Tuesday, December 23, 2008

Happy Holidays and Happy New Year to All My Readers; The Rest of the Story Will Return on Monday, January 5

2008 Anti-Smoking Hypocrisy Award Goes to the Campaign for Tobacco-Free Kids

The Campaign for Tobacco-Free Kids is the hands-down winner of the 2008 Anti-Smoking Hypocrisy Award.

Here is an organization which bemoans what it says is the use of menthol flavoring in cigarettes to entice youths but then works to block a Congressional amendment to the FDA legislation which would have added menthol to the list of flavorings banned by that legislation.

Here is an organization that encourages youths to simulate physical violence on tobacco industry executives, but secretly meets with those representatives to negotiate legislation that will be favorable to the nation's leading cigarette company.

Here is an organization that talks about the need to stop the tobacco companies from deceiving the public, but runs a campaign of deception so convincing that even a renowned history professor at Harvard re-writes history due to the Campaign's deception.

Here is an organization that blasts tobacco companies for putting pink on their packs, but lobbies to protect the companies' ability to put menthol in their cigarettes.

Here is an organization that attacks the tobacco companies for not respecting the law but tries to elicit billions of dollars from those companies without any legal basis.

Here is an organization that criticizes tobacco companies for using public relations to skew public opinion, but uses its own public relations propaganda strategy to skew opinion within the tobacco control community about the FDA tobacco legislation.

Here is an organization which proposes regulating the tobacco industry because it cannot be trusted to tell the truth, but which is itself incapable of telling the truth to the public or to its constituents.

Here is an organization whose executive director violates President-Elect Obama's ethics rules for his transition team by joining a group to oversee the Department of Health and Human Services (which includes the FDA) when he lobbied for the FDA tobacco legislation during the past year, a practice which is disallowed by the transition team ethics rules.

In 2008, the Campaign for Tobacco-Free Kids' actions started with hypocrisy and ended with hypocrisy. There is no more deserving winner of the 2008 Anti-Smoking Hypocrisy Award.

Monday, December 22, 2008

CDC Concludes that Reductions in Tobacco Constituents Would Not Necessarily Reduce Health Risks of Cigarettes; Folly of FDA Tobacco Bill is Revealed

In an article published in the current issue of Cancer Epidemiology, Biomarkers & Prevention, researchers from the Centers for Disease Control and Prevention (CDC) have demonstrated that the health protection strategy in the proposed FDA tobacco legislation is severely flawed, as a chemical-by-chemical approach to trying to reduce the harms of cigarette smoking is foolish (see: Ding YS, et al. Levels of tobacco-specific nitrosamines and polycyclic aromatic hydrocarbons in mainstream smoke from different tobacco varieties. Cancer Epidemiology Biomarkers & Prevention 2008; 17: 3366-3371).

The researchers attempted to reduce the levels of nitrosamines and polycyclic aromatic hydrocarbons - two of the known categories of carcinogens in cigarettes - in tobacco smoke by altering the tobacco blends used. Unfortunately, they found that when changes are made to reduce the levels of one type of carcinogen, the levels of the other type increase: "Our results tend to indicate an inverse relation exists between NNK and PAH deliveries when considering different tobacco blends."

Most importantly, the researchers concluded that even if one could reduce levels of both of these types of carcinogens - nitrosamines and polycyclic aromatic hydrocarbons - it is unknown whether this would have any protective impact on the health of smokers. As the authors explain: "There are more than 60 known carcinogens in cigarette smoke and at least 16 in unburned obacco. Among these, tobacco-specific nitrosamines (TSNA), polycyclic aromatic hydrocarbons PAH), and aromatic amines likely play important roles in causing cancer. The IARC lists 10 PAHs, 8 TSNAs, and at least 45 other compounds or substances as potential human carcinogens."

Ultimately, the authors conclude that even if levels of both nitrosamines and polycyclic aromatic hydrocarbons could be reduced in cigarettes, it is unknown what effect this would have on health: "Whether such reductions [in both the TSNAs and PAHs] would reduce the health risk associated with smoking is unknown."

The Rest of the Story

As the new year approaches, I think this is an ideal time for anti-smoking groups to take a step back and to realize that the entire approach underlying the FDA tobacco legislation is ludicrous.

As this research and much other work like it demonstrates, a chemical-by-chemical approach to regulating the safety of cigarettes - as taken by the FDA tobacco legislation - is absurd.

Not only do strategies that reduce the levels of one tobacco smoke constituent tend to increase the levels of other constituents, but it is widely acknowledged in the first place that reducing the levels of a wide range of tobacco smoke constituents is not known to reduce the hazards associated with cigarette smoking. Thus, there is simply no science base to support the approach taken by the current FDA tobacco legislation.

Claims by anti-smoking groups - like the Campaign for Tobacco-Free Kids, American Cancer Society, and American Medical Association - that the proposed legislation would save countless lives are pure propaganda.

The New Year's resolution taken by anti-smoking groups should be to somehow lose their obsession with the FDA legislation over the holidays and to come back in the new year behind a new approach to federal tobacco legislation, one that is based on science rather than propaganda.

Such an approach would be based on the two strategies which have actually been shown to work: raising cigarette prices and running aggressive anti-smoking media campaigns. The legislation would pair these two approaches. A series of graduated fines would be levied on cigarette companies based on the number of youths smoking their cigarette brands. The allowable levels of youth smokers would decrease over time so that fines would only be levied if companies failed to reduce youth smoking of their brands to specified levels over time. The money raised would be allocated to establish a national anti-smoking media campaign as well as similar campaigns in all 50 states, for the first time in history. In addition, a substantial proportion of funds would be used to support programs specifically for smokers, including research into smoking-related diseases, treatment of such diseases, and smoking cessation programs. The bill introduced last year by Senator Enzi contains many elements of such an approach.

Unfortunately, I don't think that the anti-smoking groups will seriously consider promoting an effective approach. Why? Because they are being driven largely by propaganda and ego, rather than by science and a pure concern for protecting the public's health. While only an idealist (which I no longer am) might expect that anti-smoking groups would be driven by a pure concern for public health protection and not affected by the desires for money and power, the public has the right to expect that these groups' actions will be driven by science, rather than propaganda.

Friday, December 19, 2008

Boston's WGBH Airs Debate on New Boston Tobacco Regulations

Boston's WGBH - on a segment called Greater Boston with Emily Rooney - aired a very interesting debate about the newly enacted smoking regulations, which: (1) outlaw new cigar and hookah bars and eliminate existing cigar and hookah bars in 1o years; and (2) prohibit the sale of tobacco products in pharmacies and on college campuses.

Dr. Barbara Ferrer, the executive director of the Boston Public Health Commission, supported the regulations while Professor Leonard Glantz of my own Boston University School of Public Health argued that these regulations go too far and are not advancing any public health purpose.

The Rest of the Story

I thought the most interesting and informative part of the segment was when Dr. Ferrer defended the ban on tobacco sales in pharmacies by arguing that: "It's like alcohol or guns. You shouldn't be able to buy it anywhere."

I agree that like alcohol or guns, cigarettes are dangerous and that you shouldn't be able to buy them anywhere. However, what sense does it make to say that you just shouldn't be able to
buy cigarettes in a pharmacy? How is buying cigarettes at a liquor store, convenience store, gas station, or grocery store any better than buying cigarettes at a pharmacy?

I can understand the rationale for limiting where guns are sold because the state has an interest in making sure that those who purchase guns meet specific criteria (age, past criminal record, waiting period, etc.). I can understand limiting where alcohol is sold because the state has an interest in making sure that young people (under age 21) cannot easily purchase alcohol. I can even understand regulating where tobacco is sold to the extent that the state has an interest in ensuring that minors cannot purchase tobacco and thus some form of tobacco sales licensing seems appropriate.

However, I simply don't see any legitimate state interest in ensuring that of all places where people can buy tobacco, pharmacies are not one of them. This is the point which Dr. Ferrer never seemed to address during the segment.

After watching the segment, I have become more convinced that the pharmacy tobacco sales ban makes little public health sense and more confused as to the rationale for this regulation.

If the concern is that youths shouldn't be exposed to tobacco products, then why didn't the Commission ban the sale of tobacco products in all places where youths are allowed? Clearly, the problem is not that youths are exposed to tobacco products -- it's that youths are exposed to tobacco products in pharmacies. But why that very narrow concern? Why is it only pharmacy sales of tobacco that are problematic? This seems to be a very narrow, not a holistic, view of public health. But most troublesome to me is that I can't seem to find the public health protection that this law is providing.

