASH (UK) Becomes First Anti-Smoking Group to Publicly Acknowledge that Other Groups are Making False Statements to the Public About Secondhand Smoke

In a letter to the editor of New Scientist magazine, Action on Smoking and Health (UK) became the first anti-smoking group to publicly acknowledge that a number of tobacco control organizations have made false statements to the public about the acute cardiovascular effects of secondhand smoke.

The letter responds to the article in last week's issue which highlighted my concerns about misleading and inaccurate statements being made by nearly 100 anti-smoking groups about the cardiovascular effects of brief secondhand smoke exposure.

In the letter, ASH (UK) writes: "ASH (UK) endorses your conclusion that bad science can never be justified. ASH, unlike some organisations, has never asserted that a single 30-minute exposure to second-hand smoke is enough to trigger a heart attack, and we are not aware of any UK health advocates who have done so. What we do say, based on a growing body of evidence, is that repeated exposure to second-hand smoke can damage coronary arteries, which in turn can trigger heart disease. As a matter of course, we aim to ensure that our work is evidence-based and we would never deliberately distort science to justify a particular campaign. The evidence of the harm to non-smokers exposed to tobacco smoke is so robust that there is no need to exaggerate it to justify tobacco control measures."

ASH (UK) is not to be confused with ASH (US), which in contrast to its British counterpart, has claimed not only that a 30-minute exposure to tobacco smoke can trigger a heart attack, but that such an exposure increases the risk of a fatal heart attack to the same level as that of an active smoker.

The Rest of the Story

ASH (UK) is to be congratulated for its courage and its willingness to publicly condemn the use of inaccurate health claims to support an agenda which it supports. ASH (UK) makes it very clear that in its opinion, the ends do not justify the means. In fact, it argues that the use of bad science can never be justified. I praise ASH (UK) for taking such a principled stand.

In breaking from all of its counterparts in the tobacco control movement by acknowledging that some of its fellow groups are making false statements, ASH (UK) has taken a courageous action. As I know too well, groups or advocates within tobacco control who make any statement of criticism of other groups -- even if justified -- are subject to vicious attack and ostracism from the movement. This is why it is laudable that ASH (UK) was willing to take this principled stand, and to do so in a visible (public) way. In fact, ASH (UK) apparently initiated this response, since it is a letter to the editor. No one forced ASH (UK) to speak out. They did so, apparently, because they felt the issue was important enough.

It is reassuring to me that after two years of challenging these ridiculous statements, one anti-smoking group has finally come out publicly and agreed that I am correct. Yes - some groups have asserted that "a single 30-minute exposure to second-hand smoke is enough to trigger a heart attack." And yes - such a claim, if unqualified by noting that it refers only to people with very severe coronary artery stenosis, is simply wrong. It is bad science. It is unjustified.

ASH (UK) accurately communicates the results of the actual science when it explains to the public that "repeated exposure to secondhand smoke can damage coronary arteries, which in turn can trigger heart disease."

Now that ASH (UK) has spoken out, I hope that other groups will follow suit. However, I don't predict that any U.S. groups will display the integrity shown by ASH (UK).

Incidentally, although the letter may be technically correct in stating that no UK health groups have claimed that a brief exposure to secondhand smoke can cause a heart attack, a number of such groups have made very misleading health claims -- suggesting, for example, that 30 minutes of secondhand smoke causes reduced blood flow to the heart or that it causes clot formation, either of which could be easily (and correctly) construed as potentially triggering a heart attack:

British Medical Association: "Just 30 minutes in a smoky room can reduce the flow of blood to the heart."

British Medical Association, Tobacco Control Resource Centre: "Just 30 minutes in a smoky room can reduce the flow of blood to the heart."

Smoke Free Liverpool: "Just 30 minutes exposure to other people’s tobacco smoke can be enough to reduce blood flow through the heart."

Royal College of General Practitioners: "Just 30 minutes exposure is enough to reduce coronary blood flow in a non-smoker."

Scottish Executive: "Short-term exposure to tobacco smoke also has a measurable effect on the heart of non-smokers: just 30 minutes' exposure is enough to reduce coronary blood flow."

British Heart Foundation: "Furthermore, exposure to cigarette smoke does not have to be particularly prolonged for it to damage your heart. One study has shown that just 30 minutes exposure is enough to reduce coronary blood flow to the heart."

Smoke Free North East: "Just 30 minutes exposure is enough to reduce coronary blood flow."

Smokefree England: "Just 30 minutes exposure is enough to reduce coronary blood flow."

British Heart Foundation: "Just 30 minutes exposure to tobacco smoke can affect the cells lining the coronary arteries and this can contribute to the development of atheroma narrowing the coronary arteries and reducing blood flow to the heart."

