Wednesday, March 11, 2009

The Four Commandments of the Anti-Smoking Movement: A Tribute to the Memory and Legacy of Gian Turci

I was saddened by the news today that Gian Turci, the C.E.O. of FORCES International, has passed away. I had the great pleasure of getting to know Gian quite well during the past four years, and spent some wonderful time having long phone conversations with him around a range of issues, mostly related to tobacco control and public health. I found Gian to be a remarkable individual and I enjoyed the relationship that we developed. Gian was a great general in the fight to preserve individual liberty, but what may not be readily apparent is that he was also a kind and gentle person on an individual level. Gian also showed a great deal of respect for me, despite some major differences in how we viewed certain issues. But the beautiful thing was that these differences did not come in the way of our friendship and collegueship. In fact, we found many areas in which we agreed and we both believed that these aresas of common ground greatly overshadowed our differences. The respect Gian showed me at all times was a great sign of his character and integrity and it is something that I will never forget.

The particular writing of Gian Turci's that I want to highlight today - my personal favorite - is his Four Commandments of the Anti-Smoking Movement. In this post, I highlight each of these "commandments," and share examples of the truth of these precepts from my own experience in the tobacco control movement. Many of these examples come from my own commentaries, to which I link below.

Commandment #1: Smoking kills, always and at any rate (no redemption other than quitting).

Gian was insightful, because there is great truth to the idea that in the tobacco control movement there is an almost abstinence-only approach to public health. The idea of harm reduction has been almost entirely shunned, but without careful consideration of the actual science-base and evidence for what might be the most effective strategies for tobacco control.

An excellent example of this was the American Cancer Society's response to a study showing that smokers who smoke just 1-4 cigarettes per day are still at significant risk of heart disease, lung disease, and cancer. The study was a longitudinal (cohort) study of more than 42,000 adults, ages 35-49, in Norway, who were followed for nearly 30 years. The adjusted relative risk among smokers of 1-4 cigarettes per day of dying from heart disease was about 2.8 and for dying from lung cancer was about 2.8 among men and 5.0 among women.

The authors concluded: "In both sexes, smoking 1-–4 cigarettes per day was significantly associated with higher risk of dying from ischaemic heart disease and from all causes, and from lung cancer in women. Accordingly, five cigarettes per day is not a threshold value for daily cigarette consumption that must be exceeded before serious health consequences occur."

In response to the study, the American Cancer Society (ACS) issued a statement, which read in part: "The finding that smoking just 1 to 4 cigarettes a day can significantly boost heart disease and cancer rates is important because many smokers, due to expanding restrictions on smoking in public places and at work, are cutting back on the number of cigarettes they smoke each day. By doing so, they often feel that they are sharply reducing or eliminating the health dangers from smoking. But this study shows that this is not the case and reiterates the important message that there is no such thing as a safe level of smoking."

I find that statement to be misleading, or possibly inaccurate. The statement suggests, I think, that cutting back on cigarette consumption does not "sharply reduce" the health dangers from smoking. But for smokers of 1 pack per day who cut down to 1-4 cigarettes per day, the reduction in the relative risk for death from all causes drops from about 3.3 to about 1.5. For death from lung cancer, it drops from about 30 to about 4. And for all cancers, it drops from about 3 to 1.1 (basically, no increased risk). I do find these reductions in risk to be "sharp" reductions, and it is both misleading and damaging to suggest to smokers that there is no point in their trying to cut down on the amount they smoke because it is not going to improve their health.

While I obviously agree with the suggestion that quitting smoking completely is far better than continuing to smoke at lower levels, I just don't think it's accurate to imply that reducing cigarette consumption will not sharply reduce the health dangers from smoking.

The real danger here, however, is not in the possible misrepresentation of the scientific evidence. It is, rather, the possibility that in making this statement, the ACS might actually play some part in convincing smokers who would otherwise continue to cut down on the amount they smoke that it is simply not worth it because they aren't going to see any health improvement anyway. Given the addictive power of nicotine and cigarette smoking, it is far more likely that these discouraged smokers will simply continue smoking at their current amounts then that they will quit smoking entirely. And they may even increase their cigarette consumption, since it may appear from the ACS statement that the amount smoked does not relate directly to disease risk.