Thursday, December 18, 2008

Channel 5 Boston (WCVB) Airs Story on Massachusetts Smoking Ban/Heart Attack Study

Boston University broadcast journalism student Mary Stackhouse has done an excellent investigative report into the Massachusetts smoking ban/heart attack study conducted by the Department of Public Health. The piece appears on the Channel 5 web site, and I encouraged readers to have a look.

The Rest of the Story

There are two important points that I make in the piece that I wish to emphasize here.

First, the study results do not seem consistent with the conclusion that the statewide smoking ban is what led to a decline in heart attack deaths in Massachusetts during the second year post-implementation. If that was the cause, one would have expected to see this decline only in communities that did not already have a smoking ban in place. But the decline occurred in all communities, even those which already had a smoking ban in effect. This, combined with the fact that there was no observed decline in heart disease mortality during the first year following the smoking ban, casts doubt on the conclusion that it was the statewide smoking ban that caused the observed acceleration in the rate of decline in heart disease mortality in the state.

Second, the study is an example of science by press release - an all too common approach in tobacco control these days. The study was released to the media prior to publication or even peer review. However, only the conclusions of the study were released, not the actual methodology or the study text itself. This makes it impossible for the public to scrutinize and evaluate the study's conclusions. Moreover, if any changes are made due to peer review, it will be too late. The conclusions have already been disseminated widely.

We saw the problem of science by press release first-hand with the Scottish smoking ban/heart attack study. There, the conclusions of the study were released to the media prematurely (before review and publication of the paper). Subsequent data now shows that those study conclusions were wrong. But it is too late to correct the findings. And no anti-smoking group (nor the researchers themselves) even seem interested in communicating the truth about the data in the first place. (No - there has been no response to my challenge to report these new data).

Tuesday, December 16, 2008

Campaign for Tobacco-Free Kids Decries Use of Menthol to Recruit Youths, But Protects Menthol from Cigarette Flavoring Ban

In its Kick Butts Day activities guide (the same one in which it recommends that youths simulate physical violence against tobacco industry representatives), the Campaign for Tobacco-Free Kids decries the use of menthol to recruit youth smokers. In particular, the Campaign blasted R.J. Reynolds for using a crushable menthol tablet in its new Camel Crush brand.

The Campaign states: "In May 2008, R.J. Reynolds launched a new cigarette, the Camel Crush. Inside each cigarette is a blue pellet that the user can crush to turn the regular cigarette into a menthol one. The cigarette is packaged in a sleek black and blue box and this new innovation can be seen as marketing to youth."

The Rest of the Story

The rest of the story is that at the same time it is blasting R.J. Reynolds for using a crushable menthol pellet to recruit youth smokers, the Campaign for Tobacco-Free Kids is lobbying Congress to exempt menthol from a ban on cigarette flavorings which the Campaign itself has argued is necessary to prevent tobacco companies from marketing to youth.

The Campaign has now itself acknowledged that the menthol pellets are an example of marketing to youth which it says must be outlawed, but rather than call for a ban on the use of these pellets, the Campaign is actually working to protect these pellets from regulation.

If these were strawberry pellets, cherry pellets, or chocolate pellets, you can be sure the Campaign for Tobacco-Free Kids would be calling for a ban on their use. In fact, the FDA tobacco legislation would ban each of these flavorings (plus every other flavoring in existence). Except for menthol, and that is at the Campaign's insistence.

Am I arguing here that menthol should be banned in cigarettes? No. What I am arguing is that the Campaign for Tobacco-Free Kids is full of hypocrisy and insincerity. It is clear to me that they don't really mean what they are saying. They say that tobacco companies must not be allowed to market to kids and they acknowledge that menthol flavoring in Camel Crush is marketing to kids, yet they then lobby to prevent Congress from banning the use of this flavoring.

What has become clear to me now - as suggested by a number of commenters - is that the Campaign for Tobacco-Free Kids is nothing more than a political, propaganda organization. It is not a legitimate public health organization. It has no sincerity, no regard for honesty and integrity, and it is playing a game of politics and deception with our nation's youth, and with its own constituents.

A large part of the reason for this blog in the first place is that my conscience could not live with the unethical, inappropriate, insincere, dishonest, and deceptive propaganda-based methods of the Campaign for Tobacco-Free Kids. Their tactics have bothered me - and my conscience - for a long time. What I realize now is that the only way for me to rid myself of this blight on my conscience is to dismiss the Campaign as a public health organization. What troubles me is that a public health organization is using such techniques. But if I view the Campaign as a political propaganda organization that is not a legitimate part of public health, then it becomes possible to dismiss its behavior without bothering my conscience as much.

The good news - for the Campaign - is that it is now very much in the running for the 2008 Anti-Smoking Hypocrisy Award, which will be announced at the end of the year.

Monday, December 15, 2008

Campaign for Tobacco-Free Kids Urges Kids to Simulate Physical Violence on Tobacco Industry Representatives

Today, the Campaign for Tobacco-Free Kids released its recommended activities for Kick Butts Day 2009. According to the web site: "On Kick Butts Day we all help empower youth to stand out, speak up and seize control against Big Tobacco with fun, educational activities and events." One of the activities being promoted by the Campaign is a boxing match where youths simulate committing physical violence on a mock tobacco industry representative.

Specifically, the Campaign for Tobacco-Free Kids is calling for kids to set up a boxing match. They are to set up a boxing ring and have a mock tobacco industry representative wearing a suit or cigarette costume. An announcer is to stand in the ring and attract passersby to the ring. They put on inflatable gloves and punch the tobacco industry representative. This activity is recommended for middle school and high school groups.

The centerpiece to the activity is described, word for word, as follows: "Have passersby put on the inflatable gloves and let them punch the tobacco industry representative."

The Rest of the Story

Is it just me, or is this despicable for a public health group? It seems to me that it is completely inappropriate for a public health group to be promoting physical violence - albeit simulated - against individuals.

We should be teaching youths that if they find fault with a corporation's practices and policies, they should use legal advocacy mechanisms - such as the legislative, executive, and judicial branches of government - to try to effect change in society. Simulating the commission of physical violence against the executives of that corporation is not only inappropriate, but undermines the very message we are supposed to be sending to our children.

The Campaign for Tobacco-Free Kids will apparently stoop as low as it needs to in order to misuse kids to serve the organization's own political purposes. Last week, I highlighted how the Campaign is misusing young people, through its bogus Youth Advocates of the Year awards, to serve its pet political goal of passing the FDA tobacco legislation. The Campaign is hiding the truth from youths, hoping to recruit them to its political goals by deceiving them about the facts behind the FDA legislation.

Now, the Campaign has stooped to a new low: promoting the idea of physical violence as a means of reacting to corporate wrongdoing and teaching this to our youths.

I think the Campaign has an obligation to not only delete the boxing match from its activity guide for Kick Butts Day, but to send out a message apologizing to youths throughout the country for suggesting and incorporating physical violence against identified individuals into a public health activity.

One of the most effective television advertisements from California's anti-smoking media campaign contained the tagline: "The tobacco industry: how low will they go to make a profit?"

I think we should put out a new ad with the tagline: The Campaign for Tobacco-Free Kids: how low will they go to pass the FDA tobacco legislation?"

Sunday, December 14, 2008

Sunday Edition - Two Posts on Outdoor Smoking Bans and Pharmacy Tobacco Sales Ban

Because of the abundance of issues to write about as well as the fact that the Patriots are playing the Raiders today and shouldn't require too much of my attention, I am publishing two posts today. The first addresses outdoor smoking bans. The second addresses the recently enacted regulations in Boston that ban tobacco sales in pharmacies and on college campuses.

Tobacco Control Advocates Argue that Smoking Should Be Banned Outside to Prevent Children From Seeing Smokers

In previous posts, I have inferred that anti-smoking groups' rationale for supporting widespread outdoor smoking bans includes the desire to prevent people from even seeing a smoker, but today, I can say that this inference is no longer speculative - it is confirmed. In a commentary published in this month's issue of BMJ, anti-smoking researchers from New Zealand argue explicitly that smoking should be banned in outdoor places in order to prevent children from merely seeing smokers in public.

In their commentary entitled "Should smoking in outside public places be banned? Yes," researchers from the Universities of Otago and Auckland argue that even though secondhand smoke may not be a problem in most outdoors locations, banning smoking is still justified because it prevents young people from seeing smokers.

According to the commentary: "Legislation to ban smoking indoors in public places is now commonplace, driven mainly by the need to protect non-smokers from exposure to secondhand smoke. A new domain for tobacco control policy is outdoor settings, where secondhand smoke is usually less of a problem. However, the ethical justification for outdoor smoking bans is compelling and is supported by international law. The central argument is that outdoor bans will reduce smoking being modelled to children as normal behaviour and thus cut the uptake of smoking."

