Monday, November 30, 2009

Rest of the Story Author Expelled from Smokefree Air List-Serve for Criticizing Unfounded and Inflammatory Smear Campaign Against Smoking Ban Opponent

The true colors of the modern-day anti-smoking movement showed brightly last week, as a prominent smoke-free air advocate (me) was thrown off a smoke-free advocacy list-serve for daring to criticize an inflammatory and unfounded personal attack, bordering on defamation, of an individual (private citizen) who is a smoking ban opponent which was posted on the list-serve.

A fellow smoke-free advocate - Tim Filler, who is on the steering committee of Smoke Free Indy - posted on the list-serve a nasty personal attack against Michael McFadden, a smoking ban opponent. In the attack, Filler insinuated that McFadden is a tobacco lackey who is taking tobacco money. The suggestion was that McFadden is not speaking for himself as a private citizen, but that he actually is affiliated with Big Tobacco. The attack was posted without the knowledge of McFadden, who had no opportunity to defend himself. I opined that the attack was not only unsupported, because no evidence was presented to document that McFadden was affiliated with Big Tobacco, but also potentially defamatory, since it was clearly a malicious attack on McFadden's character that showed at least a partial disregard for the truth.

I responded to the list-serve with a note challenging the values and ethics behind issuing a personal attack against a private citizen on this list-serve, insinuating that he is a tobacco lackey, without any evidence and without any opportunity for the individual to defend himself. Essentially, I saw it as an inflammatory and unsupported smear campaign against an individual citizen, and I opined that such an attack has no place on this tobacco control forum.

As a result of my having the courage to question the use of the list-serve for offensive and potentially defamatory personal attacks against private citizens, I was expelled from the list-serve.

The administrator of the list-serve - Americans for Nonsmokers' Rights (ANR) - wrote: "We have removed Dr. Siegel from this listserve because his recent inflammatory comments and attacks are neither constructive, productive, nor accurate."

The Rest of the Story

Of course I was thrown off off the list-serve. Any comments that are not supportive of the established anti-smoking cause and its aggressive agenda - which includes attacking individual citizens with no affiliation with Big Tobacco - are automatically viewed as non-constructive and non-productive and therefore, the dissenter must be immediately silenced. There is truly no room for dissent in the tobacco control movement. Dissent is met swiftly and firmly with censorship. The movement will not allow dissenting views to be heard, lest advocates consider those views and decide to challenge the prevailing wisdom and tactics of the movement.

It is quite clear that the smoke-free list-serve wants to preserve itself as a forum where members can take pot shots at smoking ban opponents and make false insinuations that attack their integrity and character, even without documentation of any inappropriate activity. The list-serve wants to remain free for these inflammatory personal attacks to take place, without being challenged by anyone who might feel that personal smear campaigns like this are inappropriate and potentially defamatory.

While the list-serve is advertised as a forum to exchange information and strategies for achieving smoke-free air, it has recently become more of a forum for advocates to let out their hatred of smoking ban opponents, and smear them with unfounded personal attacks that cannot be challenged because the forum is private and thus their victims are not provided an opportunity to defend themselves. ANR is clearly trying to protect the freedom of smoke-free advocates to conduct these smear campaigns in peace, without having to worry about being challenged on their facts, on the truth, and on the ethics of conducting such smear campaigns in the first place.

As far as the accuracy of my comments, ANR did not mention in its note what aspect of my post it is claiming was allegedly inaccurate. I stand by my commentary and so far, no one has pointed out to me any inaccuracies in what I wrote. Moreover, everyone on the list saw the precise communication to which I was responding and so they are all free to judge the accuracy of the posting. In my extensive communications with Tim Filler himself, Tim did not point out any inaccuracies in what I wrote.

The inaccuracy in question, actually, is the false insinuation that Michael McFadden is affiliated with Big Tobacco. That is demonstrably false. It is interesting that ANR is defending an advocate's right to personally attack and potentially defame a private citizen, while it is not interested in allowing an advocate to criticize such an attack.

This episode is just the latest in a series in which ANR has orchestrated smear campaigns against smoking ban opponents and silenced anyone who tries to say anything potentially positive about these individuals.

Here is the rest of the story:

If you take part in secondhand smoke policy training in the tobacco control movement, chances are that you will be taught that all opposition to smoking bans is orchestrated by the tobacco industry, that anyone who challenges the science connecting secondhand smoke exposure and severe health effects is a paid lackey of Big Tobacco, and that any group which disseminates information challenging these health effects is a tobacco industry front group. Consequently, the a chief strategy of tobacco control is to smear the opposition by accusing them of being tobacco industry moles. And in no situation should one say anything positive about an opponent, even if true.

How do I know this?

Because for many years, I was one of the main trainers of tobacco control advocates in the United States. And this is what I taught, because this was what I was led to believe. I attended many conferences and trainings and this is precisely what I was taught. I accepted it for the truth, and passed it along to others.

However, in 1999, a sentinel event in my career occurred which woke me up to the fact that I had in fact been brainwashed to believe these errant ideas. I wrote an article summarizing some of these ideas. In the article, I suggested that if any group opposes a smoking ban, advocates should not discuss the substance of the opponents' claims, but should instead try to discredit them by exposing their ties to Big Tobacco.

I woke up one morning to find that, without my permission, my article had been posted on the internet by Americans for Nonsmokers' Rights (ANR). Something about having my work published on the world wide web for everyone to see awoke me from my brainwashing and snapped me back to reality. Immediately, I realized that I had made a mistake. I called ANR and asked them to please change the article to reflect a clarification, in which I made it clear that I was not in fact accusing certain individuals who had challenged the severity of secondhand smoke health effects of having personally received money from tobacco companies.

To my shock, ANR refused to accede to my request, even though I was the author of the article. They responded that they did not want to say anything even remotely positive about an opponent and that they had to place their own political agenda ahead of my scientific integrity:

"we have concluded that the possible 'clarification' that you and I discussed is simply not feasible. There is a strong concensus that we do not want to post ANYTHING on our web page that can be construed as an apology or as backtracking from the position taken in the paper you wrote. More specifically, XXXXXX has convinced me that, given XXXXX's long history of attacking ETS science, it would be a mistake to state anything that would give him credence. ... I realize that your views on the matter are heart-felt and sincere, and that mere removal of your name from the paper, without more, will not be entirely satisfactory to you. But at this point ANR must put its political credibility ahead of what you consider to be your scientific credibility."

ANR then decided to completely disrespect my authorship rights and my copyright of the article, and to subsume copyright of the article for itself by publishing it on its website without my name. I never gave ANR permission to do this. What I told ANR clearly was that given its refusal to change my article as I re-wrote it, I wanted the article removed from its website. It was only when ANR refused to honor this author's request that I demanded that my name be removed from its website.

(Read the entire story here)

What turned out to be errant information about the nature of opposition to smoking bans was delivered to me via a systematic method of formal trainings in which these ideas were deliberately spread to me and other tobacco control advocates with the purpose of furthering the anti-smoking cause.

These ideas ran counter to my own pre-conceived and firmly held ideas about the nature of opposition to smoking bans and to challenges of the health effects of secondhand smoke. After all, I had many good friends who challenged the connection between secondhand smoke and chronic disease, so I "knew" that not everyone who challenges the science is a Big Tobacco lackey. I also had met many of the opponents of smoking bans and it never occurred to me that they were tobacco moles. Nevertheless, this wisdom was so strongly imparted upon me in the trainings (which were largely delivered by, or influenced by ANR) that I came to believe this information, even though it was at odds with my pre-conceived beliefs.

Importantly, only one perspective on this issue was presented to us in the trainings. There was no room for disagreement or challenge. These ideas were presented as scientific facts, not subject to debate. In fact, if we were to challenge the ideas, the implication was that we - ourselves - might be accused of working for Big Tobacco or receiving secret payoffs.

The most prominent and dogmatic idea presented to us was that "The debate is over." There is no room for questioning of the link between secondhand smoke and chronic disease. Anyone who challenges that link or suggests that it is being exaggerated must therefore be a front for the tobacco industry. No reasonable person - acting of their own accord - would challenge this undebatable science.

This dogma, however, is untrue. While it is certainly the case that most of the scientific challenges to secondhand smoke science came from tobacco industry-funded initiatives, there are a number of scientists and others who have challenged the science but are not paid by Big Tobacco to do so. The American Council on Science and Health, for example, has challenged the strength of the link between secondhand smoke and chronic disease, while acknowledging the acute effects of tobacco smoke. Martha Perske wrote some very well-researched and meticulous critiques of secondhand smoke science. I have myself challenged the claims made by many anti-smoking groups about the acute cardiovascular effects of secondhand smoke. So no - not everyone who suggests that secondhand smoke health claims have been exaggerated is a paid lackey of the tobacco industry.

Moreover, not all opponents of smoking bans are tobacco industry front groups. FORCES International - one of the groups most prominent in opposing smoking bans - is not a Big Tobacco front group, despite continued accusations by ANR that this is the case.