Action on Smoking and Health (London): "Short term exposure to tobacco smoke also has a measurable effect on the heart in non-smokers. Just 30 minutes exposure is enough to reduce coronary blood flow."

Clearing the Air Scotland: "30 minutes exposure to second hand smoke is sufficient to reduce coronary blood flow in otherwise healthy adults."

Smokefree Islington (UK): "A study published in the Journal Of The American Medical Association found that just 30 minutes' exposure is enough to reduce coronary blood flow."

Smoke-free Bristol (UK): "Short-term exposure to second-hand smoke has a measurable effect on the heart in non-smokers -– 30 minutes exposure is enough to reduce blood flow to the heart muscle."

Smoke Free North West: "Short term exposure to tobacco smoke also has a measurable effect on the heart in non-smokers. Just 30 minutes exposure is enough to reduce coronary blood flow."

East Cambridgeshire and Fenland PCT: "Being exposed to 30 minutes cigarette smoke can significantly reduce the coronary blood flow in a fit healthy adult."

Smokefree England: "Just 30 minutes exposure is enough to reduce coronary blood flow."

Smoke Free Solihull: "Just 30 minutes exposure is enough to reduce coronary blood flow."

Bradford City Teaching Primary Care Trust: "Within 30 minutes of exposure, platelets thicken, triggering clot formation."

Leeds, Grenville, and Lanark Health Unit: "within 30 minutes, blood platelets are activated, which makes the blood 'stickier' and damages artery linings which can lead to a heart attack."

County Durham and Darlington National Health Service (UK): "Within 20 minutes, passive smoking activates platelets causing them to stick together forming blood clots."

Oldham Primary Care Trust (UK): "Just 30 minutes in a smoky room can thicken the blood and reduce the oxygen needed for red-blooded passion."

Stating that 30 minutes of secondhand smoke exposure reduces blood flow to the heart is incorrect, because the very study which is being used to support such a claim demonstrated that coronary blood flow was not reduced. What was decreased was the coronary flow velocity reserve. I have explained in detail why coronary blood flow and coronary flow velocity reserve are very different things and how by conflating the two, a large number of anti-smoking groups are deceiving the public.

Stating that 20 minutes of secondhand smoke exposure causes blood clots is also inaccurate. On a cellular level, brief tobacco smoke exposure does increase platelet activation, but it is not going to trigger actual clot formation unless a person already has severe, pre-existing coronary artery disease. A healthy person is not going to get a blood clot due to 20 minutes in a smoky environment.

Also worth noting is that the
Leeds, Grenville, and Lanark Health Unit does appear to claim that a single 30-minute exposure to secondhand smoke can trigger a heart attack, and they do not qualify this claim by clarifying that it refers only to those with severe existing coronary artery stenosis: "within 30 minutes, blood platelets are activated, which makes the blood 'stickier' and damages artery linings which can lead to a heart attack."

In addition, ASH (UK) does appear to have made the statement that 30 minutes of secondhand smoke is enough to reduce coronary blood flow, which I believe is misleading for the reasons noted above. However, to their great credit, it appears that they have retracted this claim, or at least removed this web page.

Finally, I would just love to know how the Oldham Primary Care Trust determined that 30 minutes in a smoky room reduces the oxygen needed for red-blooded passion. That sounds like a fun study to conduct, or better yet - in which to be a subject.

Tuesday, December 04, 2007

FDA Commissioner: Proposed Tobacco Legislation Would Undermine the Public Health Role of the FDA and Increase Cigarette Consumption

In testimony submitted on October 3 to the Subcommittee on Health of the House Committee on Energy and Commerce, Food and Drug Administration (FDA) Commissioner Andrew C. von Eschenbach argued that the legislation currently being considered by Congress to give the FDA limited regulatory authority over tobacco products would undermine the essential public health role of the Agency.

The FDA Commissioner also testified that the legislation would harm the public's health itself by creating a perceived FDA stamp of approval for cigarettes, which would lead consumers to believe that cigarettes are safer than they previously thought. This would encourage people to smoke more, rather than less. The bill, then, would have what the Commissioner calls the "perverse" effect of increasing, rather than decreasing cigarette consumption.

The testimony was not immediately available after the hearing because it was submitted in written form. Dr. von Eschenbach declined the offer to testify in person because unlike the respect shown to other Administration officials who are customarily allowed to testify independently, the Committee apparently insisted that the FDA Commissioner testify among a panel of non-government officials.

According to his testimony:

"We have concerns that the bill could undermine the public health role of FDA. ... FDA is a public health agency, structured to facilitate and regulate the development of products that promote and protect the public health. The Agency enjoys widespread public support for its role in defining and assuring effectiveness and safety of products they consume. Our responsibility includes approving products based on scientific evidence that benefits of the product outweigh the risks. We have extensive experience in such evaluations and we have developed finely tuned methodologies."

