Tuesday, June 18, 2013

Anti-Tobacco Advocate Argues that Cigarettes Should Remain More Freely Available to the Public than Fake Electronic Ones Without Any Tobacco

I remember years ago when a colleague was pressuring a chain of stores to stop selling candy cigarettes. While I certainly agreed that stores shouldn't sell candy cigarettes, I asked my colleague a question: "Why are you asking the store to stop selling the fake cigarettes but to continue selling the real ones?" That made no sense to me.

Now, in a story that is quite similar, an anti-tobacco advocate is arguing that steps should be taken to make sure that real, deadly, tobacco cigarettes remain much more readily available to the public than fake ones which have not been shown to cause any substantial harm and which are actually helping thousands of people to quit smoking.

In a commentary published in the journal Tobacco Control, Dr. Simon Chapman argues that electronic cigarettes are a tobacco industry ploy to keep people smoking, that reducing smoking has no health benefits, and that real cigarettes should remain more readily available to the public than the fake ones.

(See: Chapman S. Should electronic cigarettes be as freely available as tobacco cigarettes? No. Tobacco Control 2013; doi: http://dx.doi.org/10.1136/bmj.f3840. Published 14 June 2013.)

One of the key arguments made in the commentary is that there is no health benefit to reducing the amount one smokes -- even if the reduction is substantial (e.g., greater than 50%). Chapman argues that: "importantly, cutting down cigarettes rather than quitting confers little if any health benefit, so dual use may be as bad as continued smoking in terms of health outcomes."

The Rest of the Story

If a physician made the same claim to a patient that Dr. Chapman is making, it would - in my opinion - constitute medical malpractice. Why? Because the statement is blatantly false and runs contrary to both medical science and widespread clinical experience. It is blatantly untrue that a major reduction in cigarette consumption confers no health benefits to a patient. In contrast, there are immediate and important health benefits.

Now obviously, cutting down is not nearly as beneficial as quitting entirely, but the statement made in this commentary is not that quitting is better than cutting down. The statement is that cutting down substantially has no health benefits.

But, wait, you say. Dr. Chapman cites research which found no health benefits associated with smoking reduction. Well, there are two problems. First, the paper did not look at all of the important health outcomes. For example, it does not report on whether smoking reduction improved patients' respiratory symptoms. In other words, did it improve their lives? Second, the paper did not have sufficient power to detect the health benefits that might accrue with smoking reduction. So even though some of the relative risks are not statistically significant, they are substantially less than 1.0 and probably represent an important health benefit. With a larger sample size, the study would likely have found these benefits to be statistically significant.

The first benefit that is unequivocally related to smoking reduction is an improvement in respiratory symptoms. That alone makes the statement false. Now the reduction in respiratory symptoms may not necessarily translate into a measurable improvement in lung function, but there is almost certainly a health benefit in terms of respiratory symptoms. This is an important health benefit because it improves people's lives. If they can actually climb up a flight of stairs, which they couldn't before, then how can one argue that they have not experienced any health benefit?

The second benefit that is almost certainly related to smoking reduction is a decreased risk of lung cancer. Even the research that the commentary cites as showing no health benefit actually shows that smokers who reduced their consumption were less likely to die of lung cancer. The relative risk was 0.66. This means that their lung cancer risk declined by one-third. That is a substantial decline. While the relative risk was not statistically significant, this was likely due to the low power of the study.

Importantly, other research - with a more appropriate sample size - has documented a reduction in lung cancer risk associated with smoking reduction. For example, a study published in the Journal of Clinical Oncology which had a sample size almost 10 times higher than the study which found the non-significant relative risk of 0.66 found a very similar reduction in lung cancer risk, but the reduction was statistically significant.

The study results were as follows: "For lung cancer, patients who reduced from heavy to moderate smoking and from heavy to light smoking (< 10 cigarettes/d) had significantly decreased risks based on multivariable-adjusted HRs (HR = 0.72, 95% CI, 0.49 to 0.89; HR = 0.63, 95% CI, 0.46 to 0.84, respectively)." This means that smokers who reduced their consumption were able to decrease their risk of lung cancer by one-third.

This is hardly evidence for a lack of any health benefit from smoking reduction.

This paper concludes that: "Smoking reduction was associated with a significant decrease in the risk of lung cancer...".

The third benefit that may be related to smoking reduction is a slowing of the progression of chronic lung disease. The research cited in the commentary did not even examine whether smoking reduction lowers the risk of death from chronic obstructive lung disease. So even from that research alone it is not appropriate to conclude that there are no health benefits associated with smoking reduction.

The upshot of this advice is that many patients who are unable to quit smoking but might well be able to reduce the amount that they smoke may decide that it's not worth the bother. If there are no health benefits, then why bother reducing consumption?

Well, perhaps the greatest health benefit of reducing cigarette consumption is that it makes it easier, ultimately, to quit smoking. There is no question that reducing smoking is often a behavior that lies along the pathway from heavy smoking to quitting. It is easier to quit smoking for someone who smokes a half pack per day than for someone who smokes three packs per day.

My point is not that smoking reduction should be the focus of tobacco control efforts. Readers will remember that last week I highlighted a recent chapter I wrote which emphasizes the importance of jolting smokers into spontaneous, cold turkey cessation. And in fact, I cited Dr. Chapman's important work in this area. He has been a pioneer in challenging the dogma of the tobacco control movement. I should make it clear that I have the greatest admiration for Dr. Chapman.

However, on this particular issue, I sense that there is some sort of ideological barrier that is slanting his take on the issue. The point of this post is to demonstrate that in opining about electronic cigarettes. Dr. Chapman has misrepresented the science on the benefits of smoking reduction. In doing so, he has negated any health value associated with switching from smoking to vaping for smokers who are not able to completely make the switch.

I challenge Dr. Chapman to actually speak to vapers who have made the switch, but are still maintaining some cigarette use, and ask them to report whether it is indeed true that they have not experienced any improvement in their respiratory symptoms. We know from speaking to many vapers that there is unquestionably a health benefit associated with switching from real cigarettes to fake ones, and that this benefit accrues even among those who are unable to achieve a 100% substitution of non-tobacco cigarettes for tobacco cigarettes.

The rest of the story is that once again, here is an example of an electronic cigarette opponent who seems more guided by ideology than by the facts. I understand that anti-tobacco advocates have a hatred for the act of cigarette smoking and for the tobacco companies. But we can't let that hatred blind ourselves to the scientific facts. And the fact is that vaping has improved the lives of hundreds of thousands of smokers and ex-smokers. To take this away from them, or even to make it more difficult for other smokers to experience these benefits, would be a public health tragedy.

At the end of the day, I would much rather that the public has easier access to fake cigarettes than to the real ones.

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