ANR has instructed local anti-smoking groups to suggest to the public that any group opposing a smoking ban is a Big Tobacco front group, even if we can't prove it: "Advocates should shine the light on these associations and connections to the tobacco industry. See our factsheet on how to follow the money to find industry connections in your community. There isn't always a "smoking gun" linking the tobacco industry to these groups, either due to lax local campaign finance laws, or money getting funneled through third parties. Often we don't find out until years later that the tobacco industry was funding opposition activities. In any case, showing that suspicious groups are pulling out all the familiar tricks will encourage people to take the Big Tobacco message delivered by these groups with a grain of salt."

ANR has claimed that any scientist who finds no relationship between secondhand smoke and chronic disease is not legitimate: "All major governmental and public health agencies and legitimate researchers have clearly affirmed that secondhand smoke kills."

In other words, if I conduct a study and it fails to show a significant relationship between secondhand smoke and chronic disease, then all of the sudden, I have automatically become an illegitimate scientist.

Speaking of illegitimate scientific claims, keep in mind that ANR claims that active smoking is no worse than 30 minutes of secondhand smoke exposure in terms of the amount of heart damage that it causes and that this brief exposure to secondhand smoke deprives the heart of life-giving blood: "Just thirty minutes of exposure to secondhand smoke can cause heart damage similar to that of habitual smokers. Nonsmokers' heart arteries showed a reduced ability to dilate, diminishing the ability of the heart to get life-giving blood."

If one conducts a search of the ANR Tobacco Industry Tracking Database, looking for evidence that Michael Siegel is a Big Tobacco front, you will find an entry that describes my May 2006 appearance on 20/20, during which I suggested that it is inaccurate to claim that 30 minutes of secondhand smoke can cause heart disease. You will also find a link to my blog being quoted by Jacob Sullum in his article "Second Thoughts About Tobacco Tar." Furthermore, there is a link to my being quoted in an Inside Bay Area article in which I question the need to ban all outdoor smoking.

While it is great that ANR is providing these important links, the fact that they are provided under the tobacco industry tracking database seems to me to suggest to the public that I am somehow affiliated with the tobacco industry. I can understand ANR linking to these documents, but it is beyond me why such documents would appear in a tobacco industry tracking database. In what way is tracking me related to tracking the tobacco industry? The implication, of course, is that there is indeed a connection there, and I'm sure that my appearance in the database has given reason to some members of the public who do not know me to suspect that I am a tobacco industry mole.

My point is simply that there is a systematic effort to try to put doubt in the minds of the public about the legitimacy and integrity (and financial independence) of anyone who expresses any opposition to a proposed smoking ban or who in any way challenges anti-smoking groups' claims about the health effects of secondhand smoke, despite the fact that not everyone who opposes smoke-free policies or challenges the health claims of anti-smoking groups is in fact on the tobacco payroll. This means that some individuals and groups are going to end up being falsely accused.

Given the indoctrination that takes place in the tobacco control movement, it is perhaps not a surprise that no less than five of my colleagues have recently accused me of taking tobacco money or implied that I am being paid by tobacco companies. The brainwashing that takes place is so strong that some anti-smoking advocates lose their ability to distinguish between a tobacco mole and a dedicated and committed, long-time tobacco control advocate.

Brainwashing is defined as "persuasion by propaganda." Propaganda is defined as "ideas, facts, or allegations spread deliberately to further one's cause or to damage an opposing cause." Thus, brainwashing is a systematic, deliberate attempt to further one's cause by persuading people via spreading ideas and allegations.

There is little question in my mind that there has been a systematic and deliberate attempt to promote the anti-smoking cause by spreading what turns out to be disinformation about the opposition to smoking bans and the challenges to secondhand smoke science. It is my opinion that many tobacco control advocates are indoctrinated with these ideas and beliefs and that this indoctrination may result in the implantation of beliefs that run counter to an individual's pre-conceived or natural ideas and conceptions. In addition, an environment has been created in which one cannot challenge the ideas being presented because by definition, those who challenge the establishment are viewed as being traitors to the movement. Thus, not only is brainwashing occurring, but it is a self-perpetuating type of process which feeds itself by placing a nearly insurmountable barrier to anyone challenging it.

I was able to overcome my "brainwashing," but it took a lot of courage to do so, and a lot of risk to my career. I paid a heavy price for breaking out of the mold into which I had been cast. It shattered my career in tobacco control. But at least it didn't shatter me, and the person who I really am.

I am not about personal attacks on individuals. I am not about making undocumented allegations and claims about people that could damage their reputations unfairly if they end up being untrue. I am not about denigrating the character of other researchers based on the opinions which they may express about secondhand smoke. I am not about making undocumented accusations against groups which may oppose policies that I support.

This, unfortunately, is what the anti-smoking movement has become. So be it, but don't try to indoctrinate yet another generation of public health advocates with this propaganda.

Wednesday, November 25, 2009

Study that Reported a 27% Decline in Heart Attacks in Starkville Due to Smoking Ban Wasn't Actually a Study; Analysis Hasn't Yet Been Conducted

On November 10, I reported on a press release issued by Mississippi State University which claimed that a new study demonstrated that a local smoking ban in Starkville resulted in a 27% decline in heart attacks.

According to the press release: "A Mississippi State study released Monday [Nov. 9] shows a 27 percent decrease in heart attacks among Starkville residents since the city passed a smoking ban in 2006. Researchers associated with the university report also are recommending a statewide public ban on smoking. The study by Robert McMillen and Dr. Robert Collins shows fewer heart attacks being treated at the Oktibbeha County Hospital. It focused on Starkville residents in the three-year span after the ban became law, compared to three years prior."

The Starkville smoking ban went into effect in May 2006. The researchers found that the rate of heart attack admissions among Starkville residents at the Oktibbeha County Hospital decreased by 27% from the three -year period proceeding the ban (2003 through 2005) to the three-year period following the ban (2006 through 2008). They attribute this decline to the smoking ban.

The conclusions in the press release were widely disseminated through the media (example 1; example 2; example 3; example 4). Headlines boasted that: "Study Links Decline in Heart Attacks to Smoking Bans."

A summary of the study appeared on the internet, but the actual study itself did not (at least I could not find it).

One of the study authors was quoted in the Starkville Daily News as quantifying the precise effect of the smoking ban on reduced heart attacks: "We have saved $750,000." This calculation assumes that all of the 27% decline in heart attacks during the period 2006-2008 was attributable to the smoking ban.

The Rest of the Story

As it turns out, it appears that there was no study. These were simply preliminary data on hospital admissions in one community. There is a study ongoing in which acute myocardial infarction (heart attack) rates will be compared between communities with and without smoking bans, but those data have not yet been collected.

Jacob Grier over at Coffee, Cocktails, and Commentary has discovered, through a communication with one of the authors of the so-called study, that there is no study written up. There is only the 2-page summary, which explains why my attempt to locate the study on the internet was futile.

According to Grier, when he asked the "study" authors for a copy of the actual study, all he received was an email from one of the study authors which stated:

"The results that we released in our 2 page report are preliminary results from a larger study. The study examine[s] AMI admissions from several communities that have passed smoke-free ordinances, as well as communities that have not. The latter will serve as controls for the purpose of comparison. The hospital in Starkville was the first to provide us with AMI admission data. When we have received data from the other communities in our study we will prepare a manuscript that compares AMI admissions before and after the smoke-free laws were enacted in communities with and without smoke-free laws."

In other words, the study has not yet been conducted!

As the author admits, the study consists of the following methodology: compare trends in heart attack rates between communities with and without smoking bans. That is an appropriate methodology, as it will control for secular changes that are occurring in heart attack rates.

Well, if the study has not yet been conducted, then how can the "authors" issue a press release with the study's conclusion?

If ever there was an example of researchers coming to a pre-determined conclusion about their research hypothesis, this is it.

Anti-smoking researchers are apparently so eager to communicate favorable findings to the public that they can't even wait to conduct their studies any more. In this case, data from the intervention group was obtained and immediately released, before the data from the control communities could be examined for comparison purposes.

As Grier correctly points out, the 27% decline in heart attacks in Starkville doesn't mean anything in the absence of knowledge of what happened in communities without smoking bans. If there were also large declines in heart attacks in those localities, then the observed decline in Starkville was not attributable to the smoking ban.

Fortunately, the researchers appear to be aware that they cannot draw such a conclusion without having a comparison group. This is presumably why they are collecting data from a number of communities that did and did not implement smoking bans.

However, the researchers did draw such a causal conclusion and they disseminated it widely through a press release. Moreover, they attributed the entire 27% reduction in heart attacks to the smoking ban, and went as far as calculating the cost savings associated with the reduction in heart attacks, concluding that the smoking ban resulted in a $750,000 savings.

What exactly is the point of doing the study at this point? The conclusion has already been widely disseminated. If the study is done and the conclusion turns out to have been wrong, are the investigators going to frantically issue press releases urging newspapers to blast headlines on their front pages saying "Never Mind"?

