If the debate over the FDA tobacco legislation during the 110th Congress has taught us anything, it is that for both Congressional anti-tobacco "leaders" and the leading national anti-smoking organizations, money and politics are more important than protecting the public's health. While this may not be a revelation as it applies to political leaders and is perhaps to be expected, it is not expected, nor excusable, among public health leaders.
An article published in Saturday's New York Times reveals that Congressional leaders are unwilling to allow the menthol exemption in the FDA tobacco legislation to be removed because the states and federal government are dependent upon tobacco tax revenues and banning menthol flavoring in cigarettes could seriously threaten cigarette sales. The legislation, while banning every other cigarette flavoring, exempts menthol.
The leading anti-smoking groups -- including the Campaign for Tobacco-Free Kids, American Cancer Society, American Heart Association, American Lung Association, and American Medical Association -- have all opposed the removal of the menthol exemption, citing a need to make sure that menthol cigarettes remain available to the millions of smokers who use these products. Essentially, then, these groups are arguing that such an amendment would threaten tobacco sales.
In other words, the leading anti-smoking groups support the menthol exemption specifically because they are afraid that it might just work! The danger of the amendment to remove this provision, they argue, is that it might actually strengthen the bill and give it real teeth. It might just succeed in substantially reducing cigarette use.
But because a reduction in cigarette use translates into a reduction in cigarette company profits -- including those of Philip Morris, a key ally of the anti-smoking groups -- amending the legislation so that it might actually achieve its stated purpose is unacceptable to the anti-smoking groups because it would threaten breaking up the anti-smoking group/Philip Morris alliance.
The reason behind the opposition of Congressional anti-smoking "leaders" to the removal of the menthol exemption is also based on the desire to maintain cigarette sales. In this case, however, the biggest threat is to the heavily relied upon stream of cigarette tax revenues that the federal and state governments are dependent upon to fund everything from roads and bridges to health care for the poor.
As Stepanie Saul writes in the New York Times: "The decision to exempt menthol from the flavoring ban may appear illogical until you dissect the economics of cigarettes and their impact on government. A growing reliance by the states and federal government on cigarette taxes — as well as a popular proposal to increase federal taxes by 61 cents to an even $1 per pack to finance the State Children’s Health Insurance Program, S-chip — provide a sort of insurance policy for the continued survival of menthol cigarettes. The National Conference of State Legislatures reported last month that states were facing combined budget deficits of more than $40 billion in 2009. Raising cigarette taxes is one way some states are trying to make up the shortfall. In 2007, states collected more than $19 billion in cigarette taxes, and Maryland, which doubled its tax to $2 in January was one of 10 states that voted last year to increase those collections. More states are considering cigarette tax increases this year. The federal government, meantime, collects nearly $7 billion annually in cigarette excise taxes and would have raised those taxes, effective this year, but for the presidential veto of the S-chip legislation, which House Democrats have said is near the top of their agenda for next year."
"But taxes are not the only government revenue from cigarettes. Settlements in the late 1990s to end state lawsuits against tobacco companies mean that the cigarette industry is paying states nearly $250 billion over 25 years. Under the agreement, those payments to states will continue flowing even beyond 25 years as long as the tobacco industry is healthy. But the payments would phase out as cigarette company profits decline and would ultimately disappear if people stop smoking. So the government has become a financial stakeholder in smoking, some would argue, even as public health officials warn people about its deadly consequences. Smoking declines as cigarette taxes increase, but a core group of smokers hang on to the habit. The reliance of government coffers on the taxes smokers pay, and on the tobacco settlement money, essentially provides a financial cushion for state governments and could be viewed as a government guarantee for the survival of the tobacco industry. Would politicians shut down an industry that supplies so much money?"
"Now we come to menthol cigarettes, which make up 28 percent of the market. Unless menthol smokers switched to other types of cigarettes, a menthol ban would cut nearly a third of the tax revenues for states and federal governments. ... With many states currently broke, menthol provides a revenue stream few would want to give up."
The Rest of the Story
You know you are dealing with an anti-smoking movement which has largely lost its integrity when the leading anti-smoking groups are opposing changes to federal tobacco legislation because they fear those changes may actually lead to substantial reductions in smoking and to saving countless lives.
You know you are dealing with a movement overcome by hypocrisy when you hear those same anti-smoking groups boasting about how the legislation is critically needed because it would reduce tobacco use and save countless lives.
It truly saddens me to see the tobacco control movement go down the tubes like this. I think we desperately need to restore integrity to the movement, but it's hard to imagine overcoming an actual desire to protect tobacco industry sales and the formation of an alliance between the leading national anti-smoking groups and Big Tobacco!
My conclusion from this story is that the tobacco industry is absolutely brilliant. First, they forged an alliance with the states and federal government by enticing the Attorneys General into signing the Master Settlement Agreement. They did this by dangling billions of dollars and the opportunity for political gain in front of them.
Then, Philip Morris pulled of the unthinkable. They forged an alliance with numerous anti-smoking groups by enticing them into joining them in supporting very weak federal tobacco legislation. They did this by dangling the opportunity for a legislative victory - no matter how meaningless - in front of these groups. Somehow, Philip Morris correctly figured that the groups were more interested in being able to say that they had gotten something accomplished than in actually achieving real protection of the public's health.
The tobacco industry is in a very solid position because of the alliances it has successfully forged with the federal and state governments and the national leadership groups of anti-smoking movement. It succeeded in forging these alliances because it correctly calculated that the leading anti-smoking groups and leading politicians had one thing in common: they were more interested in money and political and organizational prestige than in actually standing up for the principles they publicly espoused.
The tobacco companies were right.
While I understand and am not surprised by the industry's calculation with respect to leading politicians in Congress, I have to applaud them for their insight into the psyche of the national leaders of the anti-smoking movement. I would never have guessed that these groups lacked the integrity to stand up for their espoused principles and that they would cave in so easily.
I guess that's why I am a tobacco policy blogger and not a tobacco company executive.
Tuesday, September 02, 2008
Friday, August 22, 2008
Wednesday, August 13, 2008
Los Angeles City Councilor Claims that Secondhand Smoke is More Harmful than Active Smoking; Pushes Ban on Smoking Everywhere Outdoors
According to Los Angeles City Councilor Bernard Parks, breathing in secondhand smoke is more dangerous than actively smoking. In a commentary in City Watch and a press release, Parks uses this "fact" to justify his proposed ordinance which would ban smoking in virtually every outdoor location in Los Angeles. Anti-smoking groups, including Breathe LA, are supporting the ordinance.
According to the commentary: "Research has shown that inhaling secondhand smoke is more harmful than actually smoking, primarily due to the unfiltered nature of the smoke and its having been cooled by the air."
The ordinance would ban smoking in every outdoors location where people "reasonably congregate." Essentially, this means that there would be no outdoors smoking anywhere, with the exception of some dark deserted alleys. If enacted, this would be the most restrictive smoking ban in the nation.
The Rest of the Story
I now understand why anti-smoking advocates and groups are distorting the truth. Because they are promoting such extreme proposals that go far beyond the documented scientific evidence that they need to create their own facts in order to justify these proposals.
You can't credibly argue that smoking needs to be banned everywhere outdoors to protect the health of nonsmokers using the actual truth about the severity of health risk from secondhand smoke exposure. There simply is no evidence that a few wisps of secondhand smoke, as one might encounter from someone smoking on a sidewalk or in a street, parking lot, or park puts people's health at risk and represents a significant public health problem.
The only way to advance these policies, then, is to artificially build up the severity of the harms of secondhand smoke so that you can convince people that any exposure - even a few wisps of smoke - is a severe health hazard.
This, I now realize, is the impetus behind the widespread fallacious claims that are being made by over 100 anti-smoking groups about the cardiovascular effects of brief secondhand smoke exposure.
I no longer believe that this distortion of the science, which goes right up to the level of the Surgeon General (who claimed that brief secondhand smoke exposure was sufficient to cause heart disease and lung cancer), represents a simple, innocent mistake.
It is now clear that this is part of a new agenda (one that I never thought was part of the movement) to extend smoking bans beyond workplaces, restaurants, bars, and other places where there is substantial exposure. The movement is now to virtually ban all smoking outside of the home, so that no nonsmoker ever has to even see a smoker in public.
There simply is no credible alternative explanation for claims - like this one - which are so absurd that they are patently false on their face. You need only think about it for about 3 seconds before you realize that secondhand smoke exposure cannot possibly be more harmful than active smoking.