"H.R. 1108 would ask us to apply this framework to tobacco products that, when used as intended, produce disease rather than promote health. FDA cannot “approve” a tobacco product in this context, because there is no scientific context to determine benefit to outweigh the numerous risks. It will be very challenging to transform existing science into a logical regulatory structure. There is little science available to the FDA on which to base decisions on tobacco product standards (such as reducing or eliminating harmful constituents, reducing the amount of nicotine in products, or requiring changes to tobacco product components) or premarket approval."

"Associating the Agency with the approval of these inherently dangerous products would undermine the Agency’s mission. Indeed, associating any agency whose mission is to promote public health with the approval of inherently dangerous products would undermine its mission and likely have perverse incentive effects. This proposed legislation would direct FDA to regulate tobacco products in a variety of ways, most significantly by the establishment of tobacco product standards, pre-market approval of new tobacco products, and standards for the sale of modified risk tobacco products. Approval of tobacco products that are dangerous to health even if used as directed runs directly counter to FDA’s historical mission to protect and promote the public health by reviewing and approving products that prevent and treat disease, not products whose only impact on health is to cause disease."

"In addition, the provisions authorizing pre-market approval of new and reduced risk tobacco products are of special concern. Most fundamentally, we are concerned that FDA “approval” of tobacco products may become confused with the Agency’s regulation of therapeutic products such as drugs and devices. For example, the bill provides potential loopholes for grandfathered” and “substantially equivalent” products, which will be permitted to stay on the market. We are concerned that the public will believe that products “approved” by the Agency are safe and that this will actually encourage individuals to smoke more rather than less."

"As another example, the bill would attempt to apply current requirements for medical products such as drugs and medical devices to tobacco products. These include adverse event reporting, adulteration and misbranding, and record keeping. These concepts are not applicable to inherently dangerous tobacco products. One example of the awkwardness of applying medical product standards to tobacco products is contained in the bill’s definition of an adulterated tobacco product. Section 902 of the bill provides that a “tobacco product shall be deemed to be adulterated if—‘(1) it consists in whole or in part of any filthy, putrid, or decomposed substance, or is otherwise contaminated by any added poisonous or added deleterious substance that may render the product injurious to health.’”

"Tobacco products, however, are intrinsically injurious to health, i.e. adulterated according to this definition. This concept, therefore, does not fit when applied to the regulation of tobacco products. There are other examples in the bill where similar problems would arise."

The Rest of the Story

Based on the FDA Commissioner's testimony (which mirrors the major comments I have been making about this legislation for the past two years), the health and anti-smoking groups should immediately drop their support for this legislation and go back to the drawing board.

Imposing regulatory responsibility on an agency which clearly has no interest in accepting that responsibility is a recipe for disaster. The Agency clearly agrees with me: this legislation will undermine the public health role of the FDA. And more importantly perhaps, it will undermine the public's health itself by increasing cigarette consumption.

With a stroke of the pen, this proposed law could undermine decades of public health efforts to underscore to the public the serious health consequences of smoking and the absence of any health benefit to smoking any particular kind of cigarette (e.g., low-tar, low-nicotine, additive-free, natural, etc.).

According to the FDA Commissioner (again, in agreement with many of my previous postings), the legislation will increase, not decrease cigarette consumption. Rather than "save countless lives," as the Campaign for Tobacco-Free Kids and American Medical Association claim, it will actually result in increased deaths from cigarettes.

That's hardly the prescription for a sound public health measure.

I think it's time that the health groups follow exactly what the Doctor ordered: scrap this absurd plan, which will protect Philip Morris profits at the expense of the public's health, and go back to the drawing board.

We should be able to do a whole lot better than this.

American Legacy Foundation Calls for Removal of Camel No. 9 Cigarettes from Shelves, But Apparently Has No Problem with Brands that are Killing People

In a November 27 press release, the American Legacy Foundation called for a national recall of all Camel No. 9 cigarettes, based on the contention that this new cigarette brand is targeting teenage girls and young women.

The American Legacy Foundation is demanding that R.J. Reynolds remove all Camel No. 9 cigarettes from store shelves and discontinue selling this brand of cigarettes. However, Legacy is not similarly calling on any other cigarette brands to be pulled off store shelves.

According to the press release: "Following months of pressure from public health organizations, groups dedicated to protecting and improving women’s health, and negative press, R.J. Reynolds Tobacco Company has announced its decision to discontinue print advertising in 2008 of its cigarette brands. This announcement is long overdue, especially for America’s teenage girls and young women, who have been the recent targets of Reynolds’ pervasive advertising for its new Camel No. 9 brand. With its stylish packaging and advertising featuring black, bright pink and teal colors, and a name evocative of women’s fashion icons, Camel No. 9 is plainly targeted to teen-age girls and young women. Now, the company should do the only responsible thing and follow suit by pulling the brand off the shelves."