It's too late. The conclusion has already been communicated to the public. Anti-smoking groups are already disseminated the results of this "study" themselves and touting it as evidence that smoking bans produce immediate reductions in heart attacks.

Although I am myself a strong anti-smoking advocate who supports smoking bans, I have to agree with Jacob Grier when he concludes that: "to go public with results now, before the data is even collected, is a corruption of science for the pursuit of political ends and unfortunately all too typical for today's anti-smoking movement."

There is a great deal of bias apparent in these smoking ban/heart attack studies. Perhaps that's why the objective data from all the large population-based analyses do not support the conclusions from the individual studies conducted in small communities. The Institute of Medicine committee wasn't even interested in examining the data from these population-based analyses.

The rest of the story is that the anti-smoking researchers down in Mississippi have already come to a pre-determined conclusion about the effects of smoking bans on heart attacks. The study itself is not needed. This is why it's apparently viewed as reasonable to disseminate the conclusions before the study has been conducted. This loss of scientific integrity is becoming all too common in the tobacco control movement these days.

Tuesday, November 24, 2009

Without Evidence, Anti-Smoking Advocates Should Not Question the Integrity of Private Citizens by Insinuating that They May Be Taking Tobacco Money

Yesterday, I reported that Tim Filler, who is a steering committee member of Smoke Free Indy, sent a communication to the national smoke-free advocate list-serve maintained by Americans for Nonsmokers Rights (ANR) in which he insinuated that Michael McFadden - an opponent of smoking bans - may be taking money from tobacco companies. The intent of the communication appeared to be to suggest to advocates facing McFadden in "battle" that they discredit McFadden by linking him in some way to the tobacco industry, in hopes that policy makers would view him as a tobacco mole rather than a private citizen who is sincerely representing his own personal views.

In this commentary, I opine that it is inappropriate for anti-smoking groups or advocates to personally attack the integrity of private citizens like McFadden by insinuating that they may be affiliated with Big Tobacco unless they have documented evidence to support their suggestion.

The Rest of the Story

To understand my views, perhaps it is helpful to start by explaining the way in which I see tobacco control. I see tobacco control as a part of public health. The first class I ever took on tobacco (taught by one of my heroes - Dr. Tom Novotny - at UC Berkeley) was entitled: "The Public Health Practice of Tobacco Control." I sincerely believe that tobacco control is supposed to be a part of public health.

As such, I think that anti-smoking advocates like myself need to view ourselves first and foremost as public health advocates. By definition, this means that we are working to improve the health of the public. The public is not restricted to smokers or nonsmokers. It is not restricted to people who support smoking bans or those who oppose such bans. The public includes everyone. We are charged with serving everyone in the public, not just people who happen to agree or disagree with certain positions that we have adopted.

Therefore, our relationship with private citizens is one that needs to be treated carefully. We should not be in the business of attacking private citizens and maligning their character and integrity simply because they hold an opposing opinion about a tobacco control policy.

We are, however, fighting the tobacco industry and it is appropriate to educate policy makers about the financial connections between smoking ban opponents and the tobacco companies when such connections exist. The consideration of the scientific issues by policy makers takes on quite a different picture when they know that a particular argument is being offered by someone who is being paid by the tobacco industry to offer that opinion. In essence, that individual represents an arm of the tobacco industry and they cannot be viewed as speaking solely on their own behalf. So if there is documented evidence that an individual is a tobacco mole, then it is fine to point that out.

However, if we do not have evidence that an individual is funded by Big Tobacco, then I believe it is wrong to throw out the suggestion that the person may be a tobacco mole just because we want to discredit them because they oppose our position.

The integrity of practicing public health includes having a respect for individuals. This respect should not disappear simply because an individual opposes our position. Where the tobacco industry is extending itself into the debate by paying individuals to make their arguments for them, it is a different story. But without evidence that a person is such a tobacco lackey, we really need to show respect and courtesy to all members of the general public. And that includes not suggesting that they may be funded by Big Tobacco, which questions their character and their integrity, unless we have evidence to document that suggestion.

Monday, November 23, 2009

On National Tobacco List-Serve, Anti-Smoking Group Insinuates that Michael McFadden is a Tobacco Lackey, But Offers No Evidence or Documentation

In a communication sent out to many smoke-free advocates on a national tobacco control list-serve, Smoke Free Indy (the coalition that is pushing for a workplace smoking ban in Indianapolis) insinuates that Michael McFadden (an activist with the Pennsylvania Smokers Action Network and regular commenter at The Rest of the Story) has received tobacco industry funding for his efforts to fight smoking bans and that he therefore is essentially working for the tobacco companies -- a tobacco industry lackey so to speak.

According to the communication:

"Some of you may have heard of Michael McFadden, who is a long-time opponent of tobacco prevention policies from Pennsylvania who also vociferously and continually says he “has no links in any way to the tobacco industry.” McFadden posts on newspaper message boards and in blog comments across the country with messages critical of tobacco prevention policies, such as smokefree workplace laws, and spreading the misinformation we see from tobacco industry allies in states and cities across the country. McFadden has taken issue with any suggestion that he might have any links in any way to the tobacco industry, even to the point of posting the following on his website about something he wrote in 2001: "The editorial by activist Michael McFadden below was selected by the Americans For Nonsmokers Rights Foundation as being worthy of inclusion on its ‘Tobacco Industry Tracking Database.’ Mr. McFadden has no links in any way to the tobacco industry, but by including him, and others who dare to express similar opinions, on their database they perform a de-facto smear against his integrity.”

"So, with all the umbrage being taken by McFadden to the suggestion that he might be a tobacco industry ally or be getting assistance from the tobacco industry in his efforts, it would be surprising to find McFadden writing to a tobacco company to ask for help to get the resources to do the kind of undermining of tobacco prevention policies that he attempts to do, right? Well, be surprised then. Or not. According to internal tobacco industry documents, in March of 2000, Michael McFadden wrote to RJ Reynolds Tobacco Company specifically for the purpose of soliciting “resources/help” to fight local smokefree ordinances. He specifically asks for information regarding research that would help “the fight against antismokers” [that’s what he called supporters of smokefree policies]. McFadden also asks for the tobacco company’s help getting in contact with other local opponents of smokefree policies to facilitate communication between these smokefree opponents."

The Rest of the Story

I don't quite understand the values that would lead an anti-smoking group to engage in this personal attack against an individual who has not received funding from the tobacco industry. Moreover, the communication admits that Americans for Nonsmokers Rights, through its Tobacco Industry Tracking Database, is suggesting that McFadden is "getting assistance from the tobacco industry," something which is demonstrably false. Essentially, this comes very close to, if not crossing the line into being a defamatory statement.

The fact that McFadden once asked R.J. Reynolds for support is immaterial to the suggestion that he is getting assistance from the industry. RJR rejected his request. The fact that he asked for money does not mean that he received money and thus is affiliated with the industry. The American Legacy Foundation also asked R.J. Reynolds for money; we would hardly argue that Legacy is being financially assisted by RJ Reynolds (actually, all of Legacy's money comes from the industry, if the truth be told).

Moreover, the document to which Smoke Free Indy is referring is not a request for money. It is simply a request for research information. If writing to the tobacco companies for information makes one a tobacco industry ally, then I guess I must be a strong ally. Because I've written to the tobacco companies for information far more than Michael McFadden. I regularly corresponded with tobacco companies to obtain various types of information, most typically the industry's Tax Burden on Tobacco reports which document state-specific cigarette consumption, a very useful piece of information in my research.

I suggest that anti-smoking groups and advocates refrain from making potentially defamatory statements (attacks) against individuals who are in fact private citizens in the absence of documentation that they have received tobacco funding. If they do not have the evidence, then it is defamation of character to suggest that the individual is a tobacco mole. And they should not be engaging in potentially defamatory behavior.

Remember, one of the things that supposedly separates the anti-smoking groups from the tobacco industry is that they don't engage in personal attacks against private citizens, even if they disagree with anti-smoking positions. If ANR or Smoke Free Indy have documentation that McFadden is a tobacco industry mole then fine, they can publicize the fact that he is funded by the industry. But in the absence of such documentation, these groups have no business insinuating that he is anything other than a private citizen. These groups are in no position to insinuate that he is receiving or has received funding from the tobacco industry. That would be defamation of character, and it is not something these groups should have any part of as public health organizations.

This tactic of attacking anyone who opposes anti-smoking policies by accusing them of taking tobacco money and being affiliated with the industry is an all-too-common one. It's fine if these groups have documentation to back up their accusations, but if not, then it is inappropriate for them to level the attack.

If anything, the document to which Smoke Free Indy refers demonstrates that McFadden is not funded by Big Tobacco. If the companies had written back to him and cut him a check, we would have expected to see some positive response to his inquiry. The absence of such a response should have indicated to ANR (and to Smoke Free Indy) that the request was ignored, and that McFadden remained as just a private citizen working on his own to support smokers' rights. We may disagree with his opposition to smoking bans, but we have no right to falsely accuse him of taking tobacco money.