The authors further argue that "the modelling of smoking can also be reduced by policies to restrict smoking in the presence of children. The entrenched nature of tobacco use in most societies, and its highly addictive qualities, require that such policies are far reaching. Smoking bans in many outdoor public areas are therefore an important additional approach to tobacco control."

The Rest of the Story

The argument presented in this commentary is not compelling in the slightest. The government must not restrict individual autonomy to the extent that it interferes with the right of adults to engage in lawful, unhealthy behaviors that may be observed by children. To do so would represent an extreme - and an unwarranted - intrusion into individual liberty and autonomy.

The same reasoning being used to support outdoor smoking bans would also support banning the consumption of alcohol in front of children. It would support banning adults from eating junk food, soda, or Vienna Fingers in front of children. It would support banning adults from playing hockey or engaging in any similar high-risk activities in front of children. Auto racing would certainly have to be banned in cases when any children were present. So would boxing. So would most movies, including those that are currently rated PG and PG-13.

The only compelling justification for government to restrict public behaviors from the sight of children is if those behaviors are viewed as morally reprehensible. For example, we protect children from seeing public nudity, public drunkenness, and public sex because there is a violation of public morals that we attribute to these behaviors. By putting smoking in the same category, anti-smoking advocates are basically arguing that smoking is an immoral behavior that needs to be regulated in the same way. I find this to be quite unfortunate, as public health practitioners should not be ascribing moral value to lawful, unhealthy behaviors.

I actually see this justification for outdoor smoking bans to be a dangerous one. Because once we start ascribing moral value to legal choices that people make which are truly not ethical decisions, we are in trouble. I certainly would hope that we won't start to view obesity this way, for example. But the same argument being advanced by these anti-smoking researchers would support interventions to ban fat people from the view of children in public.

Fortunately, Professor Simon Chapman has written a counter-point which argues that these outdoor smoking bans are unjustified because they are paternalistic. They are intended not to protect nonsmokers from secondhand smoke, but to discourage smokers from smoking.

Dr. Chapman writes: "Some are affronted by the mere sight of smoking. Others have an evangelical mission to use paternalistic "tough love" to help others quit. Prohibitions on personal behaviours can be justified by the right to interfere with the liberty of people to harm to others. But paternalism is most odious when used as a justification for limiting the choices that adults make when they put only themselves at risk. ... we do not evaluate the ethics of public health by the willingness of people to give up their autonomy, nor with the success of commandments to obey laws. The ethics here is about respect for the autonomy of individuals to act freely, providing their actions do not harm others."

IN MY VIEW: Rationale for Pharmacy Tobacco Sales Ban Doesn't Make Sense

This Thursday, the Boston Public Health Commission enacted regulations that ban the sale of tobacco products at pharmacies and on college campuses. This makes Boston the second city in the nation to ban tobacco sales at pharmacies (San Francisco is the first) and the first to ban tobacco sales on college campuses.

In an article published in the Roslindale Transcript, the executive director of the Commission explains the rationale behind the regulations: "Tobacco exposure continues to be a significant factor that contributes to preventable sickness and death. The board’s actions will help reduce young people’s exposure to tobacco products, and ensure that they are not exposed to products that make them sick when they go to places like pharmacies to get well."

The Rest of the Story

Based on the Commission's reasoning, we apparently don't have a problem with young people being exposed to products that make them sick, except on the rare occasion that they are in a pharmacy. When they go to a convenience store, we don't care if they are exposed to products that make them sick. When they go to a grocery store, we don't care if they are exposed to products that make them sick. When they are outside of a college campus, we don't care if they are exposed to products that make them sick.

This rationale makes no sense at all to me.

If the Commission feels that it has the appropriate authority to regulate young people's exposure to products that are harmful, then why exercise this authority only when it comes to pharmacies and college campuses?

Though not intended this way, what the Commission is basically saying to young people is this: "We don't care if you smoke and we don't care if you are exposed to tobacco products. We just don't want you to be exposed to tobacco products when you are in a pharmacy or at a store on a college campus. Outside of that, you can have all the exposure that you want and it's not a problem."

To my mind, it is no consolation to know that in the future, when patients die of lung cancer, we will be able to say: "Well at least they didn't purchase their cigarettes at a pharmacy."

How does it make it better to know that people are buying their cancer-causing products at convenience stores and gas stations rather than pharmacies?

And what public health justification is there for regulating the types of places where people obtain the products that may cause them to die from cancer? Why is it any better that people should purchase their cigarettes at a gas station or convenience store rather than a pharmacy?

The biggest problem with the regulations, other than the lack of a compelling government interest in regulating the places where this legal, though harmful product is sold, is that it frames the problem of tobacco use in the wrong way. It frames the problem as one of the sale of healthy and unhealthy products in the same store. Not only does there not seem to be any compelling government interest in ensuring that a healthy and unhealthy product are not sold in the same establishment, but this framing of the issue doesn't convince me that it is a public health issue in the first place.

By that definition of the problem, is it not also problematic that pharmacies are selling junk food, candy, and soda? Is it not also a problem that Boston Medical Center has a Dunkin Donuts inside it? Shouldn't the Commission ban the presence of junk food stores inside a hospital, of all places? And shouldn't the Commission ban the sale or serving of alcohol on college campuses? To be sure, the sale and serving of alcohol on college campuses in Boston has led directly to many serious injuries, illnesses, and even deaths. But at least the smokers on these campuses won't be able to buy their cigarettes at campus stores any more.

I've seen hundreds of my patients die from smoking-related disease. But not once did it occur to me to think that there might be some consolation in knowing that the situation might have been made somewhat more bearable through the knowledge that they didn't purchase their cigarettes at a pharmacy.

Thursday, December 11, 2008

New Study Finds that Harm Reduction Cigarettes are More Toxic Than Traditional Cigarettes; Shows Absurdity of the FDA Tobacco Legislation

A new study published in the journal Human Reproduction has concluded that harm reduction cigarettes are more toxic, as measured by effects on cell reproduction in cell cultures, than traditional cigarettes. The research, carried out by investigators from UC Riverside, concluded that: "For all endpoints (cell attachment to a gelatin, survival, proliferation and death), harm-reduction cigarette smoke (Marlboro Lights, Advance Lights and Quest) was as potent as, or more potent than, traditional cigarette smoke (Marlboro Red)." (see: Lin S, Tran V, Talbot P. Comparison of toxicity of smoke from traditional and harm-reduction cigarettes using mouse embryonic stem cells as a novel model for preimplantation development. Human Reproduction 2009).

Importantly, the researchers "found that both kinds of smoke from traditional and harm-reduction cigarettes are toxic to pre-implantation embryos and can retard growth or kill embryonic cells at this stage of development. Equally surprising to them was their discovery that mainstream smoke and sidestream smoke from harm-reduction cigarettes are more potent than the corresponding smoke from traditional brands of cigarettes. 'This result was unexpected since harm reduction brands purportedly have lower concentrations of toxicants,' Talbot said."

The Rest of the Story

This research reveals that the proposed FDA tobacco legislation would have absurd and disastrous consequences for the public's health. The legislation authorizes the marketing of reduced exposure cigarettes. To market such a product, a cigarette company merely needs to show that the product produces lower concentrations of toxicants and would therefore be anticipated to pose lower risks to human health. However, manufacturers do not need to actually show that the product is safer.

Nevertheless, by marketing the product as "reduced exposure," consumers are naturally going to infer that the product is safer. Also, since it will have the approval of the Food and Drug Administration, consumers will assume that the product is safer.

However, as shown by this study, it may well be the case that the product is no safer than traditional cigarettes, or the toxicity of the product may even be higher.

Thus, the FDA legislation will create a situation in which consumers are being defrauded by being deceived about the health effects of a cigarette product. The only difference between the current situation and that under the FDA bill will be that now, it is the cigarette companies that is defrauding the American public. Under the FDA legislation, it will be the federal government that is committing the fraud.

Moreover, while the research being done to study the effects of harm reduction cigarettes use animals or cell cultures as the "guinea pigs," under the FDA tobacco legislation, smokers will become the guinea pigs for testing of these products. But the relative safety of the products will not be known prior to the human testing. And even worse, both the cigarette companies and federal government will be implying to consumers that these reduced exposure products are safer than traditional cigarettes.

In my opinion, this will be not only absurd - because it transfers the fraud from the cigarette companies to the federal government - but disastrous for the public's health. We would likely see an increase in cigarette consumption as the public is led to believe that because of these reduced exposure products, cigarettes have been made safer.

This is truly a public health disaster in the making.