The press release goes on to say that: "Given the fact that smoking continues to be the nation’s leading preventable cause of death, the danger of a product specifically targeted to young women cannot be underscored."

The Rest of the Story

The rationale behind the American Legacy Foundation's response to the announcement that R.J. Reynolds is going to discontinue magazine advertising of cigarettes in 2008 is baffling to me. Why respond by demanding that this particular cigarette brand -- which so far has not been documented to have effectively recruited any substantial proportion of teenage smokers -- be removed from the market, while all other brands -- which are smoked by literally 1.3 million teenage girls -- remain on the market?

If the danger of a product targeted to young women cannot be underscored and the appropriate response is to pull the product off the market, then why should Camel No. 9 be removed from the market while the cigarette brands smoked by almost all of the other 1.3 million adolescent girls who smoke be allowed to continue to addict them, and ultimately, to kill many of them?

Wouldn't a more productive response have been to demand that all cigarette companies and all brands follow R.J. Reynolds' lead and discontinue advertising in magazines? If Reynolds' decision to stop advertising Camel No. 9 cigarettes in magazines was appropriate, then why is it appropriate for all other cigarette brands to continue to advertise in magazines?

I just don't understand the logic here. It is terribly inconsistent and it seems to me, very hypocritical.

Is this the message that Legacy really wants to send to the public? That it is OK to addict our teenage girls and young women and increase their risk for lung cancer and heart disease, as long as you do not use the colors pink and teal?

After all, let's look at who the true culprits are. If we are truly concerned about the recruitment of girls and young women to cigarette use, then the primary concerns should be the marketing and availability of Marlboro, Newport, other Camel brands (besides No. 9), and Basic, Kool, and Parliament cigarettes. These are the cigarettes that are addicting our nation's girls.

The most problematic brand is Marlboro, which is the cigarette of choice for 51.0% of teenage girls. Second is Newport, smoked by 23.2%. Third is Camel at 7.4% (and most of these girls are not smoking Camel No. 9, but are smoking other Camel varieties).

Also problematic is the marketing of Kool, which has captured 2.6% of the female youth market, Parliament at 2.0%, and Basic at 1.6%.

If we have concluded that it is unacceptable to market cigarettes in a way that targets teenage girls, then why demand that Camel No. 9 be removed from the market, but allow Marlboro, Newport, other Camel brands, Basic, Kool, and Parliament to remain on the market?

If anything, the way that this Legacy campaign is framing the issue of tobacco marketing to teenage girls is counter-productive. It focuses attention on a single campaign, which apparently is problematic because it uses pink and teal, but it diverts attention away from the multiple marketing campaigns that for many years have been effectively recruiting girls and young women to smoke their brands.

Pulling Camel No. 9 cigarettes from the market will have essentially no impact on the use of tobacco by young females. Only a small proportion of teenage girls are smoking this brand to begin with. However, putting an end to the magazine advertising of all cigarette brands which are currently smoked by teenage girls would have an impact.

Addressing only a miniscule slice of the problem risks losing public attention to the actual problem - which is that cigarettes are marketed to youths, period.

This is not just a problem of Camel No. 9. It is a problem of cigarettes. If tobacco companies do not market to youths, they are going to lose market share. That is not acceptable to anyone within these companies with any knowledge or understanding of business.

The American Legacy Foundation's press release is an example of a larger concern that I have noted over the past several years. The tobacco control movement seems to be losing a broader perspective on the issue of tobacco use in our society. It seems to be developing a very narrow perspective, in which only the most politically hot and politically advantageous issues are highlighted.

If the American Legacy Foundation is only going to condemn Camel No. 9 for targeting girls, then that's a shame. I, however, am not limited in my view of the problem such that I only see Camel No. 9 as the cause of our girls' and young women's health woes.

If we're going to call for a recall of Camel No. 9, then to be consistent, we must also call for a recall of Marlboros, Newports, and all other Camel brands.

I am not calling for such a recall. However, I am calling for some degree of consistency in the positions taken by tobacco control groups. Their favored policies are becoming so flimsy that you can poke a gaping hole in them.

We need to return to the days when we had a strong, solid, and thoughtful basis for tobacco control policy. Science and solid policy analysis must return as the cornerstones of tobacco control action - not political expediency.

Monday, December 03, 2007

On the Dangers of Cigarette Equivalents: More Misleading Claims by Anti-Smoking Groups

In order to promote smoking bans to protect nonsmokers from the hazards of secondhand smoke exposure, a number of anti-smoking groups are appropriately providing estimates of the cigarette equivalent exposure of nonsmokers. This is an estimation of the amount of a particular tobacco smoke constituent that a nonsmoker would inhale in a given environment in comparison to the amount of that same constituent which would be smoked by an active smoker of a given amount of cigarettes per day.