Incidentally, Michael's placement in the Tobacco Industry Tracking Database puts him in good company. I appear in the database as well, due to my having opposed a number of extreme tobacco control policies. You see, while I support bans on smoking in all workplaces, including bars and casinos, and although I testified against the industry seven times, including a landmark case that resulted in a $145 billion verdict against the companies, that isn't quite enough. I didn't buy the entire agenda; thus, I am a tobacco industry ally who must be tracked in the database.

Michael - welcome to the club.

ADDENDUM -- November 23, 12:52 p.m.: Tim Filler, the author of the communication, informed me that his intent was for the communication to represent his own personal attack on McFadden, rather than an attack by Smoke Free Indy. I tend to think that since Filler is on the Steering Committee for the group, his statements reflect on the group as a whole, but nevertheless, he would like his statements to be construed as coming from him as an individual. I don't think it matters. The point is that this is what I would consider to be unethical behavior, as it is attacking a private citizen and making a false insinuation that he is associated with the tobacco industry.

Friday, November 20, 2009

President Obama No Longer Eligible for Employment at Susquehanna Health Systems

According to a new policy that goes into effect on January 1, 2010, smokers, smokeless tobacco users, and occasional customers of a hookah bar need not apply for employment with Susquehanna Health Systems, a health care company in the Williamsport, Pennsylvania area.

According to an article in the Williamsport Sun-Gazette: "To further expand its smoke-free environment, Susquehanna Health has adopted a new policy that prohibits the hiring of smokers and other tobacco users. Health system officials and legal experts noted the policy, to take effect Jan. 1, is perfectly legal under state law. It affects every position within the health system."In Pennsylvania, tobacco users are not a protected class under the law," explained health system spokeswoman Tracie Witter. "So prohibiting the hiring of tobacco users is not discrimination."

"Everyone who seeks health system employment must apply online, Witter noted. At that time, they are made aware of the policy. "We have been testing for drugs. We are adding a nicotine component," she said." ...

"We are aware that we may lose some top candidates as a result of this policy," Witter said. "It's really a demonstration of our commitment to promote healthy behaviors."

"The local chapter of the American Cancer Society endorsed the new policy. Announcement of the health system's policy coincides with today's annual American Cancer Society "Great American Smokeout," which embraces smoke-free lifestyles. "As a regional health system and a leader in both medical education and community health improvement, we have an important obligation to practice the healthy behaviors we promote to the general public and to our own employees," said Susquehanna President and CEO Steven P. Johnson."

The Rest of the Story

Let's first get one thing straight. The Susquehanna Health systems spokesperson is dead wrong when she states that: "tobacco users are not a protected class under the law, so prohibiting the hiring of tobacco users is not discrimination."

It's not illegal discrimination, but it sure as heck is discrimination.

The spokesperson herself essentially admits this later on in the article when she acknowledges that she is "aware that we may lose some top candidates as a result of this policy." She is thus stating that the policy represents a systematic exclusion of a group of people from employment upon a criterion that is not directly related to the qualifications for employment. That is, in fact, the definition of employment discrimination.

At least the lawyer gets it right when he defends the legality of the policy on the grounds that while it is discrimination, employment discrimination against smokers is legal: "It is not illegal to discriminate against a smoker. The reason for that is an institution may discriminate against smokers."

That reasoning seems a little circular, but the point is that it is well established that this policy is precisely employment discrimination.

The policy affects every position in the health system, so if President Obama were to apply for the position of Chief Executive Officer of the Susquehanna Health System (please refrain from jokes that with the public option, that's what he is actually doing), he would not be eligible and in fact, his application would not even be considered.

The current CEO of the health system defended the policy, stating that he has an obligation to ensure that the employees of the company practice the healthy behaviors that they promote.

OK, then, is the CEO also going to refuse to hire obese people, since obesity is arguably the number two public health problem (some would say number one) behind smoking and no one would disagree that the Susquehanna Health System should be discouraging obesity? Is the CEO also refusing to hire people who eat crappy diets or who fail to get adequate exercise? Of course not. This is not a policy which comes from a sincere desire to make sure that employees are adhering to healthy behavior; it is a policy which comes from a desire to punish smokers by denying them employment.

If this were a sincere effort to make sure that employees' behaviors are not inconsistent with the advice they are giving to patients, then applicants whose nutrition is poor, who eat too many calories, or who don't get enough exercise would also have to be excluded from employment.

It is disappointing, but not surprising, to see that the American Cancer Society is supporting this policy. Since when did supporting and promoting employment discrimination become a public health objective? It is one thing to embrace healthy lifestyles. It is quite another to systematically punish and discriminate against people who do not adhere to such a healthy lifestyle in one way or another.

Thursday, November 19, 2009

Physicians Group Supports Electronic Cigarettes for Smoking Cessation and Challenges Opponents to Justify their Condemnation of the Product

The American Association of Public Health Physicians (AAPHP) has challenged opponents of electronic cigarettes to justify their condemnation of this product given that the FDA's study of these devices found that they contain only miniscule levels of carcinogens, compared to the high levels present in traditional cigarettes.

According to a press release issued earlier this week: "In July of this year, the Food and Drug Administration released a study that condemned electronic cigarettes as an unsafe alternative for smokers, but not all physicians are convinced that the study was accurate or even completely transparent to the tax payers that fund them. "We urge FDA to make public the laboratory data behind the July 22 condemnation of electronic cigarettes, along with comparable data on pharmaceutical nicotine products and conventional cigarettes. Then, on the basis of these data, either fully justify or retract the July 22 condemnation of electronic cigarettes," says Joel L. Nitzkin, Chair of the American Association of Public Health Physicians Tobacco Control Task Force in a letter to the FDA."

"The letter specifically targets the new tobacco legislation that passed through Congress this summer which gives the FDA power to regulate tobacco products in the United States and notes that the success rate of current smokers who attempt to quit by using pharmaceutical aids is as low as 5%. Making smokers more aware of less harmful alternatives, snus and e-cigarettes included, could significantly reduce the amount of smokers who die due to tobacco-related illnesses."

"The message the AAPHP is sending to the FDA is a clear one and that is that electronic cigarettes are not the wildly dangerous alternatives that they have been portrayed as in news publications and on television, but perhaps one of the best products available for current smokers to switch to. Only time will tell if the FDA will retract their July study in favor of a more complete one or if smokers will continue to be limited to only products offered by big tobacco or big pharma with no explanation."

The Rest of the Story

I applaud the AAPHP for taking this strong and science-based stand, which contrasts with the ideology-driven positions that have been taken by a number of anti-smoking groups that have called for the removal of electronic cigarettes from the market, despite clear evidence of their utility in helping smokers quit and their relative safety compared to cigarettes. As I have mentioned previously, every one of these anti-smoking groups, it turns out, has received funding from pharmaceutical companies and thus have a conflict of interest -- none have disclosed this conflict.

In contrast, the AAPHP position is based not on pure ideology, but on the science, which clearly indicates that electronic cigarettes are a far safer alternative to regular cigarettes and that they appear to be effective in helping highly resistant smokers to quit successfully.

The anti-smoking groups' condemnation of electronic cigarettes is based largely on the FDA's laboratory findings, which actually indicated that e-cigarettes are much safer than regular ones because they contain miniscule levels of carcinogens, while cigarettes contain very high levels of a large number of carcinogens. The level of tobacco-specific nitrosamines is reduced by a factor of up to 1400, indicating a substantial degree of relative safety compared to smoking.

Taking electronic cigarettes off the market is the worst single thing we could do to harm the public's health. Hundreds of thousands of vapers would be forced to return to cigarette smoking and they would therefore suffer a deterioration in their health. How is that a good thing for the public's health? So far, none of the anti-smoking groups have answered this question.

Another thing that none of the anti-smoking groups have done is to disclose their conflicts of interest with Big Pharma, a failure which I believe is unethical. Financial interests in pharmaceutical companies which rely upon smoking cessation drugs for substantial profits are quite relevant to policy regarding e-cigarettes because these products represent a huge threat to the financial well-being of these companies. E-cigarettes represent a huge potential threat to Big Pharma, because they appear to be much more effective than pharmaceutical smoking cessation products.

A final thing that none of the anti-smoking groups has done is to meet my challenge of naming even one specific hazard that e-cigarettes likely pose to vapers. While the damage that would be done to the health of huge numbers of vapers if e-cigs are taken off the market is definite, the health damage that is supposedly being done to vapers from using e-cigarettes is purely speculative and completely hypothetical.

The anti-smoking groups don't appear to want to address the specific scientific issues, probably because they have little ground upon which to stand. Instead, they insist on diverting the issue to talk about anti-freeze, children shelling out $90 to buy e-cigarette kits, and dangerous carcinogens present in e-cigarette cartridges (without mentioning that the levels of these carcinogens are trace levels, and orders of magnitude lower than in cigarettes, confirming their relative safety).