Wednesday, December 10, 2008

My Challenge to Anti-Smoking Groups Highlighted on Hit & Run Blog; So Far, No Takers

On Reason Online's Hit & Run blog, Jacob Sullum has highlighted my challenge to anti-smoking groups to report the two-year follow-up data from Scotland, which show that admissions for acute coronary syndrome in Scotland increased during the second year post-ban, meaning that overall, there has been no decline since the smoking ban went into effect. These results refute the earlier conclusions - widely publicized in the media - that the smoking ban led to a 17% decline in heart attacks.

Sullum writes: "As I noted in connection with smoking bans in Massachusetts, such laws, to the extent that they encourage smokers to quit and deter others from picking up the habit, can be expected to reduce heart disease over the long term, even if secondhand smoke has no effect on the cardiovascular health of bystanders. But the sharp, immediate reductions reported in some jurisdictions with smoking bans (beginning with Helena, Montana, in 2003) are not biologically plausible and are almost certainly due to random variation or pre-existing trends."

"Michael Siegel challenges anti-smoking groups that seized on the NEJM report as evidence of the benefits from smoking bans to acknowledge the more recent data. He cites misleading statements about the Scottish ban from 19 groups and offers a $200 prize to the one that corrects the record first. 'I am not going to lose sleep worrying about my $200,' he says, 'because I am sure that no anti-smoking groups will respond appropriately.'"

The Rest of the Story

So far, not a single anti-smoking group has publicized - or even acknowledged - the findings from Scotland. To me, this shows that the anti-smoking movement is not really interested in the scientific truth. What they are interested is finding and publicizing data that are favorable to the cause. The truth is not an issue. The only issue is selectively finding data that will support the agenda, even if those conclusions turn out to be wrong.

No corrections or apologies are necessary, you see, because the truth isn't what matters. It's all about publicizing favorable findings and suppressing findings that are unfavorable.

In other words, the movement is no longer about science. It is about propaganda.

This is very disappointing to me because it didn't used to be like this. The difference? The tobacco industry is no longer active in monitoring and responding to the movement's pronouncements. That used to keep the movement somewhat honest, because practitioners knew that anything they said would be challenged by the tobacco industry and they had to have the solid scientific basis to back up their claims. Now, the industry has relinquished that role and practitioners no longer need to back up or defend their claims. The truth just doesn't matter any longer.

Ironically, while one might question the industry's decision to relinquish its watchdog role, it turns out that by letting the groups spin out of control, they have lost their scientific integrity and reputation and have done more damage to themselves and the movement than the industry could have done through publicly challenging the communications. Plus, this is happening without the industry even having to lift up a finger. They can just sit back quietly and enjoy watching the movement destroy its own credibility.

Tuesday, December 09, 2008

The Mistake of Tying Health Insurance to Cigarette Revenue: Colorado Will Have to Cut Off Insurance for Children and Poor Adults, Says Report

According to a Kaiser Daily Health Policy Report, the state of Colorado will need to cut off health insurance for many children and poor adults due to declines in cigarette consumption. In 2004, the state used a cigarette excise tax increase to fund an expansion of Medicaid and SCHIP to cover impoverished adults and children who lacked health insurance. While that may have sounded like a good idea at the time, it has now produced a situation where because of declining cigarette consumption and tax revenues, many children and poor adults will need to be cut out of the program in order for it to remain solvent.

According to the report: "A decline in smoking rates in Colorado has led to a decline in cigarette tax revenue that is used in part to fund state health insurance programs, the Denver Rocky Mountain News reports. In 2004, the state increased the cigarette tax by 64 cents per pack with the goal of using the revenue for health care and tobacco education. The tax generated $169.6 million in the first year, but revenue has fallen for two straight years and budget forecasts show the revenue is expected to decline to $135.5 million in fiscal year 2012 -- a 20% drop before accounting for inflation. The purchase of cigarettes across state lines, over the Internet and on the black market also is contributing to lower cigarette tax revenue. ... 46% of the cigarette tax revenue is used to expand enrollment in public health insurance programs, such as Medicaid and SCHIP. State Sen. Betty Boyd (D) said, "That's a problem if the funds aren't there, because you can't provide services if you don't have money. In the end, if we lose enough money, less kids will get services." ... Sen. John Morse (D-Colo.) said the state could reduce the income eligibility level to reduce costs but that would reverse years of expanding eligibility."

The Rest of the Story

Tying children's health insurance and insurance for the poor to a cigarette tax increase may have seemed like a good idea in 2004, but four years later it is apparent that this decision resulted in making health insurance for the poor dependent on sustained levels of cigarette consumption. As consumption has fallen, there is not enough money left to retain the program and it appears that the income eligibility level will need to be reduced in order to keep the program solvent. This means, of course, that poor people and children will need to be thrown out of the health insurance program.

Can you imagine having to explain to a child or a poor family who is thrown out of the program the reason for the problem: "You see, the reason you had to be thrown out of the program and why the state will not be able to provide health care for you is that not enough people in the state are smoking. Unfortunately, lots of people in our state have quit smoking or reduced the amount they smoke, so as a result, you no longer have health insurance coverage. Sorry about that."

Anti-smoking groups have been quick to support any proposed cigarette tax increase, but the Colorado story illustrates that a little more careful consideration of these proposals is warranted. The long-term problems created by funding critical state programs with cigarette tax revenues outweigh any short-term benefits.

Sales of my T-shirt are taking off in Colorado.

Monday, December 08, 2008

Campaign for Tobacco-Free Kids is Hiding the Truth from Youths, Misusing Them to Promote Its Pet Legislation

According to the Campaign for Tobacco-Free Kids, "The Youth Advocates of the Year Awards, sponsored by the Campaign for Tobacco-Free Kids, honor the outstanding work of young advocates who have taken the lead in holding the tobacco companies accountable for their efforts to market products to youth. These young activists are fighting to protect their peers, their communities and the nation from the dangers of tobacco use through public education efforts, student-to-student training and outreach to policymakers. Many have worked to change policies at the national, state and local events to limit youth access to tobacco, protect people from secondhand smoke, and ensure that tobacco prevention programs continue to receive funding. Their work inspires and motivates other young people to join in their advocacy efforts."

The Rest of the Story

At first glance, this may look like an innocent, well-intentioned, appropriate program to honor youths who are health activists in their communities.

But upon closer inspection, it turns out to be an unethical, deceptive, propaganda program which misuses youths in an attempt to promote passage of legislation which, unbeknownst to the youths, is supported by Philip Morris - the nation's largest tobacco company.

The telling fine print is on the application form itself, where tucked in among the required questions about what activities a youth has undertaken is a mandatory question in which youths are required to state their position about the proposed FDA tobacco legislation, after reviewing a Campaign for Tobacco-Free Kids propaganda page about the bill.

There's one major problem: nowhere on the propaganda page does it disclose the truth - that the legislation is supported by the the nation's leading tobacco company. Such information would be crucial to obtain informed consent from youths regarding their willingness to work for such legislation, something they will be asked to do if they win this youth advocate "award."

The very fact that youths are required to state their position on the FDA legislation is despicable. This is supposed to be an award for community service, not a test of whether a youth supports the Campaign's political positions.

These youths are going to be used to promote the Campaign's pet legislation (the FDA bill), which might be fine if they were informed of the truth about the bill. If you are going to use youths for your own advocacy purposes, you must - at a minimum - inform them of the relevant details about the legislation. In this case, the most important detail is omitted: the fact that the legislation is actually favored by the nation's largest tobacco company. Thus, the Campaign is violating the principle of informed consent, making their misuse of these youths unethical.

That the Campaign for Tobacco-Free Kids is deceiving its adult constituents and the rest of the public is bad enough. But to do this to youths is just where I have to draw the line and say: enough of this nonsense. This is really despicable.

It is, by the way, this same organization which has been called out for violating the Obama transition team's policy of not allowing lobbyists to serve in the field in which they lobbied. According to an Associated Press review, the Campaign's executive director - Bill Corr - has lobbied the Congress in support of the FDA legislation and is now on the team reviewing the Health and Human Services Department, which oversees the FDA. According to the review, "the group has spent $675,000 this year trying to influence policymakers." This is a clear violation of the transition team's ethics policies.

The Campaign for Tobacco-Free Kids appears to have the ethical integrity of ... well ... a tobacco company, to be frank. Which is ironic, because the hallmark of the Tobacco-Free Kids campaign for the FDA legislation is that we need to end the deception and unethical practices of the tobacco companies.

The Campaign for Tobacco-Free Kids' lack of ethics, however, are far better than the tobacco companies' lack of ethics, because they are working for a noble cause, or at least the Campaign would like people to think. But the truth is that the cause they are working for is not so noble (protecting the profits of the tobacco companies at the expense of the public's health) and ethics are ethics, no matter who you are. Being an organization with supposedly noble interests does not absolve you of the responsibility to conduct your business in an ethical manner.