The epidemiologic evidence obviously does not support such a conclusion. The relative risk of lung cancer associated with chronic active smoking is about 17. The relative risk for lung cancer associated with chronic secondhand smoke exposure is about 1.3. That's a 13-fold difference. It is intuitively clear that smoking is worse than breathing in secondhand smoke. This isn't an example of stretching or exaggerating the facts - it's an example of creating (i.e., fabricating) them.
I should point out that if you take this message seriously, then a rational nonsmoker might actually start smoking. After all, according to the message, it's better to smoke yourself than to be exposed to secondhand smoke. The message truly undermines the severe health effects of active smoking because it states that active smoking is less harmful than secondhand smoke exposure. Thus, the statement is not only fallacious, but it is a dangerous one which undermines years of education of the public about the severe harms of active smoking.
While the main reason why I object to the fabrication of the science is that I view it as unethical, I wish to point out that I also think it undermines our cause of protecting nonsmokers from secondhand smoke. It gives the public the impression (rightly so, apparently) that our goal is not just to save lives and prevent serious medical conditions but instead, that our goal is simply to protect nonsmokers from ever having to breathe in a wisp of secondhand smoke or see a smoker. It makes it appear that we are trying to prohibit smoking through the back door and that de facto prohibition is our real agenda, rather than a legitimate public health interest in protecting nonsmokers from a severe health threat.
To use a half-marathon analogy, I feel like I have been running a half-marathon and I get to the finish line and stop, but everyone else keeps running. I thought the goal was to provide a safe working environment for all employees and to protect nonsmokers from a substantial health hazard in certain outdoors locations where they cannot easily avoid tobacco smoke exposure. Instead, the movement just keeps on going, trying to ban smoking in every possible outdoors location and even starting to infringe upon the private home.
I feel all alone at the finish line, wondering where everyone has gone.
The rest of the story is that I have come to the conclusion that the distortion of the science by anti-smoking groups is not merely an innocent mistake or an uninformed interpretation of scientific evidence. It is, instead, a deliberate attempt to promote an extremist agenda by fabricating scientific evidence that will support an agenda that is simply not supported by the scientific truth.
As I prepare for a brief vacation and a half-marathon (and trust me - I'm stopping at 13.1 miles, no matter what anyone else does), this seems like a fitting post with which to close before my summer vacation.
The Rest of the Story will return just after Labor Day, on Tuesday, September 2.
In the mean time, I leave you with this thought: For a movement that is largely based on its differentiation from the tobacco industry -- on its perception as the purveyors of truth and scientific accuracy in contrast to the industry's lies, distortion, and misrepresentation of the science -- it is essential that the movement remain beyond reproach in its scientific integrity.
The tobacco control movement is failing to do that. We are fabricating scientific evidence to support our increasingly aggressive agenda that cannot be justified otherwise.
And you know what? Other than the American Council on Science and Health (ACSH - which has written extensively on this topic) and Smokefree Pennsylvania (which has challenged some of the reliance on shoddy science), no anti-smoking groups are speaking out -- either against the extremist agenda or the fabrication of scientific evidence. The anti-smoking groups are either part of the deception or they are essentially complicit in the campaign of deception through their silence.
The realization I have come to - and it is a sad one for me - is that the misrepresentation of the effects of brief secondhand smoke exposure by anti-smoking groups is not simply due to a series of innocent mistakes. It is not merely an exaggeration of scientific findings. Instead, it represents a fabrication of a body of scientific evidence with a deliberate purpose - to promote an increasingly aggressive anti-smoking agenda that goes beyond protecting people from a significant health hazard as documented by actual science.
I have been very patient and understand and I've tried to use every imaginable rationalization to characterize the distortion of the science. But at this point, it is clear to me that the distortion of the science is not innocent; it is deliberate and it is intended to justify an agenda that could not be justified without scientific fabrication.
The one thing which no anti-smoking group I have challenged has said is that they defend the claims they are making. They recognized that what they are stating is not accurate. Even Stan Glantz admitted to me privately that some of the statements about the acute cardiovascular effects of secondhand smoke are not accurate. He rationalized them by arguing that we don't have time to present, and the public doesn't have the intellectual capacity to understand, the actual details.
Similarly, Breathe California of Sacramento-Emigrant Trails admitted to me privately that they don't believe the statistic on their web site is true (120 young people die each day from smoking). And while they claim that the reason they won't take the claim down is that the webmaster is away, it has now been nine months and no job has 9-months per year vacation as a benefit. It is clear that the statistic is still up there because they want it to be up there. They have chosen to knowingly allow a false claim to remain on the site because it is favorable to their cause.
TobaccoScam could have clarified that its statement "20 minutes [of exposure to tobacco smoke] = stiffened, clogged arteries" does not mean what it says: that 20 minutes of tobacco smoke exposure will lead to stiffened, clogged arteries. But it chose not to.
Breathe California of Sacramento-Emigrant Trails could have corrected its statement that 120 young people die each day from smoking. But it chose not to.
The bottom line is that it can no longer be argued that the deception of the public about the health effects of brief secondhand smoke exposure is accidental. There has been plenty of opportunity to remove, clarify, or correct these claims and for the most part, organizations have made deliberate decisions not to do so.
Even the Surgeon General's office has had plenty of time and opportunity to correct or clarify the Surgeon General's claim that a brief exposure to secondhand smoke is sufficient to cause atherosclerosis and lung cancer. No clarification was forthcoming, and the claim remains on the web site to this day, without any note of correction.
In my opinion, this means we are not just exaggerating or distorting the science - we are lying to the public. And we're doing so knowingly and intentionally.
And I don't think the tobacco control movement can remain as a legitimate and viable one within public health if it continues to do so.
According to the commentary: "Research has shown that inhaling secondhand smoke is more harmful than actually smoking, primarily due to the unfiltered nature of the smoke and its having been cooled by the air."
The ordinance would ban smoking in every outdoors location where people "reasonably congregate." Essentially, this means that there would be no outdoors smoking anywhere, with the exception of some dark deserted alleys. If enacted, this would be the most restrictive smoking ban in the nation.
The Rest of the Story
I now understand why anti-smoking advocates and groups are distorting the truth. Because they are promoting such extreme proposals that go far beyond the documented scientific evidence that they need to create their own facts in order to justify these proposals.
You can't credibly argue that smoking needs to be banned everywhere outdoors to protect the health of nonsmokers using the actual truth about the severity of health risk from secondhand smoke exposure. There simply is no evidence that a few wisps of secondhand smoke, as one might encounter from someone smoking on a sidewalk or in a street, parking lot, or park puts people's health at risk and represents a significant public health problem.
The only way to advance these policies, then, is to artificially build up the severity of the harms of secondhand smoke so that you can convince people that any exposure - even a few wisps of smoke - is a severe health hazard.
This, I now realize, is the impetus behind the widespread fallacious claims that are being made by over 100 anti-smoking groups about the cardiovascular effects of brief secondhand smoke exposure.
I no longer believe that this distortion of the science, which goes right up to the level of the Surgeon General (who claimed that brief secondhand smoke exposure was sufficient to cause heart disease and lung cancer), represents a simple, innocent mistake.
It is now clear that this is part of a new agenda (one that I never thought was part of the movement) to extend smoking bans beyond workplaces, restaurants, bars, and other places where there is substantial exposure. The movement is now to virtually ban all smoking outside of the home, so that no nonsmoker ever has to even see a smoker in public.
There simply is no credible alternative explanation for claims - like this one - which are so absurd that they are patently false on their face. You need only think about it for about 3 seconds before you realize that secondhand smoke exposure cannot possibly be more harmful than active smoking.
The epidemiologic evidence obviously does not support such a conclusion. The relative risk of lung cancer associated with chronic active smoking is about 17. The relative risk for lung cancer associated with chronic secondhand smoke exposure is about 1.3. That's a 13-fold difference. It is intuitively clear that smoking is worse than breathing in secondhand smoke. This isn't an example of stretching or exaggerating the facts - it's an example of creating (i.e., fabricating) them.
I should point out that if you take this message seriously, then a rational nonsmoker might actually start smoking. After all, according to the message, it's better to smoke yourself than to be exposed to secondhand smoke. The message truly undermines the severe health effects of active smoking because it states that active smoking is less harmful than secondhand smoke exposure. Thus, the statement is not only fallacious, but it is a dangerous one which undermines years of education of the public about the severe harms of active smoking.