When groups make national policy recommendations without a willingness to actually address the science, you know we've got a problem. Never is that more apparent than with the issue of electronic cigarettes.

Wednesday, November 18, 2009

San Francisco to Consider Legislation to Limit to 385 the Number of Stores that Can Sell Tobacco

According to an article in the San Francisco Examiner, San Francisco will soon consider legislation that would limit to 385 the number of stores in the city allowed to sell tobacco products. The proposal is intended to protect the public's health by limiting tobacco exposure to children.

According to the article: "An initial proposal imposes a cap of 35 permits for each of the 11 supervisor districts — 385 total in The City. That is more than a two-thirds reduction from the 1,097 stores currently selling tobacco products citywide. The proposal would not take away permits from businesses, but it would reduce them through attrition until there are no more than 35 per district. Also, owners would not be able to transfer the permits when they sell their stores, said Janet Clyde, a commissioner in the Office of Small Business. The proposal might limit options for smokers, but it would also limit tobacco exposure to children, said Matt Rosen, senior director of community programs for the Youth Leadership Institute. The institute wrote the legislation and is receiving guidance from Supervisor Ross Mirkarimi and the Department of Public Health. The legislation is still being vetted and has not been endorsed by a supervisor. “[Children] can see advertising,” Rosen said. “They can see stores that are visibly selling tobacco and other kinds of products that aren’t very good for them.” The Department of Health says limiting permits would be an extension of its 'commitment to public health.'"

The Rest of the Story

This is the latest in a series of proposals coming out of San Francisco that make it appear policy makers are truly concerned about the devastating effects of tobacco, but which actually accomplish nothing.

The first in the series was the city's ban on tobacco sales at pharmacies......except, of course, pharmacies located in box stores (like Costco) and supermarkets. What sense does it make to prevent cigarettes from being sold in your corner pharmacies, but allow them to be sold in big box stores and supermarkets? Clearly, this policy is not going to curtail the sale of cigarettes. Instead, it will merely re-distribute the income from cigarette sales from small, local businesses to large national chains. Hardly a measure that has anything to do with public health protection. But policy makers and anti-smoking groups are touting this policy to make themselves look (and feel) good. Nothing but window dressing.

It's also terribly inconsistent and hypocritical. If cigarettes are so bad that they should not be sold in corner pharmacies, then why aren't cigarettes so bad that they shouldn't be sold at Costco or in supermarkets? Obviously, this measure isn't about public health protection, it's about being political cowards and trying to achieve political gain without having to actually take a principled stand.

Now we have a similar proposal: cigarettes are so bad and their sale exposes children and promotes tobacco use. So what are we going to do about it? Get rid of the sale of cigarettes in San Francisco stores? No, of course not. Instead, we're going to set an arbitrary limit of 385 stores that can sell tobacco.

What the crafters of this proposal are basically saying is: "It's only a problem if more than 385 stores in San Francisco sell cigarettes. As long as we limit the number of stores that sell cigarettes to 385 or less, then everything is fine. There's no need to protect the kids that live around those 385 stores from the sale of cigarettes, just the kids who would live around the 386th store."

This is absurdity. It makes no sense. If there is a public health justification for banning the sale of tobacco products in San Francisco, then ban it. If not, then don't. But to pretend that arbitrarily setting the number of tobacco outlets at 385 is some sort of public health measure is insane. It does nothing to prevent the sale of cigarettes, which will certainly remain readily available with 385 outlets in the city.

Do you mean to tell me that if there 386 stores that sell cigarettes in San Francisco, there is a major public health problem, but if we get that number down to 384, we have addressed that problem?

I just don't understand this type of reasoning. What are these folks thinking?

The rest of the story is that limiting the number of stores in San Francisco that sell cigarettes to 385 is not going to have any impact on smoking and the policy therefore does not protect the public's health. As such, it represents an unjustified intrusion on private business and is therefore an arbitrary and inappropriate public policy. If advocates want to work in their communities and try to limit the sale of tobacco, that is fine. It serves an educational purpose and allows the community to mobilize around the issue. But a legislated mandate on the number of stores of a given type is not justified unless there is evidence that it would serve a substantial government interest, like protecting the public's health. Cutting the number of tobacco-selling stores from 1097 to 385 is not going to have any impact on smoking in San Francisco. Cigarettes will remain readily accessible.

An unfortunate aspect to this story is that this senseless proposal is being spearheaded by a youth leadership institute that is being funded, in part, by taxpayer money (the San Francisco Department of Health) and in part by the American Legacy Foundation, which is supposed to be "building a world where young people can reject tobacco," not "building a world in which young people are subjected to no more than 35 tobacco outlets per city district."

I don't understand what they are teaching these youths. From what I can see, it's something like: "If you see a severe public health problem, pass a law that puts arbitrary limits on the problem and interferes with business in a way that won't actually have any impact on the problem, but will make it look like you are doing something."

They're not preparing these youths to be leaders. What they're preparing them to be is the politicians and, I guess, anti-smoking practitioners of the future.

Tuesday, November 17, 2009

Birmingham East and North Primary Care Trust Forced to Remove Distasteful Anti-Smoking Ad

The Birmingham East and North NHS Trust was forced to remove an anti-smoking ad after several groups and individuals - some of whom are Rest of the Story readers - filed a compliant against the advertisement, arguing that it was not only offensive to smokers but that it promoted abuse of smokers.

The commercial depicts a smoker being brutally beaten by an invisible assailant. He is bleeding profusely and viciously abused. The message of the commercial is supposed to be that if you smoke, you are giving your body a physical beating.

According to its press release: "Freedom2Choose lodged a complaint against the material and upon consideration, the NHS Trust has agreed to remove it from all venues within the next two weeks. Phil Johnson, pub and club liaison officer of Freedom2Choose states, “I am thrilled about this decision as I have had several pub and club clientele contacting me and informing me that they had been abused as result of this material.” Freedom2Choose will actively campaign against the abuse and hatred that individuals continue to suffer as a result of modern anti-smoking techniques."

The Rest of the Story

While it is commendable that the NHS Trust responded positively and definitively by removing the ad, it should never have seen the light of day in the first place.

What would possess a public health agency to put out an advertisement that graphically depicts physical violence upon a smoker?

Can you imagine a public health group putting out the same ad about obesity? I doubt it. I think if a group was previewing a commercial which depicted an obese person being physically beaten, they would immediately realize that the ad was distasteful and that it sends an unintended message. That the same ad - except with a smoker instead of an obese person - apparently did not evoke the same sense in the NHS Trust suggests that abuse of smokers has become normalized to the point that some anti-smoking groups are subconsciously promoting violence against smokers.

When I see a story like this one, it makes me realize just how stigmatized smokers must feel. It explains much of the anger that many smokers have against the anti-smoking groups. I share that anger. And while I differ with groups like Freedom2Choose on the issue of workplace smoking bans, I support their efforts in campaigning against the abuse and hatred that many smokers continue to suffer as a result of increasingly extremist anti-smoking techniques.

Monday, November 16, 2009

Beware the Adverse Effects of Cigarette Taxes on Kids: Study Suggests Anti-Smoking Groups Should Re-Think Their Knee-Jerk Support for Tax Increases

A study published last year in the Archives of Pediatrics and Adolescent Medicine reports that the costs associated with smoking lead to food insecurity among children living in lower-income households with one or more smokers present (see: Cutler-Triggs C, Fryer GE, Miyoshi TJ, Weitzman M. Increased rates and severity of child and adult food insecurity in households with adult smokers. Archives of Pediatrics and Adolescent Medicine 2008; 162:1056-1062).

According to the study: "Food insecurity was more common and severe in children and adults in households with smokers. ... At multivariate analyses, smoking was independently associated with food insecurity and severe food insecurity in children (adjusted odds ratio, 2.0; 95% confidence interval, 1.5-2.7, and adjusted odds ratio, 3.1; 95% confidence interval, 1.4-6.9, respectively) and adults (adjusted odds ratio, 2.2; 95% confidence interval, 1.6-3.0, and adjusted odds ratio, 2.3; 95% confidence interval, 1.4-3.7, respectively). Conclusions: Living with adult smokers is an independent risk factor for adult and child food insecurity, associated with an approximate doubling of its rate and tripling of the rate of severe food insecurity."

The paper posits that the major reason for this finding is the high expense associated with cigarettes and the fact that spending on cigarettes makes it less possible to spend an adequate amount on food: "In the United States in 2005, an estimated $82 billion was spent to purchase cigarettes, with the average price of a pack of cigarettes being more than $4.38. Families with low income, in general, are more likely to experience food insecurity, spend less on food, and spend a larger percentage of available money on tobacco compared with more affluent families. In developing countries such as Bangladesh, China, and Bulgaria, tobacco expenditures crowd out expenditures for food, health care, and education. While the available data do not enable us to examine whether this is the mechanism behind the findings presented herein, it seems plausible."