And misusing youths to promote a highly controversial and political federal policy is about as low as one can go. To my knowledge, even the tobacco companies have not attempted that one. At least they used adults to do their political bidding. Not so with the Campaign for Tobacco-Free Kids. If you can walk and you can talk, then you're eligible to be used to do the Campaign's political bidding (OK, so you have to be at least in middle school).

Thursday, December 04, 2008

Anti-Smoking Group Gives Thumbs-Up for Kids to Movie With Crude and Sexual Content, Strong Language and Nudity

The Scene Smoking organization, one of the main organizations that supports the Smoke Free Movies approach to addressing smoking in movies, has given its thumbs-up, pink-lung, go-for-it rating for kids to the movie "Role Models." Scene Smoking's complete description of the important and relevant points about this movie for kids to know about, and the basis for its thumbs up rating, is as follows: "No tobacco of any type is depicted during this movie - even the party scenes stay smoke-free."

The Rest of the Story

The rest of the story is that this anti-smoking group is giving its thumbs-up rating to, and praising, a movie that contains "
crude and sexual content, strong language and nudity."

That's not all. According to a complete review of the potentially inappropriate content for youths:

"a main theme of the movie is that Wheeler likes to have sex with women and makes several jokes about it;"

the movie contains "a scene where Wheeler tells Ronnie that KISS songs are all about sex and how they got "pussy" with them;"

"Ronnie draws several cartoons involving jokes about and depicting Penises;"

the movie depicts "two pairs of breasts (one towards the middle one towards the end)";

"Wheeler is shown naked face down in front of the tent (we see his butt)";

"A real-life role-playing game called "LAIRE" is played by Augie and he's seen playing it several times, "deaths" are acted out with fake swords. The final scenes involve a "LAIRE" battle which shows people acting out their deaths.";

the movie contains "a fair amount of course R-Rated language....some of which is said by a 10 year old, and high-school student...which may offend some viewers";

the movie contains "some very strong references to genitailia (men and women) the words "pussy" and "dick" are used several times whether in print or audible";

"Wheeler smokes pot in one scene, drinks alcohol, and, abuses Ambien;"

"Gayle constantly talks about her drug addiction;"

"the fact that a highschooler and 10-year-old are using hard R-Rated language and talking about sex may upset and offend some viewers."

Sounds like a nice movie for anti-smoking advocates to be recommending for youths!

How narrow-minded can you possibly be? How can you be so narrow-minded so as to look only at whether there is any depiction of smoking in a movie, and completely ignore the presence of profanity, sex, alcohol use, illegal drug use, prescription drug abuse, and other crude and sexually offensive content for youths?

Now don't get me wrong. I'm not arguing that there is necessarily anything wrong with the policy being used to regulate exposure to the movie. The movie is rated R and parents are forewarned about the crude and sexual content, strong language, and nudity. So I'm not criticizing the movie per se. What I'm criticizing is the narrow-minded approach of the entire Smoke Free Movies campaign and its supporting groups, which looks so narrowly only at whether there is smoking that they have ended up praising as youth-friendly a movie that contains crude and sexually offensive content that most would probably view as inappropriate for kids.

Is this really the health message that the Smoke Free Movies groups want to be sending?

The Smoke Free Movies movement is so narrow-minded that they have ended up casting public health praise upon a movie whose keywords include: "black panties, girl in bra and panties, topless, urination scene, sexual fantasy, child driving car, one night stand, male rear nudity, racial slur, public nudity, throat slitting, drunkenness, and vulgarity.

In the mean time, Scene Smoking doesn't seem to be concerned about lying to the public to support its agenda. The organization continues to publicly claim (on the same web page as the thumbs-up rating for "Role Models") that "Smoking Kills About 340 Young People a Day."

I guess their web master is still on vacation on a tropical island.

Wednesday, December 03, 2008

Florida Proposes to Balance State Budget by Increasing Cigarette Excise Tax; Levy is Being Called a "User Fee"

Faced with a dismal financial situation, the state of Florida is considering using an increase in the state's cigarette excise tax to balance the budget. However, reluctant to call the proposal a "tax," lawmakers have inserted into the legislation language that terms the source of the revenue stream a "user fee."

According to an article in the Ocala Star-Banner: "While the Legislature has increased a myriad of fees on everything from boating to court costs in recent years, they generally refuse to tackle anything associated with the word 'tax.' Seeking to exploit that is a not-so-subtle provision in Waldman's bill that changes the 'cigarette tax' to a 'user fee,' an obvious move to avoid the political poison of debating a 'tax increase.'"

Florida is apparently facing a $2 billion budget shortfall and the idea being floated - a 50 cent per pack cigarette tax increase - would raise between $400 million and $500 million.

The proposal is being supported by the American Cancer Society, the American Heart Association, the American Lung Association and the Florida Hospital Association.

The Rest of the Story

Don't be hasty on this one. While it may appear - at first glance - that increasing the cigarette tax is a perfect way to raise the revenue needed to balance the budget, a closer look reveals that this could be a disastrous idea.

The chief problem with the proposal is that it makes vital government programs dependent upon continued cigarette consumption for their solvency. By definition, it ties the future fiscal status of the state to the health of its cigarette market. If cigarette consumption falls, an automatic budget shortfall is created. Thus, the proposal makes the state dependent upon continued cigarette consumption in order for it to sustain vital government programs.

This has the further disastrous effect of taking away any incentive for the state government to implement interventions to seriously reduce smoking rates and it makes the state a fiscal partner with the tobacco companies, something Big Tobacco could otherwise only dream about.

To see how disastrous such a proposal might be, one need only look so far as the Master Settlement Agreement, which created a host of cigarette sales-dependent government programs in the states, thus making the states fiscal partners of Big Tobacco. The state Attorneys General even went so far as to go to court to protect the financial interests of their newly-found tobacco industry partners when the companies were threatened with damaging litigation because of their wrongdoing. The Attorneys General and other state-level government officials helped bail the tobacco companies out of a number of potentially devastating messes created by what otherwise might have been very successful litigation.

Because of the Master Settlement Agreement, the tobacco companies have had no greater friends in the world than the 46 states which entered into that agreement.

So while health advocates in Florida might initially think that tying a tobacco tax increase to critical government programs is a good idea that will improve the public's health, in the long run, it may actually serve to institutionalize tobacco use in the state of Florida and to put an end to any serious prospects of substantially reducing tobacco use in the Sunshine State.

An editorial in the Palm Beach Post articulates just this argument: "The Legislature could tee up lots of good responses to Florida's financial problem. Unfortunately, a bad one is the leader in the clubhouse. That would be a higher tax on cigarettes. As always, a sin tax is the last refuge of politicians who don't want to annoy people with money or face the big issues. ... using a sin tax to fund recurring expenses creates an adverse incentive - the revenues from the sin tax are inversely related to the public policy goal of reducing and deterring tobacco use."

The same argument is reflected by the title of a recent column in the St. Petersburg Times: "Smokers: Time to Inhale to Help the State."

While I support cigarette tax increases for the purpose of reducing smoking and raising revenues specifically for smoking-related purposes, including programs that directly benefit smokers (such as research into the prevention and treatment of smoking-related diseases, treatment for those diseases, and other services - such as cessation programs - for smokers), I think there are potentially dangerous public health implications of using cigarette taxes to balance budgets. When these taxes are used to finance vital government programs, it creates a dependence on the part of the government on continued cigarette consumption.

To illustrate what might be viewed as the absurdity of having critical government programs funded by smokers, I have designed a T-shirt that smokers in Florida can wear if the cigarette tax increase is enacted. I am hopeful that sales of this T-shirt will provide me with enough money to live up to the accusations of some of my colleagues that I am being bankrolled by Big Tobacco to express these radical opinions.

Tuesday, December 02, 2008

Challenge to Anti-Smoking Groups to Publicize Two-Year Data from Scotland on Trends in Heart Attacks

Today I am challenging anti-smoking groups to publicize the two-year follow-up results of trends in heart attacks or acute coronary syndrome in Scotland since the smoking ban went into effect.

The first group to do this will receive a $200 donation to their organization.

The rules are quite simple:

1. To be eligible, an anti-smoking organization must have previously issued a public communication (including a web site posting), press release, or media statement in which it publicized the results of the Scottish smoking ban study (either the original press release before the study was published or the results of the published paper in the New England Journal of Medicine) and communicated to the public the conclusion that the smoking ban in Scotland led to an immediate, dramatic (17%) decrease in heart attacks (or acute coronary syndrome) in Scotland.