Such a comparison is very useful and important because it gives policy makers and the public a sense of the actual amount of tobacco smoke constituents that a nonsmoker may inhale. This may be more meaningful to a lay person than simply providing data on the level of a constituent in the ambient air.

For example, if I say that the level of NDMA in a restaurant is 0.05 ng/L, it might not mean anything to a policy maker. But if I say that the amount of NDMA that a nonsmoker working in such a restaurant would inhale over an 8-hour shift is the same amount inhaled by an active smoker of 1 pack of cigarettes per day [this is just a hypothetical example], that provides a lot more meaningful data for the policy maker.

So the desire and attempt to present cigarette equivalents is a natural one and a reasonable one.

A number of anti-smoking groups are presently disseminating estimates of cigarette equivalents on their web sites:

Smoke-Free Illinois: "One eight hour shift in a smoky workplace is the equivalent of smoking 16 cigarettes."

Pennsylvania Alliance to Control Tobacco: "During an 8-hour shift, bartenders “smoke” the equivalent of a pack of cigarettes without ever lighting up."

: "Working in a smoker-friendly office 8 hours" is equivalent to actively smoking 6 cigarettes.

Smoke Free Cleveland: "Working in a smoker-friendly office 8 hours" is equivalent to actively smoking 6 cigarettes.

Smoke Free Cleveland: "Research from the University of California at Berkeley shows that sitting in the non-smoking section of a restaurant for two hours is the equivalent of smoking one and one half cigarettes. Working an 8-hour shift at a bar, a nonsmoker would inhale the equivalent of 16 cigarettes."

Smoke Free Galveston: "Sitting in the non-smoking section of a restaurant for over an hour can be as harmful as smoking 1-1/2 cigarettes. Two hours in a smoky bar is the same as smoking nearly four cigarettes."

Kentucky Center for Smoke-Free Policy: "Working a shift in a smoky bar is equivalent to smoking a pack of cigarettes per day. If you are in a smoky bar for two hours, it is the same as smoking four cigarettes."

Smoke Free Arizona
: "Working a shift in a smoky restaurant or bar is equivalent to actively smoking nearly a pack of cigarettes."

Smokefree Mecklenburg: "If you worked in a smoker-friendly office for eight hours, you would smoke six cigarettes without even lighting up."

Smokefree Naperville: "One eight-hour shift in a smoky workplace is the equivalent of smoking 16 cigarettes."

The Rest of the Story

The problem with cigarette equivalent statements is that the number of cigarette equivalents varies widely, depending on the specific smoke constituent that one is talking about. So if you don't provide the tobacco smoke constituent, then your statement is going to be very misleading.

Note that the deceptive nature of cigarette equivalent claims can work both ways.

If you claim, as the anti-smoking groups do above, that an 8-hour shift in a smoky bar is the equivalent of actively smoking 16 cigarettes, you are presumably referring to the nonsmoker's dose of NDMA (N-nitroso-dimethylamine) or some similar constituent which is much more highly concentrated in sidestream smoke than in mainstream smoke.

The problem is that under the same conditions, the number of cigarette equivalents of some other tobacco smoke constituents is much smaller. The most pronounced is nicotine itself, for which the cigarette equivalents under the above conditions is only about 0.8 cigarettes.

So it would be technically correct for a smoking ban opponent to claim that in terms of nicotine, the exposure of a nonsmoker working in a smoky bar for 8 hours is equivalent to less than a single cigarette.

It would be equally correct for a smoking ban proponent to claim that in terms of inhaled NDMA, working in a smoky bar for 8 hours is the equivalent exposure as an active smoker of about 16 cigarettes.

Both of these statements are correct, and accurate.

However, you can easily see that by leaving out the smoke constituent you are talking about, you can easily create a misleading statement.

For example, a smoking ban opponent could state that working in a smoky bar for 8 hours is no worse than actively smoking less than a single cigarette.

A smoking ban proponent could state that working in a smoky bar for 8 hours is the same as actively smoking 16 cigarettes.

Both of these statements are wrong. They are certainly very misleading. And by leaving out the smoke constituent in question, it seems to me that the intent of someone make such an unqualified claim is to deceive.

The smoking ban proponents who are claiming that the nonsmoker exposed for 8 hours will suffer the same health effects as if they smoked 16 cigarettes a day are wrong, and they are being deceptive, probably intentionally.

The smoking ban opponents who are claiming that the nonsmoker exposed to 8 hours will suffer the same health effects as if they smoked less than a cigarette are also wrong, and they are also being deceptive, probably intentionally.