While the main reason why I object to the fabrication of the science is that I view it as unethical, I wish to point out that I also think it undermines our cause of protecting nonsmokers from secondhand smoke. It gives the public the impression (rightly so, apparently) that our goal is not just to save lives and prevent serious medical conditions but instead, that our goal is simply to protect nonsmokers from ever having to breathe in a wisp of secondhand smoke or see a smoker. It makes it appear that we are trying to prohibit smoking through the back door and that de facto prohibition is our real agenda, rather than a legitimate public health interest in protecting nonsmokers from a severe health threat.
To use a half-marathon analogy, I feel like I have been running a half-marathon and I get to the finish line and stop, but everyone else keeps running. I thought the goal was to provide a safe working environment for all employees and to protect nonsmokers from a substantial health hazard in certain outdoors locations where they cannot easily avoid tobacco smoke exposure. Instead, the movement just keeps on going, trying to ban smoking in every possible outdoors location and even starting to infringe upon the private home.
I feel all alone at the finish line, wondering where everyone has gone.
The rest of the story is that I have come to the conclusion that the distortion of the science by anti-smoking groups is not merely an innocent mistake or an uninformed interpretation of scientific evidence. It is, instead, a deliberate attempt to promote an extremist agenda by fabricating scientific evidence that will support an agenda that is simply not supported by the scientific truth.
As I prepare for a brief vacation and a half-marathon (and trust me - I'm stopping at 13.1 miles, no matter what anyone else does), this seems like a fitting post with which to close before my summer vacation.
The Rest of the Story will return just after Labor Day, on Tuesday, September 2.
In the mean time, I leave you with this thought: For a movement that is largely based on its differentiation from the tobacco industry -- on its perception as the purveyors of truth and scientific accuracy in contrast to the industry's lies, distortion, and misrepresentation of the science -- it is essential that the movement remain beyond reproach in its scientific integrity.
The tobacco control movement is failing to do that. We are fabricating scientific evidence to support our increasingly aggressive agenda that cannot be justified otherwise.
And you know what? Other than the American Council on Science and Health (ACSH - which has written extensively on this topic) and Smokefree Pennsylvania (which has challenged some of the reliance on shoddy science), no anti-smoking groups are speaking out -- either against the extremist agenda or the fabrication of scientific evidence. The anti-smoking groups are either part of the deception or they are essentially complicit in the campaign of deception through their silence.
The realization I have come to - and it is a sad one for me - is that the misrepresentation of the effects of brief secondhand smoke exposure by anti-smoking groups is not simply due to a series of innocent mistakes. It is not merely an exaggeration of scientific findings. Instead, it represents a fabrication of a body of scientific evidence with a deliberate purpose - to promote an increasingly aggressive anti-smoking agenda that goes beyond protecting people from a significant health hazard as documented by actual science.
I have been very patient and understand and I've tried to use every imaginable rationalization to characterize the distortion of the science. But at this point, it is clear to me that the distortion of the science is not innocent; it is deliberate and it is intended to justify an agenda that could not be justified without scientific fabrication.
The one thing which no anti-smoking group I have challenged has said is that they defend the claims they are making. They recognized that what they are stating is not accurate. Even Stan Glantz admitted to me privately that some of the statements about the acute cardiovascular effects of secondhand smoke are not accurate. He rationalized them by arguing that we don't have time to present, and the public doesn't have the intellectual capacity to understand, the actual details.
Similarly, Breathe California of Sacramento-Emigrant Trails admitted to me privately that they don't believe the statistic on their web site is true (120 young people die each day from smoking). And while they claim that the reason they won't take the claim down is that the webmaster is away, it has now been nine months and no job has 9-months per year vacation as a benefit. It is clear that the statistic is still up there because they want it to be up there. They have chosen to knowingly allow a false claim to remain on the site because it is favorable to their cause.
TobaccoScam could have clarified that its statement "20 minutes [of exposure to tobacco smoke] = stiffened, clogged arteries" does not mean what it says: that 20 minutes of tobacco smoke exposure will lead to stiffened, clogged arteries. But it chose not to.
Breathe California of Sacramento-Emigrant Trails could have corrected its statement that 120 young people die each day from smoking. But it chose not to.
The bottom line is that it can no longer be argued that the deception of the public about the health effects of brief secondhand smoke exposure is accidental. There has been plenty of opportunity to remove, clarify, or correct these claims and for the most part, organizations have made deliberate decisions not to do so.
Even the Surgeon General's office has had plenty of time and opportunity to correct or clarify the Surgeon General's claim that a brief exposure to secondhand smoke is sufficient to cause atherosclerosis and lung cancer. No clarification was forthcoming, and the claim remains on the web site to this day, without any note of correction.
In my opinion, this means we are not just exaggerating or distorting the science - we are lying to the public. And we're doing so knowingly and intentionally.
And I don't think the tobacco control movement can remain as a legitimate and viable one within public health if it continues to do so.
Tuesday, August 12, 2008
Half of UK Fertility Experts Would Deny In-Vitro Fertilization to Smokers if They Do Not Quit Smoking; Some Hospitals Already Refusing IVF for Smokers
According to a survey reported by BBC News, about half of fertility experts (physicians) interviewed support the concept of denying in-vitro fertilization (IVF) treatment to smokers and obese persons unless they meet certain conditions for modification of their lifestyles.
According to the article: "Almost half of fertility experts say access to IVF should be conditional - and smokers or the obese could be denied treatment, a survey shows. The poll of international experts, most of whom work in the UK, found just 29% thought IVF should be offered to all. Obesity and smoking have been linked to fertility problems, so doctors say it is fair to ask patients to change their habits before they are given care. Patient groups said lifestyle advice should be based on medical evidence. The poll asked for doctors to agree or disagree with the statement 'access to IVF should be conditional on criteria based on lifestyle choices - eg denying access to smokers'."
According to an article in The Guardian, up to 46 primary care trusts in England and Wales are already denying IVF treatment to smokers and will not allow them access to IVF unless they quit smoking.
According to that article: "Hospitals have been accused of rationing IVF by denying the treatment to smokers, in a move that will reignite debate about the right to NHS care. Childless women, and in some cases their partners, too, are being asked to give up cigarettes before they can be considered for fertility treatment in up to 46 primary care trusts (PCTs) across England and Wales. Ministers have retreated on suggestions that smokers should be denied treatment for tobacco-related conditions such as heart disease. But a Department of Health survey released to Labour MP Sally Keeble last week, shows that, despite official recommendations that all infertile couples should get three cycles of treatment free, clinics are increasingly making free IVF treatment conditional on not smoking. While smoking can affect a couple's chance of conceiving and smoking in pregnancy can damage the unborn child, tobacco use is listed as a 'non-clinical access criteria' in the survey - meaning it is not a medical requirement for treatment to work, but one of a series of optional requirements such as being in a steady relationship. Other lifestyle choices known to reduce fertility, such as drinking alcohol, do not affect eligibility in the same way."
The Rest of the Story
I suppose one effective way of knocking smokers out of society is to make sure that they cannot reproduce. As far-fetched as it may sound, this is essentially what the primary care trusts are doing in denying IVF treatment for smokers.
It is telling that these fertility clinics do not require women to stop drinking alcohol as a condition for IVF treatment. Smoking is being singled out, I believe, because it is viewed as a socially unacceptable lifestyle decision.
It is truly scary to think that a medical procedure would be denied to individuals based on a judgment about what is an appropriate or socially acceptable lifestyle. When judgments about lifestyle enter the clinical decision-making arena, the door is opened to all kinds of unacceptable consequences, such as denying treatment to individuals based on their sexual orientation or the presence of a "suitable" partner.
The hallmark of the practice of medicine is that it is supposed to be non-judgmental. As physicians, we are to provide the treatment that is in the best interests of the patient, without casting judgment upon the individual's lifestyle choices. Sure, it is perfectly appropriate to inform our patients about the health impact of their lifestyle choices, but we are not to deny medical care or to make such care conditional upon our patients conforming their lifestyle to meet our desires.
There is one reasonable criterion for denying medical care (outside of absolute medical contraindications) and that is situations in which the behavior in question is the cause of the medical problem and the treatment in question is severely limited in availability. For example, if an alcoholic seeks a liver transplant, it is not unreasonable to deny treatment or place the individual much lower on the transplant list because the alcohol was the cause of the liver damage and there are a very limited number of livers available for transplant. Clearly, this is not the case with in-vitro fertilization.