The article goes on to explain the consequences of food insecurity for children: "Children who experience food insecurity are at higher risk for cognitive and psychosocial disability, poorer quality of life, and higher rates of suicidal ideation. They have lower scores on standardized academic tests, miss more days of school, and have more difficulty getting along with others. They also have poorer overall health, higher lead levels, increased rates of iron deficiency, and more emergency department use and hospitalizations."

The Rest of the Story

According to the Campaign for Tobacco-Free Kids, which has never met a cigarette tax increase proposal that it hasn't liked, these policy measures are a win, win, win solution that benefits everyone involved. The Campaign argues: "Increasing cigarette taxes is a WIN, WIN, WIN solution for governments — a health win that reduces smoking and saves lives; a financial win that raises revenue and reduces health care costs; and a political win that is popular with the public."

The present research suggests that the Campaign's reasoning is flawed, and that there may be substantial LOSERS from cigarette tax increases: namely, the children and families of smokers who do not quit smoking after a tax increase, and thus who spend more money on cigarettes and less on food, plunging their kids and families into more severe food insecurity with its associated adverse effects.

The Campaign's perspective has been too simplistic. It just isn't true that everyone wins with a cigarette tax increase. While those who cut down or quit smoking do benefit from the tax policy and will see health benefits, for those who do not quit or cut down, especially those of lower income, the policy will likely have significant adverse effects due to its exacerbation of existing food insecurity.

In an accompanying commentary, Dr. Frank Chaloupka notes: "Significant increases in cigarette and other tobacco product excise taxes are widely considered the single most effective policy option for reducing tobacco use. The findings of Cutler-Triggs and colleagues, however, might raise concerns about higher taxes worsening food insecurity in low-income smoking households as these households divert more of their incomes from spending on food to spending on cigarettes in response to the resulting higher cigarette prices."

It is time, I believe, that anti-smoking groups acknowledge these possibly adverse consequences of cigarette tax increases.

The way to ameliorate this problem is to allocate revenues from the tax increase specifically to smoking-related causes, including treatment for smoking-related diseases, and to earmark a substantial proportion of the revenues to benefit low income communities. With these features, a cigarette tax increase can still be an equitable policy.

But without allocating revenues for these specific purposes, cigarette tax increases are no longer equitable and to be sure, there are losers as well as winners. With the current state budget crises, many states are looking to cigarette tax increases to raise revenues and balance their budgets. Most anti-smoking groups are supporting these tax increases, even though the money raised will not be allocated to smoking-related programs and in many cases, will not be earmarked for low-income communities. These policies will have big losers, and for that reason, I believe anti-smoking groups must re-assess their knee-jerk support for such policies.

In an article regarding this research that was published last year on the Health News web site, Action on Smoking and Health offered its own suggestions for how to deal with the above problems.

Its first solution? Treat smoking around children as a form of child abuse and require doctors to report parents who smoke at home in the presence of their children.

Its second solution? Promote malpractice lawsuits against physicians who do not provide effective smoking cessation treatment (i.e., pharmaceuticals) for their smoking patients.

I have previously criticized each of these policy proposals:

Click here for my criticism of ASH's suggestion that smoking around children should be treated as a form of child abuse.

Click here for my criticism of ASH's suggestion that doctors who fail to prescribe pharmaceuticals for their smoking patients should be prosecuted for malpractice.

One final point about the Health News article: It makes the ridiculous assertion that: "exposure to second-hand smoke can cause nicotine withdrawal symptoms in non-smoking family members including sleep disturbances, anxiety, depression, and concentration difficulties." The levels of exposure to nicotine associated with secondhand smoke exposure are extremely low and I am not aware of any scientific evidence suggesting that these low levels are enough to produce nicotine dependence in nonsmokers.

It's not clear where the writer got this notion, but it certainly wouldn't surprise me if she got it from ASH or another anti-smoking group.

The rest of the story is that cigarette tax increases are not necessarily a win, win, win proposition. If not implemented properly and with attention to principles of equity, there can be substantial losers. If those losers turn out to be children who are forced into more severe food insecurity because of these policies, then anti-smoking groups stand responsible for those adverse consequences. Thus, these groups must end their uniform and thoughtless rhetoric and address these concerns directly. The days of knee-jerk support for any and all proposals to increase cigarette taxes - to fund any program under the sun - must end.

(Thanks to Ladyraj and Harry for the tips).

Thursday, November 12, 2009

Federal Court Denies Request for Injunction Against Modified Risk Provisions of FDA Tobacco Law, But Suggests These Provisions are Unconstitutional

Last week, a U.S. District Court in Kentucky denied the tobacco companies' request for an injunction against the modified risk tobacco product (MRTP) provisions of the FDA tobacco law. This does not throw out the tobacco companies' (i.e., the plaintiffs') complaint about these provisions, but it does mean that these provisions will remain in force pending the outcome of the case.

While anti-smoking groups painted this as a huge victory against Big Tobacco, a close reading of the actual court decision reveals that the Court actually indicates the high probability that the modified risk provisions of the law are unconstitutional because they represent an unconstitutional prior restraint on tobacco company speech, by virtue of the law's failure to put a time limit on the FDA's review of requests to market modified risk products.

As the United States District Court decision explains:

"the Plaintiffs argue that the MRTP provision is an unconstitutional prior restraint. To a limited extent, the Court agrees. By requiring applicants to submit “proposed advertising and labeling” and “sample product labels and labelling” with their applications to market modified risk tobacco products, 21 U.S.C. § 387k(d)(1), (5), the MRTP provision operates as a prior restraint by holding that speech captive and effectively “compel[ling] [Plaintiffs’] silence” until the FDA completes its review." ...

"Under the MRTP provision, tobacco manufacturers must submit not only the would-be modified risk product but any “proposed advertising and labeling” and “sample product labels and labelling” to the FDA for review. 21 U.S.C. § 387k(d)(1), (5). Thus, any such proposed speech about a modified risk tobacco product is effectively silenced until the FDA issues a decision. Because this is so, the reasonable time limit safeguard is necessary to satisfy the “principle that the freedoms of expression must be ringed about with adequate bulwarks.” Bantam Books, Inc. v. Sullivan, 372 U.S. 58, 66 (1963). At this point, such a time limit is missing. While Congress has charged the FDA with “establish[ing] a reasonable timetable for the Secretary to review an application under this section,” it has given the FDA two years to come up with one. 21 U.S.C. § 387k(k)(F). The Court thinks it likely that this two-year delay is unconstitutional given that certain portions of the MRTP provision have been in effect since June 22, 2009."

The Rest of the Story

The District Court clearly believes that the modified risk tobacco products provision of the FDA tobacco law is unconstitutional because it represents an impermissible prior restraint on tobacco company speech regarding these products. It is an impermissible prior restraint because there is no time limit to safeguard against an undue interference with the freedom of speech.

I should emphasize that this is one of the challenged provisions of the law that I thought was least likely to succeed. The provisions which I think are most likely to be found unconstitutional are the advertising restrictions, particularly the ban on cigarette advertising within 1000 feet of schools, and the restriction on truthful speech of companies regarding the fact that the FDA regulates and approves tobacco products and that cigarette companies are in compliance with strict FDA standards.

Now it appears that there is a chance that this 3rd provision of the law may also be found unconstitutional, at least as to the absence of a time limit on the FDA's consideration of modified risk tobacco product applications.

Either way, it is clear that the anti-smoking groups are deceiving themselves by thinking that the FDA law is not without constitutional problems. And they are deceiving their constituents and the public by asserting that the full range of advertising and speech restrictions in the law are going to see the light of day.

Wednesday, November 11, 2009

Hertfordshire Man Denied Surgery to Repair Broken Arm Because He Smokes

According to an article in the Daily Mail, a Hertfordshire man with a severe disability due to a badly fractured arm has been denied surgery to repair the arm because he smokes.

The man is a plumber who is unable to work due to the injury, which he suffered 10 months ago after falling down the stairs. He was treated immediately with a plaster cast but the repair was unsuccessful because the bones were too far apart. It was determined that he needs an operation to insert a metal plate to properly repair his broken humerus.

An operation was scheduled in May 2009 to perform the appropriate repair; however, the surgery was canceled because the patient failed to follow the surgeons' advice to quit smoking.

Nick Carver, the chief executive of the East and North Hertfordshire NHS Trust, stated: "In canceling Mr Eeles' two operation dates, our surgeons were acting on clinical grounds only. If they are guilty of anything, then it is of having the best clinical interests of their patients at heart."

The Rest of the Story

This is disgusting. There are no valid clinical grounds to deny a patient surgery to repair a severely broken bone on the basis of his being a smoker. All this amounts to is the surgeons and health trust punishing this poor man for failing to follow their advice. But you don't punish someone by denying them a necessary surgery. If we punished all patients who fail to heed their doctor's advice in this way, we would perform almost no surgeries.