2. The organization must issue a public correction of the conclusion of the study, either through a press release, web site posting, or other major public communication, based on the complete two-year follow-up data, which demonstrate no significant effect of the smoking ban on admissions for acute coronary syndrome in Scotland.

The Rest of the Story

The rest of the story is that I cannot afford the $200 prize I am offering, especially given the stock market crash, which was seriously exacerbated yesterday. However, I am so convinced that no anti-smoking organization will take up this challenge that I am willing to put the money on the line.

Why am I so sure that no anti-smoking organization will take up the challenge?

Because as I have learned, these anti-smoking groups aren't truly interested in getting out the facts. They are interested in putting out information which is favorable to their cause. The goal is not scientific accuracy or integrity. It is putting out information to support the agenda. If that information turns out to be premature or wrong, so what? It's all for a good cause anyway, so there's no real harm in a little bit of premature or false information. After all, the movement is saving lives.

Now some might argue that there is nothing wrong with anti-smoking groups being biased and even inaccurate in their reporting of the science because this is what partisan advocacy groups do. I disagree, however, because I view anti-smoking groups as part of the public health movement and because they have put themselves forward as being a credible source of scientific information. In other words, these groups have taken on a responsibility to the public by virtue of their putting themselves in the position of advocating for policies to improve the public's health. Moreover, they have put themselves forward as accurate communicators of scientific information to the public. In fact, much of these groups' work is dedicated to criticizing the tobacco companies for their misleading scientific statements to the public.

You can't have it both ways. If you are going to criticize the tobacco companies for being biased and inaccurate in their communication of the scientific facts about smoking and secondhand smoke to the public, then you cannot justify being inaccurate in your own communications.

I am not going to lose sleep worrying about my $200 because I am sure that no anti-smoking groups will respond appropriately. This is not about the scientific truth. It is about putting out information that supports these groups' agenda (and agenda that I largely support, by the way). However, where I differ is that I believe that these groups should be promoting these policies based on sound science, not inaccurate science that results from biased and premature conclusions that turn out to be wrong.

Examples of Groups Which Communicated the Original Study Conclusions to the Public

Campaign for Tobacco-Free Kids: "Since the implementation of its smoking ban, Scotland has seen a 17 percent reduction in heart attack admissions in 9 major hospitals."

Americans for Nonsmokers' Rights: "A study of nine Scottish hospitals has found a 17 per cent fall in admissions for heart attacks in the first year after the smoking ban came into force."

American Heart Association: "A public smoking ban in Scotland reduced hospital admissions for heart attacks by 17 percent in one year, according to researchers at the University of Glasgow, Scotland. The ban was most beneficial for people who had never smoked (21 percent reduction in hospitalizations) and former smokers (19 percent reduction). Hospitalizations decreased by 14 percent among smokers. In the decade before the ban, hospital admissions for heart attacks had dropped by about 3 percent per year."

Action on Smoking and Health (ASH - U.S.): "Now a number of major studies – in Helena [MO], Pueblo [CO], New York State, Piedmont [Italy], Ireland, and Scotland – have consistently shown a major decrease in hospital admissions for heart attacks after smokefree laws went into effect."

ClearWay Minnesota: "Smoking ban brings big cut in heart attacks in Scotland, study finds."

Henry Ford Health System: "If Michigan were to implement a comprehensive smoking ban tomorrow, we would see a 12 percent drop in heart attack admissions after the first year," says Mouaz Al-Mallah, M.D., Henry Ford's director of Cardiac Imaging Research and lead author of the study."

ASH UK: "A study of nine Scottish hospitals has found a 17 per cent fall in admissions for heart attacks in the first year after the smoking ban came into force."

ASH Scotland: "A study of nine Scottish hospitals has found a 17 per cent fall in admissions for heart attacks in the first year after the smoking ban came into force. The research is part of a national evaluation of the impact of Scotland's smoke-free legislation which shows that the smoking ban has had an overwhelmingly positive effect. The evaluation found that after the legislation came into force there was: a 17 per cent reduction in heart attack admissions to nine Scottish hospitals. This compares with an annual reduction in Scottish admissions for heart attack of 3 per cent per year in the decade before the ban."

Healthier Scotland: "Evaluation of the smoke-free legislation has so far found: ... reduced cases of myocardial infarction and reduced hospital admissions for acute heart attack."

ASH Scotland: "A 17% fall in admissions for heart attacks in the first year after the smoking ban came into force compared with 3% in preceding years."

ASH Australia: "A study in the prestigious New England Journal of Medicine provides strong new evidence that laws requiring smokefree workplaces have a rapid and significant impact on health. The study found that after smokefree legal changes in Scotland there was a 17% fall in hospital admissions for acute heart attacks - and two-thirds of the improvement was among non-smokers. ... Several other studies have demonstrated reductions in coronary events in the wake of smoke-free laws. However, the Scottish study is particularly strong because it used larger samples, examined the effect among non-smokers and smokers, included measures of exposure to secondhand smoke, and included a strong geographic control."

Medical Research Council (UK): "The effect of the Scotland ban has been quantified in the first year after the smoking ban has come into force. There has been a 17 per cent fall in admissions for heart attacks, which compares with an annual reduction in Scottish admissions for heart attack of 3 per cent per year in the decade before the ban."

Health Scotland: "17% reduction in heart attack admitted to 9 major Scottish hospitals. Average reduction of 3% per year in Scottish heart attack admissions in the 10 years leading up to the ban."

Office of the Chief Medical Examiner (Scotland): "Heart attack admission rates fell at an average rate of 3.8% per year in the ten years before the smoke-free legislation. For the six months following the implementation of the legislation the annual rate of decline increased by more than six-fold to 25% 11. A separate study of people admitted to coronary care units in 9 major Scottish hospitals found a 17% fall in admissions in the 10 months after the legislation compared with the corresponding 10 months in the preceding year, with a larger reduction among non-smokers."

Chartered Institute of Environmental Health (Wales): "Early research findings from Scotland, where smoke-free legislation came into force in March 2006, have been extremely positive. These include a 17 per cent reduction in heart attack admissions...".

Smoke Free Action (UK): "Recently released research from Scotland shows that admissions to hospital for heart attacks have declined by 17 per cent since the introduction of the smoking ban in public places."

British Heart Foundation: "A study of nine Scottish hospitals has found a 17% fall in admissions for heart attacks during the first year of the smoking ban. This compares with an annual reduction in Scottish admissions for heart attacks of 3% per year in the decade before legislation to ban smoking in public places."

Smokefree Philly: "A new study from Scotland provides what public-health experts in the U.S. say is the strongest evidence yet that public bans on smoking improve health."

Monday, December 01, 2008

Data Released by Scottish National Health Service Show that Conclusions of Earlier Study about Effect of Smoking Ban on Heart Attacks Were Wrong

Data from the Scottish National Health Service on hospital admissions for heart attacks and unstable angina (acute coronary syndrome) obtained and released by Christopher Snowdon over at Velvet Glove Iron Fist reveal that admissions for acute coronary syndrome rose sharply during the second year of the smoking ban, such that there was little overall change over the first two years during which the smoking ban has been in effect.

This demonstrates that the decline in acute coronary syndrome admissions observed during the first year after the smoking ban was not due to the ban, but was simply a reflection of underlying variation in the data -- it is apparent now that the decline was just a blip down and the admissions have now climbed back up to where they were prior to the smoking ban.

As Snowdon writes: "Much was made of an apparent reduction in the number of patients being diagnosed with the life-threatening heart condition after the smoking ban came into effect in 2006, including a study published in the New England Journal of Medicine which claimed that the ban had caused emergency ACS [acute coronary sydrome] admissions to fall by 17%."

"However, official statistics show that the decline in hospitals admissions for acute coronary syndrome has been greatly exaggerated. The real decline in the first year of the smoking ban was just 7.2% - not 17% - and the rate then rose by 7.8% in the second year, cancelling out the earlier drop."

"In the last 12 months before Scotland enacted its smoking ban (April 05 to March 06) there were 16,199 admissions for acute coronary syndrome*. In the second year of the smoking ban (April 07 to March 08) there were 16,212 admissions, slightly more than there had been before the legislation was enacted." ...

"Hospital admissions for acute coronary syndrome have been declining in Scotland for many years. The new data show that the well-publicised fall in admissions following Scotland's smoke-free legislation was in line with the existing downward trend and was significantly less steep than has previously been claimed."

"The belief that the number of cases of acute coronary syndrome fell by 17% after the smoking ban stems from a study of volunteers in a selection of Scottish hospitals between 2005 and 2007. The study - 'Smoke-free Legislation and Hospitalizations for Acute Coronary Syndrome' - has since been criticised for its limited scope and for excluding data from several key months before and after the ban."