The policy of denying IVF treatment to obese or overweight individuals, or making that treatment conditional upon them changing their lifestyle, is equally despicable. People should not be denied basic rights because of their weight. Neither should they be denied basic rights because of their lifestyle decisions.
There are a host of medical treatments that are not as successful when the patient continues to engage in certain behaviors. There is no question, for example, that drug treatment for type II diabetes is much more effective when the patient loses weight. There is no question that treatment for hypertension is more effective when the patient restricts his or her salt intake. Insulin treatment for diabetes is more effective when the patient modifies his or her diet.
What are we going to do? Start restricting treatment of diabetes and hypertension to patients who agree to alter their diet and lose weight?
I can see why smokers are feeling persecuted by society. Their rights are being taken away. This is a threat both to basic human rights and to the integrity of medicine. As physicians, we are supposed to provide treatment to all patients without casting judgment upon them.
According to the article: "Almost half of fertility experts say access to IVF should be conditional - and smokers or the obese could be denied treatment, a survey shows. The poll of international experts, most of whom work in the UK, found just 29% thought IVF should be offered to all. Obesity and smoking have been linked to fertility problems, so doctors say it is fair to ask patients to change their habits before they are given care. Patient groups said lifestyle advice should be based on medical evidence. The poll asked for doctors to agree or disagree with the statement 'access to IVF should be conditional on criteria based on lifestyle choices - eg denying access to smokers'."
According to an article in The Guardian, up to 46 primary care trusts in England and Wales are already denying IVF treatment to smokers and will not allow them access to IVF unless they quit smoking.
According to that article: "Hospitals have been accused of rationing IVF by denying the treatment to smokers, in a move that will reignite debate about the right to NHS care. Childless women, and in some cases their partners, too, are being asked to give up cigarettes before they can be considered for fertility treatment in up to 46 primary care trusts (PCTs) across England and Wales. Ministers have retreated on suggestions that smokers should be denied treatment for tobacco-related conditions such as heart disease. But a Department of Health survey released to Labour MP Sally Keeble last week, shows that, despite official recommendations that all infertile couples should get three cycles of treatment free, clinics are increasingly making free IVF treatment conditional on not smoking. While smoking can affect a couple's chance of conceiving and smoking in pregnancy can damage the unborn child, tobacco use is listed as a 'non-clinical access criteria' in the survey - meaning it is not a medical requirement for treatment to work, but one of a series of optional requirements such as being in a steady relationship. Other lifestyle choices known to reduce fertility, such as drinking alcohol, do not affect eligibility in the same way."
The Rest of the Story
I suppose one effective way of knocking smokers out of society is to make sure that they cannot reproduce. As far-fetched as it may sound, this is essentially what the primary care trusts are doing in denying IVF treatment for smokers.
It is telling that these fertility clinics do not require women to stop drinking alcohol as a condition for IVF treatment. Smoking is being singled out, I believe, because it is viewed as a socially unacceptable lifestyle decision.
It is truly scary to think that a medical procedure would be denied to individuals based on a judgment about what is an appropriate or socially acceptable lifestyle. When judgments about lifestyle enter the clinical decision-making arena, the door is opened to all kinds of unacceptable consequences, such as denying treatment to individuals based on their sexual orientation or the presence of a "suitable" partner.
The hallmark of the practice of medicine is that it is supposed to be non-judgmental. As physicians, we are to provide the treatment that is in the best interests of the patient, without casting judgment upon the individual's lifestyle choices. Sure, it is perfectly appropriate to inform our patients about the health impact of their lifestyle choices, but we are not to deny medical care or to make such care conditional upon our patients conforming their lifestyle to meet our desires.
There is one reasonable criterion for denying medical care (outside of absolute medical contraindications) and that is situations in which the behavior in question is the cause of the medical problem and the treatment in question is severely limited in availability. For example, if an alcoholic seeks a liver transplant, it is not unreasonable to deny treatment or place the individual much lower on the transplant list because the alcohol was the cause of the liver damage and there are a very limited number of livers available for transplant. Clearly, this is not the case with in-vitro fertilization.
The policy of denying IVF treatment to obese or overweight individuals, or making that treatment conditional upon them changing their lifestyle, is equally despicable. People should not be denied basic rights because of their weight. Neither should they be denied basic rights because of their lifestyle decisions.
There are a host of medical treatments that are not as successful when the patient continues to engage in certain behaviors. There is no question, for example, that drug treatment for type II diabetes is much more effective when the patient loses weight. There is no question that treatment for hypertension is more effective when the patient restricts his or her salt intake. Insulin treatment for diabetes is more effective when the patient modifies his or her diet.
What are we going to do? Start restricting treatment of diabetes and hypertension to patients who agree to alter their diet and lose weight?
I can see why smokers are feeling persecuted by society. Their rights are being taken away. This is a threat both to basic human rights and to the integrity of medicine. As physicians, we are supposed to provide treatment to all patients without casting judgment upon them.
Monday, August 11, 2008
The Truth is Revealed: Philip Morris Helped Draft FDA Tobacco Legislation and Campaign for Tobacco-Free Kids Negotiated Bill with Philip Morris
In a press release issued on July 30, Senator Mike Enzi (R-WY), ranking member of the Senate Health, Education, Labor and Pensions Committee, denounced the House passage of the proposed FDA tobacco legislation, which he called the "Marlboro Protection Act." He stated that Philip Morris helped draft the bill, which "coddles Big Tobacco while protecting the industry's best tools to recruit and addict your children to tobacco."
According to Senator Enzi, Philip Morris supports the bill "because it will not stop anyone from smoking." He charged the anti-smoking groups with becoming so desperate to do something that they have fallen for "this wolf in sheep's clothing."
Calling the bill a "peace treaty" with Philip Morris which maintains the status quo and protects tobacco company profits rather than create real change which would reduce tobacco use, Enzi vowed to object to the bill and fight it on the Senate floor.
According to the press release: "U.S. Senator Mike Enzi (R-WY), Ranking Member of the Senate Health, Education, Labor and Pensions (HELP) Committee, today denounced passage by the House of Representatives of a so-called tobacco regulation bill he said “coddles Big Tobacco while protecting the industry’s best tools to recruit and addict your children to tobacco.” “Trying to make cigarettes safer through a billion-dollar bureaucracy is a waste of time and money,” Enzi said. “The right approach is to get people to stop smoking, or better yet, never to start. Big Tobacco supports this bill because it will not stop anyone from smoking. “Tobacco is one of the biggest contributors to our nation’s growing health care crisis. We need to fight the war on tobacco head on, not sign a peace treaty with Philip Morris, a company that perpetuates and profits from the crisis. Big Tobacco supports this bill because they have a stake in maintaining the status quo. I don't. They’re happy with a bill that doesn’t stop people from smoking; I’m not. I want real change, so I’m going to fight this bill and its Big Tobacco backers by objecting to it in the Senate.”
"Enzi noted that the bill would allow Big Tobacco to continue its aggressive marketing to kids by exempting menthol from a list of banned flavorings. Menthol is used by Big Tobacco to target and lure young smokers, particularly African-Americans. “Last year, during HELP Committee consideration of this bill, I filed several amendments addressing the menthol issue. Folks need to understand this glaring loophole in the bill and how it puts our kids at risk. “We know that Big Tobacco targets children and teenagers – particularly young African-Americans – by aggressively marketing menthol cigarettes to them,” Enzi said. “So why does this bill ban almost every type of flavoring in tobacco products except menthol? Supporters of this bill claim they want to protect children and families from unscrupulous tobacco companies, but the only people this approach protects is Big Tobacco.” The bill would gut the authority that Congress has bestowed and staunchly defended for the FDA – the authority to remove health threats from the marketplace, Enzi maintained."
"Philip Morris, the nation’s largest cigarette maker, helped draft the bill. “Poison peddlers shouldn't get to decide how we fight the war against their deadly products. I urge my friends in the public health community not to become so desperate to do something about the tobacco problem in this country that they fall for this wolf in sheep’s clothing,” Enzi added. “Keep asking yourself: if this bill is good for Big Tobacco, how can it be good for public health? The fact is it can’t. This bill is nothing more than a ‘Marlboro Protection Act,’ written to keep Philip Morris at the top of the tobacco market.”