While I'm not familiar with clinical treatment in Great Britain, I am quite familiar with surgery for broken bones in the United States, and I have never seen a patient refused surgery to repair a severely broken bone because he or she smokes. In fact, to delay the surgery for that reason would likely put the surgeon at risk for a malpractice suit, because the longer you wait to repair the broken bones, the more damage that is done and the more difficult it becomes to do the repair successfully.

In my view, this represents medical malpractice. How the surgeons could possibly argue that they are acting in the best clinical interests of this patient is beyond me. The very fact that they are making such a judgment for the patient is extremely scary. Physicians are supposed to be in the business of treating injuries, not lecturing their patients about unrelated health behaviors and then punishing those patients by denying them the clinically indicated repair.

(Thanks to GreatScot for the tip.)

Tuesday, November 10, 2009

More Science by Press Release on Smoking Bans and Heart Attacks; Mississippi Study Conclusions are Based on Shoddy Science with No Comparison Group

Failure to Analyze Pre-Existing Trends in Heart Attacks Negates Conclusions of Study

A press release issued yesterday by Mississippi State University claims that a new study has demonstrated that a local smoking ban in Starkville resulted in a 27% decline in heart attacks.

According to the press release: "A Mississippi State study released Monday [Nov. 9] shows a 27 percent decrease in heart attacks among Starkville residents since the city passed a smoking ban in 2006. Researchers associated with the university report also are recommending a statewide public ban on smoking. The study by Robert McMillen and Dr. Robert Collins shows fewer heart attacks being treated at the Oktibbeha County Hospital. It focused on Starkville residents in the three-year span after the ban became law, compared to three years prior."

The Starkville smoking ban went into effect in May 2006. The researchers found that the rate of heart attack admissions among Starkville residents at the Oktibbeha County Hospital decreased by 27% from the three -year period proceeding the ban (2003 through 2005) to the three-year period following the ban (2006 through 2008). They attribute this decline to the smoking ban.

The study contains no comparison group, nor was there any assessment of baseline trends in heart attacks prior to the ban to determine whether the observed decline was occurring anyway, even without the smoking ban. Nevertheless, the study boldly concludes that this research "clearly demonstrates" that the smoking ban was what caused the 27% decline in heart attacks in Starkville.

The study was apparently not peer reviewed nor published, nor does it appear to be available to the public for scrutiny. Nevertheless, the conclusions have been widely disseminated through the media (example 1; example 2; example 3; example 4). Headlines boasted that: "Study Links Decline in Heart Attacks to Smoking Bans."

A summary of the study appears on the internet, but the actual study itself does not (at least I could not find it). According to the study summary: "The scientists compared the standardized number of heart attacks for three years prior to the smoke-free law and the three years following the enactment of the smoke-free law, and found that the number of heart attacks decreased substantially. Although these results are preliminary and the study will not be completed until several other Mississippi communities are examined, this finding highlights the immediate impact on health that smoke-free laws in Mississippi can have."

One of the study authors is quoted in the Starkville Daily News as quantifying the precise effect of the smoking ban on reduced heart attacks: "We have saved $750,000." This calculation assumes that all of the 27% decline in heart attacks during the period 2006-2008 was attributable to the smoking ban.

The Rest of the Story

The problem with the study, and the reason why I call it shoddy science, is that it fails to investigate whether or not the observed decline in heart attacks in Starkville was attributable to the smoking ban, or whether the decline was part of an already existing pattern of secular decline in heart attacks occurring throughout Mississippi that was happening anyway, and would have continued even in the absence of the smoking ban.

Just because you observe a decline in a particular phenomenon from before to after a given year does not mean that something which happened during that year is responsible for that decline. For example, there was an 11.3% decline in divorces in Mississippi from 2003 to 2008. Can I conclude that it was the Rebels upset victory over the Florida Gators in 2003 that led to this substantial decline in divorces?

Of course not. What is first necessary is to examine whether the observed decline differs from what was happening anyway. In other words, you have to go back in time and determine the baseline or pre-existing trends in the number of divorces. In Mississippi, from 2000 to 2003, the number of divorces declined by 6.0%. If you plot the number of divorces out over a long period of time, say from 2000 through 2008, you'll see that there has been a relatively steady decline over the entire study period, and there is no reason to believe that any particular event in 2003 had any effect on this trend.

Now, back to the study. The study compared the change in heart attacks in Starkville from 2003-2005 to 2006-2008 and found a 27% decline. What we need to know is: what was the decline in heart attacks during the previous period? In other words, what was the decline in heart attacks in Starkville from 2000-2002 to 2003-2005? Without that information, we cannot possibly determine whether the 27% decline was due to the smoking ban, or whether it was merely a reflection of a long-term, secular decline in heart attacks that was occurring anyway.

Importantly, the study cannot answer this question, at least with the data it currently analyzes. However, we can investigate this question by examining data on heart attack deaths for the state of Mississippi, which are available from the state Department of Health. Heart attack deaths are likely correlated highly with the number of heart attack admissions. So looking at the pre-existing trend in heart attack deaths in Mississippi gives us some indication of what would likely have been observed in Starkville in the absence of the smoking ban.

As it turns out, from 2000-2002 to 2003-2005, there was a 19.3% decline in heart attack deaths in Mississippi. And from the period 2000-2002 to 2006-2008, there was a 29.2% decline in heart attack deaths in Mississippi.

From 2003 to 2008, heart attack deaths in Mississippi fell by 19.1%. From 2002 to 2008, they fell by 29.4%. And from 2000 to 2008, they fell by more than one-third: by 33.9%.

This demonstrates that heart attacks were declining substantially in the state of Mississippi anyway, even in the absence of a smoking ban. It suggests that if Starkville had not enacted a smoking ban, the study still would have found a very large decline in heart attacks from 2003-2005 to 2006-2008.

Just looking at the change in heart attack deaths in the state from 2005 to 2006 (the first year of the Starkville smoking ban) alone, there was a large 8.7% decline. And for the entire period 2000-2006, there was a 29.7% decline. Thus, a decline in heart attacks in Starkville on the order of about 27% appears to be exactly what one would have expected in the absence of a smoking ban.

Given these facts, I do not understand how the study can conclude that the smoking ban in Starkville resulted in a 27% decline in heart attacks. I won't quibble and argue that the smoking ban had zero impact, but it certainly appears that a decline on the order of about 27% would have occurred anyway. I simply don't see how the study can attribute all 27% of the observed decline to the smoking ban.

The decline in heart attack deaths in Mississippi during the study period is a reflection of broader underlying trends in cardiovascular disease in the state. For example, cerebrovascular disease deaths in Mississippi declined by 21.3% from 2000 to 2008. From 2000-2002 to 2006-2008, there was a 20% reduction in cerebrovascular disease deaths in the state.

It's interesting that the study summary acknowledges that the study conclusions are preliminary and that the study will not be complete until other communities are examined (which is a good idea, because it will show that heart attacks have been declining throughout the state during the study period), but that the investigators nevertheless have no problem disseminating their unequivocal conclusions throughout the country through the media.

This is once again an example of science by press release. Although I have demonstrated that the study conclusion is flawed because at least a large part of the observed decline in heart attacks was attributable to the pre-existing secular trend of declining heart attacks in Mississippi, it is too late. The conclusions have already been disseminated, and I don't believe that these media outlets are now going to publish a retraction or a new article that says: "Remember that article last week about how the smoking ban in Starkville reduced heart attacks by 27% and saved $750,000. Well, never mind."

Monday, November 09, 2009

American Cancer Society Lying to Public While Playing Politics; Does the Truth No Longer Matter?

On its web site, the American Cancer Society (ACS) states that it is supporting a ban on flavored cigarettes, which it asserts have long been used by tobacco companies to lure kids into smoking.

According to the ACS: "Candy, fruit and liquor-flavored cigarettes are smoked by school children in much higher numbers than adults. Cigarette makers have long seen sweetened cigarettes as a lure for catching young customers. The American Cancer Society supports a ban on these dangerous products."

The ACS also states: "A bill to eliminate flavored cigarettes passed the [New York] State Assembly in early 2009 and awaits action. We are hopeful this bill can become law this year."

The Rest of the Story

The bill passed by the New York State Assembly does not ban flavored cigarettes. It does not, for example, ban menthol-flavored cigarettes. It does not ban clove cigarettes. What it bans are a number of types of cigarettes that were already taken off the market several years ago. There is not a single brand of flavored cigarettes produced by Big Tobacco which is covered by this legislation. But what the bill does is specifically allow the most common flavored cigarettes - menthol and clove cigarettes - to remain on the market.

Thus, it is not true that the ACS is supporting a bill that would ban flavored cigarettes. It wouldn't ban flavored cigarettes. It would continue to allow menthol cigarettes. And it would continue to allow clove cigarettes. Thus, the supposed "ban" on flavored cigarettes turns out not to be a ban at all.

It's like stating that you support a ban on flavored toothpaste but that you are actually supporting a bill that exempts mint flavors and bubble gum. That's hardly a ban on flavored toothpaste.