So you see, the only way to be accurate and not to be deceptive is to simply make it clear for what smoke constituent you are estimating exposure.

In this case, including the "caveat" marks the difference between a correct and an incorrect statement. While Dr. Glantz has argued that we cannot include the caveats because the public cannot understand them, I strongly disagree. I think the caveats are what mark the difference between accuracy and inaccuracy, correctness and incorrectness, objective science and subjective manipulation, honesty and deception, truth and falsehood.

In fact, it is the "caveats" that mark honesty and objectivity against deception and politically-motivated bias.

I have already made my own opinion clear: the fact that nonsmokers in a smoky bar are inhaling the equivalent amount of even one carcinogen as an active smoker of about 1 pack per day is alarming, and argues for the protection of those workers from exposure to that carcinogen. The fact that other cigarette equivalents may be less does not obviate the need to protect the nonsmoker from the highest harmful constituent exposure.

However, while that fact may argue for the need for smoking bans, it does not justify the inaccurate communication of this information to policy makers and the public, as the above anti-smoking groups are doing.

Why the need to be deceptive? The truth should be enough. If nonsmokers are inhaling the equivalent amount of NDMA - a single carcinogen - as active smokers of nearly a pack per day, then how can one justify failing to protect them from this exposure?

There's no need for deception here. Just tell the truth.

(Thanks to Bill Hannegan for the tip and for the links.)

The Rest of the Story: An Act of Conscience

I realize that I have never told the full story about the reasons why I started The Rest of the Story in the first place. Today, I discuss one of the major factors in my decision to start this blog: my troubled conscience.

For the past several years, I have felt quite uncomfortable about the tactics being used by a number of major anti-smoking groups. While I wasn't losing sleep at night, I was waking up each morning feeling very uncomfortable about being part of a movement in which these kind of tactics were being used.

How could I just go off to work to do my normal, every-day routine - studying the effects of tobacco policies, studying the effects of secondhand smoke, preparing to testify in tobacco litigation, preparing to testify in support of smoking bans, etc. - when I knew that many of the groups I was working with were disseminating inaccurate scientific information about secondhand smoke, supporting increasingly intrusive policies that were no longer justified by scientific data, making false and/or undocumented accusations about individuals, misusing youths to support policies designed to protect the financial interests of tobacco companies, demonstrating blatant hypocrisy, and deceiving the public in ways similar to those used by the tobacco companies?

For some reason, I felt at least partially responsible for the actions of these tobacco control groups. Even if I wasn't a member of the particular group, I viewed myself as one of the leaders of the overall movement, and I felt some degree of responsibility for the actions of the major groups in the movement. Mostly, my conscience was shaken up.

In many ways, writing this blog was (and still is) a mechanism by which I can somewhat clear my conscience by publicly exposing the tactics being used by these groups and holding the movement accountable for its actions. I knew I was not going to be able to stop this behavior (I had already tried unsuccessfully for two straight years prior to the blog), but did I not have a responsibility to speak out, even if it was just to 20 or 30 readers of my blog?

Fortunately, my readership has gradually grown and I am now able to speak out to thousands of readers, including some of the most important players in the tobacco science and policy arena. But I still do so, each day, with at least part of my goal being to clear my conscience.

I just can't and don't feel comfortable anymore just going about my normal business. How can I, for example, spend so much of my time slaving over data in order to accurately assess the health effects of secondhand smoke when I know that there are nearly 100 anti-smoking group websites that tell the public that 30 minutes of secondhand smoke exposure is enough to clog their coronary arteries? What is the point of my continuing to publish papers about the real effects of secondhand smoke if the public is going to be told that a few minutes of exposure can kill you immediately? It seems that the groups don't need my information anymore. What's the point of my working so hard to produce and supply that information?

The response I was receiving from many groups was troubling to me. They had no problem disseminating the results of my many papers which documented the serious health effects of secondhand smoke, especially the hazards to restaurant and bar workers. But when I questioned the conclusion that brief exposure to secondhand smoke causes fatal arrhythmias (a claim for which there is absolutely no scientific support), all of the sudden I was no longer credible. As I learned, what credibility seems to mean is the direction of your conclusions. If they are favorable, you are a credible source. If unfavorable, you are not credible. So the same source (me) could at once be a credible and non-credible source of information.

My conclusions about the health effects of secondhand smoke on bar and restaurant workers are widely cited by anti-smoking groups throughout the country. But you will be hard pressed to find a single anti-smoking group that would also share with the public my conclusions about the Helena or Indiana heart attack studies.

But how can I be a credible source with respect to some conclusions and a non-credible source with respect to others? It just doesn't follow. If my conclusions about Helena are flawed because I am biased towards a pro-smoking position, then how in hell did I come up with the conclusions I drew in my JAMA article in which I concluded that the observed increase in lung cancer among nonsmoking restaurant workers must be attributable to secondhand smoke exposure? And why would I agree to testify in the Engle case, which almost ended up costing the tobacco companies $145 billion?