In an article last Thursday published in the Washington Post, Associated Press reporter Ricardo Alonso-Zaldivar confirmed that the FDA bill was the result of a negotiation between the Campaign for Tobacco-Free Kids and Philip Morris, during which the Campaign made public health compromises in order to appease the nation's largest tobacco company. According to the article: "The legislation represents a compromise among major anti-smoking groups and some tobacco companies, including Philip Morris USA, the nation's largest. The bill has the support of a majority of senators, but it's unclear whether it will become law this year because the Bush administration has threatened a veto."
In the article, Alonso-Zaldivar reveals yet another loophole in the legislation. This time, it is an escape clause which allows tobacco companies 21 months after passage of the legislation to introduce new tobacco products into the marketplace: "It would let tobacco companies begin selling a new product provided they file a report with the FDA showing why the new product is similar to an existing one. That could be done at any time in the 21 months after enactment of the legislation."
According to the article, former FDA tobacco office director Mitch Zeller said the loophole was a "gift" to the tobacco companies.
The Rest of the Story
The rest of the story is that it is now clear that the Campaign for Tobacco-Free Kids has been running a campaign of deception and dishonesty. Multiple independent sources, including a number of top-notch investigative reporters and a member of the Congress, have confirmed that the FDA tobacco legislation represents the results of a negotiation between the Campaign for Tobacco-Free Kids and Philip Morris, and that the key provisions of the bill which protect tobacco company interests are present specifically because the Campaign made compromises to appease Philip Morris, which helped to draft the bill.
It is simply inappropriate for the Campaign to have negotiated with Philip Morris, especially without the consent and involvement of the rest of the tobacco control community. It is appalling that the Campaign would have made compromises that harm the protection of the public's health at the expense of the protection of tobacco industry profits. It is even more appalling that the Campaign agreed to these compromises without the inclusion and representation of the remainder of the tobacco control community. And it is disgraceful that the Campaign is pushing for a bill that was drafted, in part, by the nation's leading tobacco company.
As bad as all that sounds, what's even worse is that the Campaign has been dishonest about the facts behind the legislation and that it continues to deceive the public about the nature of the negotiations that led to the bill. Worse still is the Campaign's continuing deception of its own constituents about the fact that Philip Morris supports the legislation and is lobbying to promote its passage.
In my view, Senator Enzi's analysis is right on the mark. This is pro-tobacco legislation and the Campaign for Tobacco-Free Kids and its partners are acting as pro-tobacco groups in promoting its passage.
Philip Morris supports the bill specifically because it will stop nobody from smoking. In fact, the bill precludes each of the potential interventions that the FDA could otherwise take that would make a dent in smoking rates.
Why anti-smoking groups would support a bill that is being championed by the nation's leading tobacco company is beyond me. Why these groups would support a bill with numerous truck-sized loopholes that sell out the public's health to protect Big Tobacco profits is also beyond me. However, my leading hypothesis is that these groups are so anxious to be able to say they got something accomplished - to be able to put a feather in their cap - that the act of passing a bill has completely overshadowed the actual substance of the bill.
In other words, the Campaign for Tobacco-Free Kids is so determined to put a feather in its cap that it is willing to exclude the rest of the tobacco control community from the process, deceive its own constituents and the public about that process, ally itself with Philip Morris, and sell out the public's health to protect tobacco company profits.
According to Senator Enzi, Philip Morris supports the bill "because it will not stop anyone from smoking." He charged the anti-smoking groups with becoming so desperate to do something that they have fallen for "this wolf in sheep's clothing."
Calling the bill a "peace treaty" with Philip Morris which maintains the status quo and protects tobacco company profits rather than create real change which would reduce tobacco use, Enzi vowed to object to the bill and fight it on the Senate floor.
According to the press release: "U.S. Senator Mike Enzi (R-WY), Ranking Member of the Senate Health, Education, Labor and Pensions (HELP) Committee, today denounced passage by the House of Representatives of a so-called tobacco regulation bill he said “coddles Big Tobacco while protecting the industry’s best tools to recruit and addict your children to tobacco.” “Trying to make cigarettes safer through a billion-dollar bureaucracy is a waste of time and money,” Enzi said. “The right approach is to get people to stop smoking, or better yet, never to start. Big Tobacco supports this bill because it will not stop anyone from smoking. “Tobacco is one of the biggest contributors to our nation’s growing health care crisis. We need to fight the war on tobacco head on, not sign a peace treaty with Philip Morris, a company that perpetuates and profits from the crisis. Big Tobacco supports this bill because they have a stake in maintaining the status quo. I don't. They’re happy with a bill that doesn’t stop people from smoking; I’m not. I want real change, so I’m going to fight this bill and its Big Tobacco backers by objecting to it in the Senate.”
"Enzi noted that the bill would allow Big Tobacco to continue its aggressive marketing to kids by exempting menthol from a list of banned flavorings. Menthol is used by Big Tobacco to target and lure young smokers, particularly African-Americans. “Last year, during HELP Committee consideration of this bill, I filed several amendments addressing the menthol issue. Folks need to understand this glaring loophole in the bill and how it puts our kids at risk. “We know that Big Tobacco targets children and teenagers – particularly young African-Americans – by aggressively marketing menthol cigarettes to them,” Enzi said. “So why does this bill ban almost every type of flavoring in tobacco products except menthol? Supporters of this bill claim they want to protect children and families from unscrupulous tobacco companies, but the only people this approach protects is Big Tobacco.” The bill would gut the authority that Congress has bestowed and staunchly defended for the FDA – the authority to remove health threats from the marketplace, Enzi maintained."
"Philip Morris, the nation’s largest cigarette maker, helped draft the bill. “Poison peddlers shouldn't get to decide how we fight the war against their deadly products. I urge my friends in the public health community not to become so desperate to do something about the tobacco problem in this country that they fall for this wolf in sheep’s clothing,” Enzi added. “Keep asking yourself: if this bill is good for Big Tobacco, how can it be good for public health? The fact is it can’t. This bill is nothing more than a ‘Marlboro Protection Act,’ written to keep Philip Morris at the top of the tobacco market.”
In an article last Thursday published in the Washington Post, Associated Press reporter Ricardo Alonso-Zaldivar confirmed that the FDA bill was the result of a negotiation between the Campaign for Tobacco-Free Kids and Philip Morris, during which the Campaign made public health compromises in order to appease the nation's largest tobacco company. According to the article: "The legislation represents a compromise among major anti-smoking groups and some tobacco companies, including Philip Morris USA, the nation's largest. The bill has the support of a majority of senators, but it's unclear whether it will become law this year because the Bush administration has threatened a veto."
In the article, Alonso-Zaldivar reveals yet another loophole in the legislation. This time, it is an escape clause which allows tobacco companies 21 months after passage of the legislation to introduce new tobacco products into the marketplace: "It would let tobacco companies begin selling a new product provided they file a report with the FDA showing why the new product is similar to an existing one. That could be done at any time in the 21 months after enactment of the legislation."
According to the article, former FDA tobacco office director Mitch Zeller said the loophole was a "gift" to the tobacco companies.
The Rest of the Story
The rest of the story is that it is now clear that the Campaign for Tobacco-Free Kids has been running a campaign of deception and dishonesty. Multiple independent sources, including a number of top-notch investigative reporters and a member of the Congress, have confirmed that the FDA tobacco legislation represents the results of a negotiation between the Campaign for Tobacco-Free Kids and Philip Morris, and that the key provisions of the bill which protect tobacco company interests are present specifically because the Campaign made compromises to appease Philip Morris, which helped to draft the bill.
It is simply inappropriate for the Campaign to have negotiated with Philip Morris, especially without the consent and involvement of the rest of the tobacco control community. It is appalling that the Campaign would have made compromises that harm the protection of the public's health at the expense of the protection of tobacco industry profits. It is even more appalling that the Campaign agreed to these compromises without the inclusion and representation of the remainder of the tobacco control community. And it is disgraceful that the Campaign is pushing for a bill that was drafted, in part, by the nation's leading tobacco company.
As bad as all that sounds, what's even worse is that the Campaign has been dishonest about the facts behind the legislation and that it continues to deceive the public about the nature of the negotiations that led to the bill. Worse still is the Campaign's continuing deception of its own constituents about the fact that Philip Morris supports the legislation and is lobbying to promote its passage.
In my view, Senator Enzi's analysis is right on the mark. This is pro-tobacco legislation and the Campaign for Tobacco-Free Kids and its partners are acting as pro-tobacco groups in promoting its passage.
Philip Morris supports the bill specifically because it will stop nobody from smoking. In fact, the bill precludes each of the potential interventions that the FDA could otherwise take that would make a dent in smoking rates.