This is, in fact, one of the downfalls of public health messages to the public in general - the fact that in trying to emphasize the health dangers of a particular behavior, we often fail to acknowledge that there is a dose-response relationship, and that there is such a thing as risk reduction (reduction in risk associated with decreased levels of the behavior).

To deny that fact may be to deprive many individuals of a golden opportunity to change their behavior and improve their health, if not to save their lives.

Commandment #2: Passive smoking kills, always and at any rate (no redemption other than bans).

I think Gian was insightful in this premise as well, because the anti-smoking movement has recently adopted the "there is no safe level of secondhand smoke" approach which basically argues that there is no point in reducing your exposure to secondhand smoke because any level of exposure is dangerous. In fact, more recently, anti-smoking advocates have argued that even "thirdhand" smoke is dangerous. This may lead smokers with children, for example, to continue to smoke in their homes rather than smoking outside because they figure that as long as the child is going to be exposed to toxic thirdhand smoke there is no point in protecting them from the secondhand smoke.

In a June 2006 column, I discussed how the Surgeon General's pronouncement that there is "no safe level of exposure to secondhand smoke" and his efforts to make this the cornerstone of communications to the public about the issue may have the unfortunate effect of undermining the public's appreciation of the relationship between dose and health risk.

There are a number of reasons why I'm not so sure that the publicity focus on the absence of any safe level of exposure to secondhand smoke is entirely appropriate and effective as a public health message.

First, the message is not particularly meaningful. One can say that there is no safe level of exposure to any carcinogen. There is no safe level of exposure to car exhaust. There is no safe level of exposure to the sun's rays. There is no safe level of exposure to X-rays. There is no safe level of exposure to the benzene that is found in some sodas. There is no safe level of exposure to radon in homes. There is no safe level of exposure to arsenic that is found in many people's drinking water.

Second, this emphasis on the hazards of minute levels of, and brief exposures to, secondhand smoke seems to belie the importance that the public must place on assessing the dose of secondhand smoke in making decisions about their potential health risk. Dose consists both of the concentration of the smoke and the duration of exposure, and both of these are important considerations that we want the public to be aware of. Don't we?

Maybe I'm wrong, but isn't it more useful and informative to provide the public with a sense of the relative levels of exposure to secondhand smoke in different environments and situations then to scare the public into simply thinking that any exposure is terrible and that (perhaps) all exposures are equally bad? I think that it is important for the public to have some appreciation of the strong and important relationship between dose and risk. And I'm afraid that the overwhelming emphasis on there being no risk-free level of smoke exposure may obscure the importance of the dose-risk relationship.

Failing to emphasize the dose-risk relationship could have negative public health consequences, both from an individual and a policy perspective. From an individual perspective, is it not possible that some people will conclude that since any secondhand smoke exposure is putting them at risk, it doesn't make sense to reduce their exposure if they cannot eliminate it. In other words, for people who cannot avoid some exposure to secondhand smoke, is there any incentive for them to reduce their exposure if they are repeatedly hammered over the head with the idea that their limited smoke exposure is going to kill them anyway?

And for smokers, what incentive is there for them to cut down on their smoking if it is true that even brief exposure to secondhand smoke may cause them to have a heart attack anyway? If you're going to have a heart attack one way or another, why not continue to smoke and at least enjoy yourself before you keel over?

The point is that by making secondhand smoke exposure sound so bad, such that even a tiny and brief exposure is hazardous and such that if you are exposed you are doomed to disease, aren't we taking away an incentive for people who cannot eliminate their exposure entirely to reduce it? Are we not taking away an incentive for smokers to quit smoking if they know that they will still hang out in the same smoky bars and be exposed to secondhand smoke. What's the point of their quitting smoking if the secondhand smoke in these bars is going to kill them anyway and there is no perceived benefit of reducing the level of their exposure?

Third, by emphasizing that any brief exposure to secondhand smoke can cause lung cancer, I believe this publicity may well harm efforts to search for the other causes of lung cancer among nonsmokers. Since I've devoted my career to the role of secondhand smoke in causing lung cancer among nonsmokers, I obviously think this is a critical issue, but by giving people the impression that any nonsmoker who gets lung cancer may well have gotten it from secondhand smoke, even if their exposure was minimal, are we not doing a potential disservice to the search for other causes of non-smoking-related lung cancer?