Writing this blog actually allows me to continue working in the tobacco control field (though not as part of the mainstream tobacco control movement). Without this release for my conscience, I simply could not continue going along with the flow.

While I clearly have a positive view of tobacco control, I don't shy away from pointing out the blemishes in the interest of accuracy. Maybe it's my lifetime in scientific research, but I do have a passion for accurate reporting, and I expect the same from others. What I also learned was that others are more likely to believe me when I point out the blemishes, because it doesn't look like I'm just spewing propaganda.

When someone takes the same side of an issue every time, you ought to have some suspicion about the potential bias that may be operating. The fact that I was willing to criticize my own side when it was called for should have been - to these groups - a sign that they had someone in the movement who was not blinded by anti-smoking zeal but who was truly a scientist who was passionate about scientific accuracy and the degree of scientific justification for the anti-smoking agenda. Instead, my willingness to criticize was viewed as heresy and traitorousness.

Actually, it was just an act of conscience.

Thursday, November 29, 2007

CHALLENGING DOGMA – POST #12: What the Tobacco Industry and Its Allies Say is Not Credible; What Tobacco Control Groups Say Has Merit

One of the most basic principles I was taught as a tobacco control practitioner was that there is no merit to anything that the tobacco companies or their allies say. By the simple virtue of any statement having been made by a tobacco company or tobacco ally, it was automatically invalid. In contrast, I was taught that virtually any statement made by a tobacco control group had merit.

In a showdown between conflicting statements between a tobacco company and a tobacco control group, it was unfathomable that the tobacco company could be correct. One did not even need to examine or analyze the statement at issue. Simply knowing the source of the two statements was enough to cast judgment. The tobacco control group’s statement was correct.

For many years, I believed this to be the case and I operated under this assumption. However, I have come to realize that it is no longer the case. The scientific integrity of the tobacco control movement has deteriorated to such a degree that one can no longer evaluate claims solely on the basis of whether they are made by a tobacco control group versus a tobacco company or tobacco ally. I’m not sure that was ever the case, but in this post, I will discuss the current state of affairs, not the past.

The Rest of the Story

Perhaps the most astounding example of the lack of credibility within tobacco control in 2007 is the Office of the Surgeon General itself.

When I worked at CDC in the Office on Smoking and Health between 1993 and 1995 and helped write and edit several of the Surgeon General’s reports, I had the highest degree of respect and admiration for the Surgeon General’s office and its scientific standards of excellence. The scientific review of the Surgeon General’s report and every statement made by the Surgeon General was meticulous. Every statement made was subjected to layer after layer of scientific review. We would analyze every word in the statement to make sure that it could not be misconstrued. There was a general feeling that the conclusions of the Surgeon General had to be completely beyond reproach.

Often, there were conclusions that I felt would be perfectly sound for the Surgeon General to make. However, because of slight hesitation on the part of some scientists, and out of fear that the tobacco industry might challenge these statements, we did not offer to the Surgeon General any statement that could not be easily and definitively defended. Even if the majority of scientific groups that had reviewed a particular health effect of smoking or secondhand smoke had concluded that the evidence for that effect was sufficient, we would hold out for the few remaining groups before putting that conclusion into the voice of the Surgeon General. The voice of the Surgeon General meant that the science was beyond reproach. The conclusion was extensively reviewed and meticulously well-documented.

Now in 2006, as I showed yesterday, the Surgeon General came in front of the American people and told them that just a brief exposure to secondhand smoke was enough to cause heart disease and lung cancer. The Surgeon General concluded that a brief exposure to secondhand smoke may have life-threatening cardiovascular and carcinogenic effects.

In contrast to the Surgeon General’s office that I once knew, this time there was not only absence of meticulous documentation for the statement, but there was the absence of any scientific evidence to support it. There are no studies (count them: zero point zero) which demonstrate that a brief exposure to secondhand smoke poses a risk of lung cancer. There are no studies which demonstrate that a brief exposure to secondhand smoke can cause hardening of the arteries (atherosclerosis). Yet this is precisely what the Surgeon General concluded in front of the television cameras for all to hear and read about. These conclusions remain online today, for all to continue to read.

Another example is a recent report by the Harvard School of Public Health on changes in nicotine yields of cigarettes over the past nine years. According to the report, cigarette companies - including Philip Morris - steadily increased the nicotine yield of their cigarettes - including Marlboro - during the period 1997-2005. The report describes the increase as being a total of 11% over the seven-year period 1998-2005, or an average increase of 1.6% each year during that period.