Why anti-smoking groups would support a bill that is being championed by the nation's leading tobacco company is beyond me. Why these groups would support a bill with numerous truck-sized loopholes that sell out the public's health to protect Big Tobacco profits is also beyond me. However, my leading hypothesis is that these groups are so anxious to be able to say they got something accomplished - to be able to put a feather in their cap - that the act of passing a bill has completely overshadowed the actual substance of the bill.
In other words, the Campaign for Tobacco-Free Kids is so determined to put a feather in its cap that it is willing to exclude the rest of the tobacco control community from the process, deceive its own constituents and the public about that process, ally itself with Philip Morris, and sell out the public's health to protect tobacco company profits.
Friday, August 08, 2008
FDA Tobacco Legislation Would Be a Death Knell to Reduced Risk Products and Could Cost Countless Lives
According to an August 1 article in the Lexington Herald-Leader, health experts have concluded that the FDA tobacco legislation currently being considered by Congress would put an end to the prospect of the development of truly reduced risk tobacco products because it bans the introduction of such products unless a reduced population-based and individual-based risk can be demonstrated through long-term epidemiologic studies.
According to the article: “Legislation approved by the House on Wednesday to give the Food and Drug Administration regulatory control over tobacco products fails to address the massive market changes of the last decade, growers and others say. Cigarette makers no longer claim nicotine isn't addictive or that their products aren't harmful, and the bill doesn't take that into account. It also doesn't acknowledge scientific advances in the potential for "reduced-harm" products, an advocate said. Scott Ballin, health and tobacco consultant with theAlliance
According to the article: “Legislation approved by the House on Wednesday to give the Food and Drug Administration regulatory control over tobacco products fails to address the massive market changes of the last decade, growers and others say. Cigarette makers no longer claim nicotine isn't addictive or that their products aren't harmful, and the bill doesn't take that into account. It also doesn't acknowledge scientific advances in the potential for "reduced-harm" products, an advocate said. Scott Ballin, health and tobacco consultant with the
“While the FDA could demand reduction or elimination of cancer-causing chemicals, manufacturers could not introduce or market lower-risk products without first proving such claims with decades-long population studies, according to a 2007 analysis by the Royal College of Physicians. That won't create much incentive to develop such products, Ballin said.”
The Rest of the Story
These are insightful and important observations about the likely impact of the proposed FDA tobacco legislation.
The key section of the bill is section 911, which sets out the criteria that need to be met before a reduced risk product can be introduced into the marketplace. According to this section:
"the Secretary shall approve an application for a modified risk tobacco product filed under this section only if the Secretary determines that the applicant has demonstrated that such product, as it is actually used by consumers, will--`(A) significantly reduce harm and the risk of tobacco-related disease to individual tobacco users; and `(B) benefit the health of the population as a whole taking into account both users of tobacco products and persons who do not currently use tobacco products.
Section 911(g)(1)(A), the (A) clause above places an insurmountable obstacle in the path of approval of modified risk products, at least for a 10-20 year period (which is enough to remove any incentive for companies to pursue such products). In order to demonstrate that the product, as actually used by consumers, will significantly reduce the risk of tobacco-related disease to individual users, large-scale, long-term epidemiologic studies are necessary. Even ignoring the requirement under 911(g)(1)(B), the (B) clause above (which itself appears to introduce an insurmountable obstacle), the bill as currently written precludes any harm reduction approach to tobacco control both by making it impossible for such products to meet the conditions for approval and by eliminating any incentive (especially economic) to develop such products. Thus, the bill may have the exact opposite effect that many believe it should have. It protects the existing high-risk products on the market.
Section 911 creates a literal catch-22 for reduced risk products. In order to introduce such a product into the market, you need to demonstrate that on an individual basis, it will reduce the risk of tobacco-related disease. However, in order to make such a demonstration, one would need to introduce the product into the market and follow a large sample of smokers for a long period of time – at least 10 years, if not longer. Thus, there is realistically no way to get a reduced risk product onto the market.
This legislation is likely to result in increased, not decreased deaths from tobacco products, because it will make it virtually impossible to research, develop, introduce, and market new potentially less hazardous tobacco products. It essentially freezes the market as it is and entrenches existing high-risk products into the market. It puts an end to any meaningful possibility of harm reduction as a tobacco control approach.
In his book “Virtually Safe Cigarettes: Reviving an Opportunity Once Tragically Rejected” (IOS Press, 2000), Dr. Gio Batta Gori (who formerly directed the National Cancer Institute’s Smoking and Health Program) describes research into potential ways to make cigarettes less hazardous. A fair amount of research was conducted on this question by the Smoking and Health Program between 1968 and 1979, but it was disbanded due to a new government policy which rejected this harm reduction approach.
Dr. Gori argues that the research conducted under this program lays the foundation for the potential development of a less hazardous cigarette. Interestingly, the major basis for believing that such a technological achievement is possible is not the belief that by selectively reducing specific components in cigarette smoke and by reducing the nicotine levels in cigarettes, a safer product can be achieved (which is precisely the approach that the FDA legislation takes in its tobacco product standards section). Instead, the basic premise is that by presenting high levels of nicotine and low levels of tar – in other words, increasing the nicotine/tar ratio – overall exposure to tar will be reduced because smokers will need to inhale less to achieve the same inhalation dose of nicotine. A major problem with existing low-yield cigarettes is that smokers increase their consumption and deepen their inhalation to achieve adequate nicotine levels.
Interestingly, the “solution” to the reduced risk cigarette is exactly the opposite of the approach being suggested by most tobacco control advocates and groups, and adopted in the FDA legislation: the reduction of nicotine levels. Instead, the only feasible and effective approach – according to Dr. Gori – is to increase the nicotine levels in combination with a variety of modifications which lower the tar. Gori presents the results of animal testing, for example, which demonstrate that a high-nicotine, high-carbon monoxide cigarette might present the best framework for a reduced risk cigarette.
Unfortunately, the current FDA legislation will not allow the development of a less hazardous cigarette – as Dr. Gori envisions – because it completely removes any incentive for tobacco companies to research and develop such a product. The barrier to introducing a reduced risk product is so great that no company would waste the millions of dollars it would take to develop the product with no meaningful prospect of ever introducing the product into the marketplace.
In my view, the best way to facilitate the development of a reduced risk product is not to regulate cigarettes with insurmountable obstacles, but instead, to allow the free market process to run its natural course. There is such a huge economic incentive for companies to produce a reduced risk product – imagine the number of smokers who would be thrilled to try such a product – that a market competition, a race to be the first to develop a safer cigarette, would take place.
Under the proposed FDA legislation, this market competition cannot and will not take place. And it could cost countless lives.
Thursday, August 07, 2008
Tobacco-Free Kids Admits It is More Interested in Changing Advocates' Negative Opinions on FDA Bill than Listening toThem and Discussing the Issues
Globalink is an international tobacco control list-serve that is intended to function as a discussion forum by which those of us working in tobacco control can engage in discussion of important science and policy issues. One of the issues that has been a major focus of discussion is the proposed FDA tobacco legislation that is currently being considered by Congress.
In an email sent to some of its staff members, the Campaign for Tobacco-Free Kids revealed last week that it is more interested in using the Globalink discussion forum to spread its propaganda on the legislation than it is in actually listening to the widespread opinion of the international tobacco control community and engaging in a discussion of the merits of the legislation.
According to the email:
"Globalink is dominated by the naysayers on our FDA bill - thus the only articles that have gotten posted are the most negative. Could I ask that we do a better job (quickly) of beginning to be sure that the positive articles get posted as well. It doesn't impact the vote in Congress but it certainly impacts opinion within the international tobacco control community."
The Rest of the Story
From the beginning, the Campaign for Tobacco-Free Kids has shown no interest in engaging in a discussion with the rest of the tobacco control community on the merits of the FDA tobacco legislation. Instead, the Campaign has run a long campaign of deception, dishonesty, and propaganda intended to jam the legislation down the throats of the tobacco control community, despite the widespread opposition to the approach taken by the bill.
This email confirms that the Campaign continues to have no interest in engaging the tobacco control community in a discussion of the merits of the legislation and no interest in considering the widespread opinion of the tobacco control community. Instead, the Campaign is committed to its pre-determined messianic mission of saving the world through the FDA legislation that it negotiated with Philip Morris.