Fourth, when you give a message like this one - everyone is at risk - do you not undermine efforts to try to reach people who really are at the most risk? By scaring everyone in the population into thinking that they are at risk of disease from secondhand smoke, are we not taking attention away, perhaps, from the groups that are at the highest risk because of the highest levels of exposure? And might not these groups be less likely to take action to protect themselves than if the message was that certain groups are at particularly high risk and need to be protected urgently?

Rather than being a call for specific and prioritized actions to prevent disease in the most effective and efficient manner possible, it seems that the publicity put out by the Surgeon General's office is more of just a general public scare, devoid of any priorities, focus, or policy or intervention directives.

In some ways, I believe that the basic message here - everyone is at risk and the dose doesn't matter; no matter how small the dose, you are still at risk - may be a counter-productive one. Or at least it may undermine some of the very important findings of the Surgeon General's report. The report reviewed, for example, the levels of secondhand smoke exposure among different population groups and came to some conclusions that should guide policy makers. But those conclusions are completely obscured by the all-out emphasis on the absence of any safe level of exposure.

Commandment #3: Public health is the paramount value of society. All other values - such as liberty, constitutionality, truth, economics, free enterprise, personal responsibility, and moral integrity - are absolutely irrelevant and/or have to submit unconditionally.

This premise rings so true and the examples are so numerous that one only need read a random selection of posts on this blog to see illustrations of this principle. Let me highlight just a few of the most pertinent examples.

First, in the desire to save health care costs for employers, anti-smoking advocates are completely ignoring the rights of smokers to fair treatment in employment. They are willing to embrace employment discrimination in order to promote the saving of health care costs. But there are only willing to promote this type of discrimination against smokers. They do not promote efforts to ban obese or overweight people from employment or to throw away the job applications of people who eat a poor diet or do not get enough physical activity. Clearly, public health is the paramount value in the promotion of these discriminatory policies. Individual rights, employer privacy, and social justice are ignored or if they are considered, they are deemed irrelevant.

Second, in the desire to promote smoking bans, anti-smoking advocates are disseminating untruthful information about the acute cardiovascular effects of secondhand smoke. The value of the protection of health is so paramount that it is deemed acceptable to use false information to promote this cause.

Third, in the desire to extract money from tobacco companies, public health organizations ignored the precepts of the law and basically asked the judge to ignore the law in order to award money for anti-smoking organizations to conduct their programs. They were in fact admonished by a federal judge for asking for money without any legal basis.

Fourth, in the desire to promote the FDA tobacco legislation, anti-smoking groups have engaged in a massive campaign of deception. The American Cancer Society, for example, claimed that Big Tobacco is lying about the ingredients in its cigarettes, but failed to provide any documentation that this claim is true. The legislation is apparently deemed as being so important that it is acceptable to deceive the public in order to promote it. The truth is secondary to the paramount value of health.

Commandment #4: The antitobacco movement is inherently right, just and true - thus, it is heresy to disagree with its goals and methods.

This commandment is basically the story of my last few years and the underlying story behind this entire blog. I have experienced the unfortunate truth of this commandment in a very personal way. My disagreement with some of the research, policies, and tactics of the tobacco control movement has largely been greeted with personal attacks, censorship, and attempts to silence me. Essentially, I have been called and treated as a heretic solely because I have disagreed with certain aspects of the tobacco control movement's tactics and agenda. It is indeed a religious-like movement and if you question any aspect of the dogma, you are a heretic. I have learned that lesson the hard way.

There are others in the tobacco control movement who have had a similar experience, and whose stories illustrate how Gian's words ring true. These individuals include Luc Martial and Dr. Carl Phillips up in Canada and Dr. James Enstrom here in the United States. They too have experienced the truth in Gian's fourth commandment.

I will cherish the short, but rich relationship that I had with Gian. I wish the best to his family and friends. May he rest in peace, and may his memory be a blessing and inspiration to those who continue his work.

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