"If the 2006-07 decline had really been the result of the smoke-free legislation, it would be expected for rates to remain low in subsequent years. The fact that Scottish hospitals have seen an unusually sharp rise - despite the smoking ban being rigorously enforced - suggests that whatever lay behind the 2006-07 dip, it was not the smoking ban."

The Whole Story

In September 2007, the University of Glasgow issued a press release announcing a new study which concluded that the smoking ban in Scotland had resulted in a 17% decline in heart attack admissions during the first year in which the smoking ban was in effect. The University of Glasgow is the home of the lead researcher on the study: Dr. Jill Pell. The study itself was not made available. However, its conclusions were blasted throughout the world via the media.

For example, in an uncritical recounting of the data and conclusions in the press release, Spiegel wrote as follows:

"it seems a miracle has happened: The number of heart attacks in Scotland has suddenly dropped by no less than 17 percent in a single year. What has happened? Have the Scots stopped eating red meat? Has the whole country started knocking back cholesterol medication? Are they all training for the marathon? No. The reason is much simpler: Scots are having fewer heart attacks because they are no longer inhaling other people's cigarette smoke when they sit in the pub, the train or the office."

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

At the time, I criticized the study for two reasons. First, I argued that the release of the study via a press release represented a "science by press release" approach that was not appropriate, because study conclusions should not be disseminated through the media until after they have undergone peer review and the study has been published, or at least until researchers are willing to make the entire study and its methodology available so that it can be reviewed by others.

I also criticized the study conclusions because it was not clear that the reported decline in heart attacks was not simply random variation and/or an existing secular decline in heart attacks that was occurring anyway, even without the smoking ban.

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

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

Importantly, about two months after the initial press release, I discussed data, reported in an article by Michael Blastland published by the BBC News, that were released by the National Health Service's Informational Services Division. These data included all hospital admissions for heart attacks nationwide in Scotland, reported as annual standardized rates. The data showed a decline of about 8% in the year following the smoking ban, which is only slightly higher than the approximate 6% decline the year preceding the smoking ban. If one looked at the trend in heart attack rates from 1998 through 2007, one would find that based on the pre-existing trends in heart attack rates, there had been no apparent change in the rate of heart attacks following the smoking ban, which was implemented in March 2006.

In addition, these data confirmed an earlier analysis, in which I pointed out that a huge decline in heart attacks in Scotland from 1999 to 2000 occurred prior to the smoking ban and revealed the large degree of baseline variability in the data, meaning that only a junk science study would conclude that the observed decline in heart attacks during the 10 months following the smoking ban was attributable to the smoking ban. In fact, the data revealed that the largest drop in heart attack admission rates occurred not following the smoking ban, but from 1999 to 2000.

Despite the shoddy nature of the study's conclusions and the unsupporting data coming from a national, population-based database, the authors proceeded to publish their study in the New England Journal of Medicine in July, 2008. The study concluded that the smoking ban in Scotland resulted in a 17% decline in hospital admissions for acute coronary syndrome (including myocardial infarctions [heart attacks] and unstable angina) (see : Pell JP et al. Smoke-free legislation and hospitalizations for acute coronary syndrome. N Engl J Med 2008; 359:482-491).

The study compared the number of admissions for acute coronary syndrome in nine hospitals in Scotland (representing 63% of admissions for acute coronary syndrome in the country) during the 10-month period prior to the smoking ban and the corresponding 10-month period the following year. The number of admissions declined from 3235 to 2684, a drop of 17%.

This 17% drop was compared to the trend in overall hospital admissions in all of Scotland during the preceding 10 years. According to the study, "the trend during the 10 years before legislation was a 3% mean annual reduction, with a maximum reduction of 9% in 2000."

Because the observed 17% reduction in admissions for acute coronary syndrome was much higher than the annual reduction during the 10 previous years and exceeded the highest annual decline between any two years, the study concludes that the observed reduction is attributable to the smoking ban.

I immediately argued that: "The problem with this article is that its conclusion is based on a comparison of apples to oranges. In order to compare the change in heart attacks in Scotland from 2006-2007 to the trend in heart attacks during the preceding ten-year period, one needs to use the same data source to compare these trends. In this article, the researchers use one source of data to estimate the change in heart attacks from 2006-2007 (observed changes in admissions for nine hospitals representing a portion of the country) and a different source of data to estimate the trend in heart attacks from 1996-2006 (national data from the Scottish National Health Service)." I argued that this is comparing apples to oranges, and it is not valid science.

In September 2008, Christopher Snowdon over at Velvet Glove Iron Fist reported that the results and conclusions of the Pell et al. study were wrong. Snowdon's article was based on a complete data set of acute coronary syndrome admissions in all of Scotland for the entire period from 1999 through 2007. He included data for the full two years following the smoking ban and for at least seven years preceding the ban. Snowdon found that contrary to the results reported by Pell et al., acute coronary syndrome admissions fell by just 9.3% in the year following the ban (compared to the year preceding the ban). But more importantly, this decline was no greater than that observed several times during the baseline period. For example: "AMI [acute myocardial infarction] admissions fell by 10.2% in 1999-2000 and angina admissions fell by 10.5% in 2005-2006 (there were also falls of 11.6%, 11% and 12% in previous years)."

Moreover, when one examined the full data, one saw that while there was a decline in acute coronary syndrome admissions in Scotland following the smoking ban, this decline was not as steep as it had been prior to the smoking ban. In other words, the rate of decline in acute coronary syndrome admissions actually decreased after the smoking ban.

Now, the data obtained by Christopher Snowdon reveal that what happened in Scotland was the opposite of what the researchers reported. Rather than to create an acceleration in the existing rate of decline in acute coronary syndrome admissions, the implementation of the smoking ban was associated with a decrease in the rate of decline. In fact, in the two years that the smoking ban has been in effect, the trend of declining acute coronary syndrome admissions in Scotland has ground to a halt.

This does not, of course, mean that the smoking ban resulted in an increase in heart attacks. It simply demonstrates that the observed decline in acute coronary syndrome admissions was a statistical blip. Data tends to zig and zag just from normal random variation. If you catch the data when it is zagging, you might inadvertently conclude that heart attacks are dropping, unless you stick around long enough to see that the next year, the heart attack rate zigs.

The zigging and zagging of statistical data is normal. What science must do is to account for this zigging and zagging and refrain from drawing conclusions about changes in data until the underlying zigging and zagging has been accounted for. This is what the authors of the Scottish smoking ban study failed to do.

And now, the most complete data yet assembled show that the conclusion of their New England Journal of Medicine study was wrong: the smoking ban in Scotland did not cause a substantial, immediate drop in heart attacks or acute coronary syndrome.

The Rest of the Story

There are three important parts to the rest of the story.

First, this story demonstrates the dangers of science by press release. The conclusions from the Scotland smoking ban study have already been disseminated widely to the public and it is far too late to retract them. Even if the researchers were to issue a media advisory in which they noted that their conclusion has been disproved, it is unlikely that it would pick up enough media attention to undo the publicity created by the initial media coverage.

Second, this story demonstrates the significant bias inherent in research by the anti-smoking movement these days. This bias is so strong that researchers can apparently not wait until they have sufficient data to draw a reasonable conclusion. The desired conclusion has to be disseminated widely when it is still preliminary in order to create a media splash that cannot be reversed if the conclusions subsequently prove to be wrong.

Third, this story demonstrates that the anti-smoking movement does not really care about the truth: it cares mostly about producing favorable evidence to support its conclusions. When the original studies came out (both the unpublished study and the published article), anti-smoking groups issued press releases and did everything they could to generate media attention about the study conclusions. Now that these conclusions have proven to be wrong, anti-smoking groups are not publicizing the error of the study. They are not issuing press releases to report these new data and to update the public with the accurate conclusion of the study. Nor are they going to do so.

I will go through the usual motions of disseminating my commentary throughout the movement, to all the key groups which have issued what turns out to be false, preliminary conclusions. But these groups are not going to do anything to correct the damage that has been done through the dissemination of these inaccurate conclusions.

You see - it doesn't really matter anyway. This is the tobacco control movement and since it is all for a good cause, there really isn't damage done by disseminating false scientific conclusions. Thus, it doesn't need to be corrected. After all, this is no longer about scientific accuracy or scientific integrity. This isn't about the truth. It's about producing favorable evidence to support the policy agenda of the anti-smoking movement.