Of course, as the widespread opinion of the "naysayers" reveals, the rest of the tobacco control community is not convinced that this FDA bill will save the world. Instead, there is widespread agreement that this bill represents little more than a huge favor to Philip Morris. The bill, it is recognized, is essentially the "Marlboro Preservation Act." It protects the financial profits of the nation's largest tobacco company at the expense of the public's health. It provides unprecedented special protections to Big Tobacco. It ends the prospect for harm reduction in tobacco control. It institutionalizes the defrauding of the American consumer. It ends any liability threat for the tobacco industry. And it will almost certainly increase smoking prevalence by deceiving smokers into thinking that cigarettes have been made safer.
The fact that the Campaign for Tobacco-Free Kids refers to the worldwide community of tobacco activists - which largely opposes the legislation - as "naysayers" is extremely revealing. A naysayer is defined not as someone who has a differing opinion, but as someone who has "an aggressively negative attitude." In other words, a naysayer is an obstructionist - someone who is merely obstructing an action that someone else wants to take.
Thus, the Campaign reveals here that it views the widespread negative opinion of many advocates about the FDA legislation not as legitimate, evidence-based opposition to the proposed policy, but as annoying, destructive obstruction to its own favored policy.
This is how the Campaign apparently views anyone who disagrees with its opinion: as an obstructionist.
It is clear to me that the Campaign for Tobacco-Free Kids has no interest in considering anyone else's opinion about the legislation and no interest in actually engaging in a discussion about the merits (or lack thereof) of the legislation.
The Campaign made a deal with Philip Morris and it has no interest in re-considering the merits of that agreement, no matter how much dissent there is in the tobacco control community.
This is not the way a leadership organization in public health should behave.
Frankly, the Campaign for Tobacco-Free Kids is operating purely as a political propaganda machine, not as a legitimate public health organization that actually has an interest in considering the views of its constituents.
The Campaign's actions remind me of the anti-smoking commercial in which a crying, coughing baby is heard over a baby monitor and then a tobacco industry executive turns off the monitor because he isn't interested in hearing the effects of secondhand smoke. Essentially, this is what the Campaign is doing. They are turning off the sound to the rest of the tobacco control movement. They simply don't want to hear the opposition.
The Campaign has already shown a disdain and disrespect for the rest of the tobacco control community by consistently trying to deceive them about the legislation. Now, it has added to that disrespect by acknowledging that it has no interest in engaging in a discussion, but merely wants to use our discussion forum to promote its own agenda -- an agenda, which I might add, is perceived by many in tobacco control as being decidedly pro-tobacco.
In an email sent to some of its staff members, the Campaign for Tobacco-Free Kids revealed last week that it is more interested in using the Globalink discussion forum to spread its propaganda on the legislation than it is in actually listening to the widespread opinion of the international tobacco control community and engaging in a discussion of the merits of the legislation.
According to the email:
"Globalink is dominated by the naysayers on our FDA bill - thus the only articles that have gotten posted are the most negative. Could I ask that we do a better job (quickly) of beginning to be sure that the positive articles get posted as well. It doesn't impact the vote in Congress but it certainly impacts opinion within the international tobacco control community."
The Rest of the Story
From the beginning, the Campaign for Tobacco-Free Kids has shown no interest in engaging in a discussion with the rest of the tobacco control community on the merits of the FDA tobacco legislation. Instead, the Campaign has run a long campaign of deception, dishonesty, and propaganda intended to jam the legislation down the throats of the tobacco control community, despite the widespread opposition to the approach taken by the bill.
This email confirms that the Campaign continues to have no interest in engaging the tobacco control community in a discussion of the merits of the legislation and no interest in considering the widespread opinion of the tobacco control community. Instead, the Campaign is committed to its pre-determined messianic mission of saving the world through the FDA legislation that it negotiated with Philip Morris.
Of course, as the widespread opinion of the "naysayers" reveals, the rest of the tobacco control community is not convinced that this FDA bill will save the world. Instead, there is widespread agreement that this bill represents little more than a huge favor to Philip Morris. The bill, it is recognized, is essentially the "Marlboro Preservation Act." It protects the financial profits of the nation's largest tobacco company at the expense of the public's health. It provides unprecedented special protections to Big Tobacco. It ends the prospect for harm reduction in tobacco control. It institutionalizes the defrauding of the American consumer. It ends any liability threat for the tobacco industry. And it will almost certainly increase smoking prevalence by deceiving smokers into thinking that cigarettes have been made safer.
The fact that the Campaign for Tobacco-Free Kids refers to the worldwide community of tobacco activists - which largely opposes the legislation - as "naysayers" is extremely revealing. A naysayer is defined not as someone who has a differing opinion, but as someone who has "an aggressively negative attitude." In other words, a naysayer is an obstructionist - someone who is merely obstructing an action that someone else wants to take.
Thus, the Campaign reveals here that it views the widespread negative opinion of many advocates about the FDA legislation not as legitimate, evidence-based opposition to the proposed policy, but as annoying, destructive obstruction to its own favored policy.
This is how the Campaign apparently views anyone who disagrees with its opinion: as an obstructionist.
It is clear to me that the Campaign for Tobacco-Free Kids has no interest in considering anyone else's opinion about the legislation and no interest in actually engaging in a discussion about the merits (or lack thereof) of the legislation.
The Campaign made a deal with Philip Morris and it has no interest in re-considering the merits of that agreement, no matter how much dissent there is in the tobacco control community.
This is not the way a leadership organization in public health should behave.
Frankly, the Campaign for Tobacco-Free Kids is operating purely as a political propaganda machine, not as a legitimate public health organization that actually has an interest in considering the views of its constituents.
The Campaign's actions remind me of the anti-smoking commercial in which a crying, coughing baby is heard over a baby monitor and then a tobacco industry executive turns off the monitor because he isn't interested in hearing the effects of secondhand smoke. Essentially, this is what the Campaign is doing. They are turning off the sound to the rest of the tobacco control movement. They simply don't want to hear the opposition.
The Campaign has already shown a disdain and disrespect for the rest of the tobacco control community by consistently trying to deceive them about the legislation. Now, it has added to that disrespect by acknowledging that it has no interest in engaging in a discussion, but merely wants to use our discussion forum to promote its own agenda -- an agenda, which I might add, is perceived by many in tobacco control as being decidedly pro-tobacco.
Wednesday, August 06, 2008
Campaign for Tobacco-Free Kids Still Hiding the Truth About FDA Tobacco Legislation; Honesty is Just Not Possible from this Organization
In an email sent to its constituents this morning, the Campaign for Tobacco-Free Kids once again deceived them by distorting the truth. In the email, the Campaign implied that Big Tobacco (which includes Philip Morris) is opposed to the FDA tobacco legislation and is using its massive lobbying resources to oppose the bill. This is dishonest, as the truth is that Philip Morris strongly supports the bill and is using its massive lobbying resources to promote passage of the legislation.
The email states: "As you know, last Wednesday the House of Representatives passed H.R. 1108 with overwhelming support. Your Representative, X, voted YES to grant the FDA authority to regulate tobacco products! Click here to say thank you! Tobacco companies spent a lot of time and money trying to persuade members of Congress to protect their profits, but Representative X had the courage to do what was right."
The Rest of the Story
The Campaign for Tobacco-Free Kids is being dishonest, and it knows it. It is not truthful to state that the tobacco companies spent a lot of time and money trying to persuade members of Congress to protect their profits by voting against the legislation. The truth is that Philip Morris - the largest tobacco company by far (it holds half of all domestic cigarette market share) - spent a lot of time and money trying to persuade members of Congress to support the legislation.
Regardless of how one feels about the merits of the FDA tobacco legislation, I would hope that we could all agree that public health groups should not be telling untruths to the public in order to promote their position on the legislation.
Ironically, one of the primary purposes of the legislation - as acknowledged by the Campaign itself - is to end the dishonesty and deception by the tobacco companies. The tactic that the Campaign is using to end this dishonesty and deception is to run a campaign of dishonesty and deception.
The unethical behavior of the Campaign for Tobacco-Free Kids just never ceases. I'm beginning to think that this organization is not capable of being honest.
It's a shame, because it really taints the honesty and integrity of the entire tobacco control movement.
The email states: "As you know, last Wednesday the House of Representatives passed H.R. 1108 with overwhelming support. Your Representative, X, voted YES to grant the FDA authority to regulate tobacco products! Click here to say thank you! Tobacco companies spent a lot of time and money trying to persuade members of Congress to protect their profits, but Representative X had the courage to do what was right."