According to the report, Marlboro brands "showed a significant increase in smoke nicotine yield." During the overall study period of 1997-2005, the report estimates the increase to be 0.019 mg per year. The report concludes that there has been a "statistically significant trend in increased smoke nicotine yield of 0.019 mg per cigarette (1.1%) per year from 1997-2005 as measured by a smoking machine under the MA method." This trend was said to hold for all market categories, and in particular, for the most popular cigarette brand - Marlboro: "The present analysis of the leading U.S. brand family, Marlboro, demonstrates a significant increase in smoke nicotine yield, contradicting the PM USA claims."

Philip Morris took issue with the study's conclusions, arguing that there was no increase in the nicotine yield of Marlboro cigarettes between 1997 and 2006 and that there are no consistent trends indicating an increase in these yields over time, although there are random fluctuations over the time period.

Using the data on nicotine yields of Marlboro cigarettes provided by Philip Morris to the Massachusetts Department of Public Health (MDPH) for the years 1997 through 2006, I conducted my own analysis of the trends in Marlboro nicotine yields. I found that the average nicotine yield of all 16 Marlboro sub-brands in 1997 was 1.81 mg, and the average nicotine yield of all 16 Marlboro sub-brands in 2006 was 1.81 mg. In other words, there was no change in the average nicotine yield of Marlboro cigarettes from 1997 to 2006.

In this particular case, Philip Morris was right and the report by anti-smoking researchers was wrong.

Another example is the decision by the Department of Justice to alter a proposed smoking cessation remedy in the RICO lawsuit from a $130 billion program to a $10 billion program. Anti-smoking groups widely attacked Associate Attorney General Robert McCallum and accused him of ethical wrongdoing. They also attacked the Bush administration for political interference in changing the nature of the proposed remedy and weakening the case.

The truth, however, was that the change in remedy did not weaken the case (if anything, it strengthened it). The initial remedy would never have passed muster with the D.C. Court of Appeals because it was not consistent with the Court's interpretation of the RICO civil remedies provisions. As it turns out, even the altered remedy did not pass muster with Judge Kessler herself.

Most recently – yesterday in fact – tobacco companies and anti-smoking groups came head-to-head over whether R.J. Reynolds’ decision to discontinue cigarette advertising in magazines in 2008 was a political response to the Campaign for Tobacco-Free Kids’ complaint about its Camel insert in Rolling Stone magazine (as claimed by the Campaign for Tobacco-Free Kids) or whether it was a business decision made prior to that revelation (as claimed by R.J. Reynolds).

If this were 1995, I would have without hesitation put my faith in the Campaign for Tobacco-Free Kids and believed that R.J. Reynolds was lying to the public. Today, however, I find myself leaning toward the R.J. Reynolds side of these conflicting views of what occurred.

The rest of the story is that it is no longer the case that you can simply trust the anti-smoking groups as being credible sources of information and discount opposing tobacco industry or tobacco industry ally accounts of the same information.

This is precisely why I have been so outspoken in challenging anti-smoking groups to remain accountable for their public statements. The days of anti-smoking groups having credibility and tobacco companies and their allies being automatically untrustworthy appear to be over. Now, you have to be skeptical of everything you hear, no matter what the source.

In fact, this is part of the reason why The Rest of the Story exists. There needs to be some source for at least a somewhat balanced and at least partially open and broad perspective on tobacco control news, policies, and issues.

Here is a complete list with links to all of my previous Challenging Dogma posts in this series:

CHALLENGING DOGMA: Post #1 - Tobacco Taxes are Not Always Appropriate Public Health Policy

CHALLENGING DOGMA: Post #2 - Anyone Who Disagrees With the Anti-Smoking Movement is Affiliated with the Tobacco Industry

CHALLENGING DOGMA: Post #3 - Promoting a Smoker-Free Workplace

CHALLENGING DOGMA: Post #4 - All Groups that Oppose Tobacco Control Policies are Big Tobacco Front Groups

CHALLENGING DOGMA: Post #5 - Anyone who Questions the Party Line is A Discredit to the Tobacco Control Movement

CHALLENGING DOGMA: Post #6 - Cigarette Companies Have a Responsibility to Produce a Safer Product

CHALLENGING DOGMA: Post #7 - Smoking Should Be Banned in All Public Areas

CHALLENGING DOGMA: Post #8 - The Anti-Smoking Agenda Justifies Itself

CHALLENGING DOGMA: Post #9 - The Agenda of All Anti-Smoking Groups is a Noble One

CHALLENGING DOGMA: Post #10 - Anyone Who Disagrees that Secondhand Smoke Causes Chronic Disease Must Be Personally Discredited

CHALLENGING DOGMA: Post #11 - Maintaining Cigarette Addiction by Increasing Nicotine Yields is the Sign of a Rogue Industry