Friday, November 28, 2008

American Academy of Pediatrics Center Director Defends Violence and Abuse in Movies Based on the Non-Addictive Quality of These Behaviors

In a response to Dr. Simon Chapman's criticism of the policy being supported by many anti-smoking groups which would require an R-rating for any movie depicting smoking, Dr. Jonathan Klein - Director of the American Academy of Pediatrics Julius B. Richmond Center of Excellence - argues that smoking, unlike violence and spousal abuse - deserves an automatic R-rating for any depiction because unlike these other behaviors it is addictive.

Dr. Chapman argued, for example, that the R-rating for movies that depict smoking is a narrow-minded approach that ignores the many other unhealthy behaviors that are portrayed in movies (for which the anti-smoking groups are not calling for an automatic R-rating), including: crime, physical inactivity, over-eating, excessive use of alcohol, unsafe sex, speeding and dangerous driving, gambling, risk taking such as extreme sport and adventure, motor cycle use and helmet-less cycling.

Dr. Chapman argues that: "an illustration of how such inconsistency plays out in practice comes from scenesmoking.org which rates the 2008 'What Happens in Vegas,' starring Cameron Diaz, as a "thumbs up/pink lung" because it contains no smoking. However, it does contain binge drinking, failure to wear seat belts, intoxication leading to possibly unprotected sex, gambling and a parody of spousal abuse."

In his response, Dr. Klein defends the proposed policy - which the American Academy of Pediatrics has endorsed - by arguing that unlike other behaviors, smoking is addictive. Apparently, the addictive nature of smoking is what warrants giving the depiction of smoking an automatic R-rating. Dr. Klein writes: "Other potentially adverse role modeled behavior does not have tobacco's highly addictive drug, nicotine, as a factor in children's exposure. The behavioral expectancy establishes a modeled response which then is reinforced by pharmacology, with well established and substantial health results. This is why the American Academy of Pediatrics and many other medical and public health organizations have endorsed the R rating."

The Rest of the Story

So let's get this straight. While smoking, crime, physical inactivity, over-eating, excessive use of alcohol, unsafe sex, speeding and dangerous driving, failure to wear seat belts, physical and sexual abuse, gambling, risk taking such as extreme sport and adventure, motor cycle use and helmet-less cycling are all unhealthy behaviors depicted in film, smoking is the only one of these which should trigger an automatic R-rating because it, unlike the others, is addictive and in which its effect on children's and adolescent's behavior is pharmacologic.

Coming from the American Academy of Pediatrics, I find this to be an unfortunate and irresponsible statement. How can an organization that is supposed to have a wide view of health problems affecting children and adolescents defend the depiction of crime, binge drinking, unsafe sex, speeding and dangerous driving, and physical and sexual abuse in movies on the grounds that these are not pharmacologically addictive behaviors?

That is, unfortunately, exactly what the statement is doing.

This response seems to me to highlight just how narrow-minded a view of the world anti-smoking groups now have. The only thing that matters is preventing even a single depiction of smoking in movies. You can have all the binge drinking, sex, violence, and abuse that you want, but please - no cigarette smoking.

I don't exactly understand what has caused the anti-smoking movement to reach the point where it has a single-minded view of the world in which smoking is the only problem in the world that needs to be addressed. It perplexes me why we would want to address only the depiction of smoking in movies, while ignoring the extreme violence and physical abuse (and a host of other unhealthy behaviors) that dominate even children's films today.

But that narrow-minded, single-issue approach is exactly what the anti-smoking and health groups that have endorsed the R-rating policy are doing.

And this response to Dr. Chapman's broad-based and well-reasoned argument demonstrates just how unreasonable, irresponsible, and even damaging this single-issue, narrow-minded approach can be.

My published "rapid response" to the commentary and responses appears here.

Wednesday, November 26, 2008

Tobacco Control Commentary Criticizes Anti-Smoking Groups' Proposal for an R-Rating for All Movies that Depict Smoking

In a commentary published in the current issue of the journal Tobacco Control, the journal's editor - Dr. Simon Chapman - criticizes the proposal being supported by many anti-smoking groups (including Smoke Free Movies, the American Legacy Foundation, and the American Public Health Association) to require an R-rating of any movie that depicts smoking (see: Chapman S. What should be done about smoking in movies? Tobacco Control 2008; 17(6):363-367).

Dr. Chapman writes: "In many liberal societies sexual, violent and illicit drug scenes in movies invoke classification as unsuitable for very young children, although there is considerable variation between nations about what is permissible to screen to children. Parents do not have time to research the content of all movies and value movie classifications as a way of helping them avoid inappropriate, possibly disturbing, content. This brings us to the widely supported proposal that smoking should not be banned in movies, but that all but manifestly anti-smoking scenes—even those where smoking is only "implied"—should cause a movie to be classified as "R". Under the Smoke Free Movies policy, this would mean that even one instance of smoking would see a movie classified as being equivalent to the Motion Picture Association of America’s standard for those depicting "adult themes, adult activity, hard language, intense or persistent violence, sexually-oriented nudity, drug abuse or other elements", where such scenes are often sustained. Is this an equivalence that many in the community would find reasonable?"

"For example, the US-based Smoke Free Movies site currently rates the new Batman movie The Dark Knight as "promoting smoking" because, amid a cast of thousands, one minor character smokes a cigar. While activists dedicated to eradicating smoking in children’s movies engage in organised complaining about such closely monitored incidents, it seems improbable that many ordinary citizens would spontaneously rise up in community protest about such minor usage in the way they would about the sort of sustained adult content that currently sees movies classified as unsuitable for children, should those movies be not so classified. In this respect, arguments based on the unacceptability to the community of any smoking scenes are highly unlikely to find widespread support and be seen as overly extreme solutions proposed by single-minded interest groups." ...

"If even a single instance of smoking were to consign a movie to R status because of its potential to influence children to smoke, immediate parallel questions arise about a wide range of other potentially adverse role modelling cues in films. Smoking causes massive health problems, but in that it is not unique. Globally, large-scale health and social problems flow from many activities that also often appear in movies. These include crime, physical inactivity, over-eating, excessive use of alcohol, unsafe sex, speeding and dangerous driving, gambling, risk taking such as extreme sport and adventure, motor cycle use and helmet-less cycling. For example, by the same reasoning that movies showing smoking might normalise or glamorise tobacco use, it could be argued that film should never show positive scenes of gluttony or actors enthusiastically eating fast food because of the obesity epidemic and millions of overweight and obese children struggling to control their weight. Countless comedy scripts would need to go back to the drawing board. Scenes of people drinking alcohol might be excised from children’s movies—particularly if those drinking seemed to be enjoying it—because this might seed inappropriate ideas about alcohol in tender minds. All car chases and speeding scenes of course would be restricted to adult movies." ...

"an illustration of how such inconsistency plays out in practice comes from scenesmoking.org which rates the 2008 What Happens in Vegas, starring Cameron Diaz, as a "thumbs up/pink lung" because it contains no smoking. However, it does contain binge drinking, failure to wear seat belts, intoxication leading to possibly unprotected sex, gambling and a parody of spousal abuse."

The Rest of the Story

I agree with Dr. Chapman's analysis and I commend him for having the courage to publicly express his criticism of a proposal being championed by many mainstream anti-smoking groups.

To me, what this article highlights is the single-mindedness, the issue-specific focus of today's anti-smoking movement and the inability of the movement to see beyond the narrow blinders that restrict its vision to nothing but smoking. There are a lot of health risks beyond smoking and there are a lot of health-related problems with movie content beyond the depiction of cigarette smoking. But because of their narrow, single-minded view, anti-smoking groups ignore everything but the smoking.

As Dr. Chapman points out, Smoke Free Movies applauded the film "What Happens in Vegas" and gave it a favorable "thumbs up/pink lung" rating because it didn't contain a single portrayal of cigarette smoking. However, the movie does depict "binge drinking, failure to wear seat belts, intoxication leading to possibly unprotected sex, gambling and a parody of spousal abuse."

Is this a film to which responsible public health practitioners should be giving a thumbs up?

Thumbs down to smoking, but thumbs up to binge drinking.
Thumbs down to smoking, but thumbs up to intoxication.
Thumbs down to smoking, but thumbs up to spousal abuse.

This is the message that Smoke Free Movies and other anti-smoking groups are actually sending to the public through their support of the very narrow-minded "R-rating for any depiction of smoking" policy.

As Dr. Chapman concludes: "If the more reasonable proposition were promoted that smoking ought to be considered as one element within movie rating panels’ assessments of how a movie should be rated, I would predict that many within government and the movie industry would be more receptive and more progress would be made."

Unfortunately, reason is not something that characterizes the anti-smoking movement. It has become more of a religion or an ideology than a specialized field of practice within the scope of public health.