It is also not true that the tobacco companies have long used the flavors banned by this legislation to lure kids to start smoking. There was one episode in which R.J. Reynolds introduced a few candy-flavored cigarette varieties but these were removed from the market. Other than that, the only flavor that has long been used by tobacco companies to lure kids to smoking is menthol. An that's not covered by the ban. So the American Cancer Society is full of crap when they assert that the cigarette flavors they seek to ban have long been used to lure children to start smoking.

It is also untrue that flavored cigarettes are currently smoked by youths in much higher numbers than among adults. If you don't count menthol, the overwhelming majority of youths are smoking non-flavored cigarettes, specifically: Marlboros, Camels, and Newports.

Finally, it is not true that the ACS is supporting a ban on these "dangerous," "flavored" tobacco products. The ACS is not supporting a ban on menthol-flavored cigarettes, the one type of flavored cigarette which is actually smoked by hundreds of thousands of youths. The ACS is supporting a ban on exactly zero products that are produced by Philip Morris, R.J. Reynolds, or Lorillard.

I challenge the ACS to name a single brand of cigarettes produced by Big Tobacco and smoked by any substantial proportion of youths that will be taken off the market as a result of the legislation it is supporting (even setting aside the fact that federal legislation has already removed these products from the market).

In contrast, I can list a host of flavored cigarette brands produced by Big Tobacco which are smoked by a huge proportion of youths and which will not be removed from the market by this legislation.

The issue here is not whether flavored cigarettes should or should not be removed from the market. The issue is why it is necessary for anti-smoking groups like the American Cancer Society to lie to the public and imply that legislation will remove flavored cigarettes when that legislation will do nothing of the sort.

Why is it necessary for groups like the American Cancer Society to deceive the public into thinking that they are doing something to protect our nation's youths when they are actually supporting a bill that fails to affect even a single Big Tobacco product? Why is it necessary for these groups to make false claims to the public in support of these policies?

How ironic it is that these anti-smoking groups are calling on the need for legislation specifically because they claim the tobacco companies have lied to, and are deceiving the American public, but that these groups are themselves lying to the public to support their meaningless policies?

Friday, November 06, 2009

NYC Council Bans "All" Flavored Tobacco Products; Well... Not Exactly... Exempt are the Products Which are Actually Used by Thousands of New Yorkers

In a move described as intended to protect youths from the enticement to use tobacco products due to their flavorings, the New York City Council has enacted an ordinance which bans the sale of flavored tobacco products in the City.

According to an article in the Staten Island Advance: "The City Council voted overwhelmingly today to ban sales of all flavored tobacco products."

Well .... not exactly.

The ordinance exempts menthol cigarettes. It also exempts mint- and wintergreen-flavored or clove cigarettes.

According to an article in the New York Daily News: "Michele Bonan, regional director of advocacy for the American Cancer Society, one of the groups pushing the ban, said flavored tobacco is "Big Tobacco's version of training wheels" to attract young smokers."

The Council Speaker was quoted in the same article as stating that the ban was needed "to protect the children of New York City."

The Rest of the Story

This is an example of political cowardice, institutional racism, public deception, and what I would call sleazy politicking.

Political cowardice

This law represents political cowardice because these health groups and policy makers do not have the courage to actually promote or enact a policy that would actually accomplish what they state is the intended purpose. If the intent is to protect kids, then protect kids. Don't say that you're protecting kids from flavored cigarettes but then exempt the single most popular cigarette flavor among kids.

The products which are being affected by this ban are almost entirely products that are used by adults. Chocolate, watermelon, lemon, cherry, strawberry, and banana-flavored cigarettes are not popular among kids. In fact, not a single such product produced by Big Tobacco is even on the market. But the leading brands of cigarettes that are smoked by African American kids in New York City are all flavored cigarettes - flavored with menthol, which is exempt from the ban.

Institutional Racism

Given the large African American population in New York City, this bill actually reeks of institutional racism. How can you get up in front of the African American population in New York and tell them that we have just taken an action to protect the kids of New York City, but fail to take any action on the one cigarette flavoring that is most responsible for the addiction of African American children in the City. Are you saying that we are going to protect white kids from tobacco addiction, but we're not interested in protecting black kids?

Public Deception

By suggesting that non-menthol, flavored cigars are Big Tobacco's training wheels to attract smokers, the American Cancer Society is making a statement that is unsupported by any evidence. The true "training wheels" to attract smokers are products that go by the names of Marlboro, Camel, and Newport. These brands account for a solid 85 to 90 percent of the "training wheels" that Big Tobacco uses successfully to recruit new smokers.

The overwhelming majority of youth smokers begin to smoke not by trying cigars or cigarillos and then eventually switching to cigarettes, but by trying something known as a cigarette. The American Cancer Society is completely off base in suggesting that it is the banned flavored tobacco products that have anything to do with the youth smoking problem. In fact, it is the exempt products that are the ones addicting youths. The American Cancer Society is completely off base and I think it owes an apology to its constituents and the public.

Sleazy Politicking

This is an example of sleazy politicking because it represents an attempt by politicians to make it look like they are doing something to address the problem of youth smoking when in fact they are doing absolutely nothing of the sort. The so-called ban on tobacco flavorings is going to have no effect whatsoever on youth smoking because practically no youths use the brands that are being taken off the market due to this policy.

The policy is pure window-dressing. It allows politicians as well as health groups in New York City to make it look like they are accomplishing something to protect children without actually having to do anything. And they are specifically avoiding the difficult move which would actually make a difference: getting rid of the menthol cigarettes which are addicting more than 75% of African American youth smokers in the City.

Thursday, November 05, 2009

American Academy of Pediatrics Calls for Ban on Electronic Cigarettes, But Fails to Disclose Its Huge Conflict of Interest with Big Pharma

In a previous post, I pointed out that every national anti-smoking organization which has called for the prohibition of electronic cigarettes has been found to have financial ties to Big Pharma. I thought this pattern had been broken when I saw a press release from the American Academy of Pediatrics calling for electronic cigarettes to be banned. I assumed that if the Academy had a financial conflict of interest with pharmaceutical companies, it would disclose it in the press release, as would be ethical behavior for a public health organization. Thus, I assumed that the pattern had been broken. What I didn't know was the rest of the story.

The Story

On October 20, the American Academy of Pediatrics issued a press release calling for a ban on electronic cigarettes.

According to the press release: "The AAP's work to eliminate children's exposure to tobacco and secondhand smoke is spearheaded at the AAP Julius B. Richmond Center, which was established in 2006. The AAP recommends bans on tobacco advertising in all media, and restrictions on the depiction of tobacco in movies and television. In addition to laws banning the sale of tobacco products to children, the AAP calls for bans on candy cigarettes, cigars, and other products that imitate smoking or tobacco use. E-cigarettes (electronic cigarettes) should also be banned. The sale of tobacco products on the same premises as pharmacies should be eliminated, including pharmacies located in supermarkets."

The Rest of the Story

It turns out that the American Academy of Pediatrics has a massive conflict of interest by virtue of substantial financial sponsorships by Big Pharma. A large number of pharmaceutical companies are major sponsors of the Academy's upcoming 2009 annual conference.

According to the conference web site, pharmaceutical company sponsors of the conference at the "gold" level include:
  • GlaxoSmithKline
  • Johnson & Johnson
  • McNeil Pediatrics
  • Merck
  • Wyeth
  • Pfizer
  • Sciele
Many of these pharmaceutical companies produce nicotine replacement products or other smoking cessation drugs for which electronic cigarettes pose a huge threat. While FDA-approved smoking cessation medications are highly ineffective, with long-term success rates of only about 8-10%, electronic cigarettes appear to be much more effective, probably because they simulate the act of smoking, thus addressing both the behavioral and pharmacologic aspects of the smoking addiction.

To make a national recommendation that electronic cigarettes be banned without disclosing its severe financial conflict of interest with Big Pharma is, in my view, unethical. The financial conflict of interest could be perceived as influencing the Academy's policy on electronic cigarettes, since a ban on these apparently very effective smoking cessation devices is a move that protects pharmaceutical company profits from what would otherwise be a severe threat to their business.

Unfortunately, a ban on electronic cigarettes would also be a public health tragedy, as it would force hundreds of thousands of ex-smokers to return to cigarette smoking, and it would therefore do massive harm - causing disease and death among people who otherwise would have continued to regain their health.

It is a shame that while the American Academy of Pediatrics cares about children, it does not seem to care about those kids' parents, many of whom are going to become very ill or die if the Academy's policy recommendation on electronic cigarettes is heeded.

But regardless of the inappropriateness of the policy recommendation itself, the rest of the story is that the American Academy of Pediatrics has violated basic ethical principles of conduct by making a national policy recommendation on electronic cigarettes without disclosing its massive financial conflict of interest with a host of pharmaceutical companies whose products are being severely threatened by the increasingly popularity of electronic cigarettes.