The Rest of the Story
The Campaign for Tobacco-Free Kids is being dishonest, and it knows it. It is not truthful to state that the tobacco companies spent a lot of time and money trying to persuade members of Congress to protect their profits by voting against the legislation. The truth is that Philip Morris - the largest tobacco company by far (it holds half of all domestic cigarette market share) - spent a lot of time and money trying to persuade members of Congress to support the legislation.
Regardless of how one feels about the merits of the FDA tobacco legislation, I would hope that we could all agree that public health groups should not be telling untruths to the public in order to promote their position on the legislation.
Ironically, one of the primary purposes of the legislation - as acknowledged by the Campaign itself - is to end the dishonesty and deception by the tobacco companies. The tactic that the Campaign is using to end this dishonesty and deception is to run a campaign of dishonesty and deception.
The unethical behavior of the Campaign for Tobacco-Free Kids just never ceases. I'm beginning to think that this organization is not capable of being honest.
It's a shame, because it really taints the honesty and integrity of the entire tobacco control movement.
Tuesday, August 05, 2008
Jacob Sullum on Scottish Smoking Ban and Heart Attack Study
As usual, Jacob Sullum has an insightful commentary on the Scottish smoking ban and heart attack study. He also comments on the Wales study and correctly points out that many locations that adopt smoking bans are invariably going to see declines in heart attacks in subsequent months or years. You can't focus only on those locations. What is needed is a systematic study of multiple locations (like that conducted by Dave Kuneman and Michael McFadden, which found no significant immediate effect of smoking bans on heart attacks).
No Reduction in Heart Attacks in Wales During First Nine Months Following Smoking Ban; Anti-Smoking Groups Cherry-picked Data to Try to Show an Effect
(Note: This post draws upon an analysis of heart attack data by Christopher Snowdon over at Velvet Glove Iron Fist. The original piece upon which this post is based can be found here).
Data from Wales released by Christopher Snowdon yesterday reveal that there was no reduction in hospital admissions for myocardial infarction (heart attacks) during the first 9 months after implementation of the smoking ban throughout Wales. Snowdon obtained monthly data on heart attack admissions from all Welsh hospitals for the years 2006 and 2007. The smoking ban went into effect on April 2, 2007.
There were 4,199 heart attack admissions in 2006 and 4,155 in 2007. Thus, there was essentially no change in heart attacks between these two years. In contrast, there was a 6.3% decline in heart attack admissions from 2005 to 2006 and a 10.3% decline in admissions from 2004 to 2005, according to Snowdon.
When analyzing the data by month, Snowdon found that comparing 2007 to 2006, there was an increase in heart attack admissions during the first five months after the smoking ban (April through August) and a decline in heart attack admissions during the next four months (September through December).
The Rest of the Story
Although it seems quite clear that the data show that the smoking ban in Wales was not associated with a decline in heart attack admissions during the first 9 months it was in effect (and if anything, the decline in heart attacks came to a halt), this did not stop anti-smoking groups from claiming that the smoking ban in Wales led to a reduction in heart attacks.
How did the anti-smoking groups pull off this miraculous feat, given that the data so clearly indicate no reduction in heart attacks?
They used a technique known as cherry-picking. By citing data for the few specific months in which there was a decline in heart attacks from 2006 to 2007, they purported to show that the smoking ban had resulted in a reduction in heart attacks.
In an article published this past June in The Daily Post, Action on Smoking and Health (UK) was quoted as saying: "It seems likely that the drop in hospital admissions for heart attacks is linked to the implementation of the smoking ban. It shows just how quickly the benefits can be felt."
What data were ASH referring to in making this pronouncement? Clearly, it was not the data for the first nine months after implementation of the smoking ban (April through December).
It turns out that ASH was citing data cherry-picked for the months October through December. Compared to the corresponding period in 2006, this three-month period in 2007 saw a 13% decline in heart attacks.
Had ASH examined data for the full period of April through December (which was obviously available at the time of its pronouncement), it could have come to no conclusion other than that there was no decline in heart attacks associated with the first 9 months of the smoking ban.
In an article published in Wales Online, the British Heart Foundation is quoted as stating: "These new statistics are very significant, and indicate the smoking ban has had a beneficial effect on the number of heart attacks quicker than many people predicted."
What "new statistics" is the British Heart Foundation referring to which purportedly demonstrate that the smoking ban in Wales resulted in a reduction in heart attacks?
Once again, it turns out that the British Heart Foundation is referring to the cherry-picked data from October through December of 2007 which reveal a 13% decline in heart attacks during these months compared to the corresponding period in 2006. But a broader look, which includes all 9 months following the smoking ban, confirms that there actually was no change in heart attack admissions. Apparently, these three months were cherry-picked in order to show an effect.
First, these data cast doubt on the conclusion of studies - such as the report from Scotland published last week - that smoking bans result in a dramatic, immediate drop in heart attacks. There seems little doubt that such a decline was not observed in Wales, a result which seems inconsistent with the conclusion of these other studies.
Second, it will be interesting to see whether anti-smoking groups acknowledge these data or ignore them. Are anti-smoking groups interested in the truth, or are they only interested in results which support their pre-determined conclusions?
Third, this story demonstrates that anti-smoking groups are not relying on solid science to draw their conclusions about the effects of smoking bans on heart attacks. They are willing to rely on cherry-picking of a fraction of the relevant data to draw their conclusions and make their pronouncements to the public.
It's quite clear that anti-smoking groups are prepared to rally around and tout the results of any study that draws favorable conclusions, regardless of the quality of the science. But what's most interesting to me is that we in tobacco control have denounced smoking ban opponents for relying on studies with exactly the same tactics - cherry-picking of data - in order to "demonstrate" that smoking bans result in a decline in restaurant sales. How can we on the one hand denounce studies that do not consider all relevant data and come to unfavorable conclusions and then on the other hand tout the results of studies using the same methodology which come to favorable conclusions?
Will the British Heart Foundation and ASH now retract their earlier statements and apologize to the public for drawing and disseminating premature conclusions? I doubt it. This is why it is essential that we get it right the first time around.
But when your sole criterion for scientific quality is whether the study results support your pre-determined conclusion, it is going to be difficult to get it right the first time, or any time.
Data from Wales released by Christopher Snowdon yesterday reveal that there was no reduction in hospital admissions for myocardial infarction (heart attacks) during the first 9 months after implementation of the smoking ban throughout Wales. Snowdon obtained monthly data on heart attack admissions from all Welsh hospitals for the years 2006 and 2007. The smoking ban went into effect on April 2, 2007.
There were 4,199 heart attack admissions in 2006 and 4,155 in 2007. Thus, there was essentially no change in heart attacks between these two years. In contrast, there was a 6.3% decline in heart attack admissions from 2005 to 2006 and a 10.3% decline in admissions from 2004 to 2005, according to Snowdon.
When analyzing the data by month, Snowdon found that comparing 2007 to 2006, there was an increase in heart attack admissions during the first five months after the smoking ban (April through August) and a decline in heart attack admissions during the next four months (September through December).
The Rest of the Story
Although it seems quite clear that the data show that the smoking ban in Wales was not associated with a decline in heart attack admissions during the first 9 months it was in effect (and if anything, the decline in heart attacks came to a halt), this did not stop anti-smoking groups from claiming that the smoking ban in Wales led to a reduction in heart attacks.
How did the anti-smoking groups pull off this miraculous feat, given that the data so clearly indicate no reduction in heart attacks?
They used a technique known as cherry-picking. By citing data for the few specific months in which there was a decline in heart attacks from 2006 to 2007, they purported to show that the smoking ban had resulted in a reduction in heart attacks.
In an article published this past June in The Daily Post, Action on Smoking and Health (UK) was quoted as saying: "It seems likely that the drop in hospital admissions for heart attacks is linked to the implementation of the smoking ban. It shows just how quickly the benefits can be felt."
What data were ASH referring to in making this pronouncement? Clearly, it was not the data for the first nine months after implementation of the smoking ban (April through December).
It turns out that ASH was citing data cherry-picked for the months October through December. Compared to the corresponding period in 2006, this three-month period in 2007 saw a 13% decline in heart attacks.
Had ASH examined data for the full period of April through December (which was obviously available at the time of its pronouncement), it could have come to no conclusion other than that there was no decline in heart attacks associated with the first 9 months of the smoking ban.
In an article published in Wales Online, the British Heart Foundation is quoted as stating: "These new statistics are very significant, and indicate the smoking ban has had a beneficial effect on the number of heart attacks quicker than many people predicted."
What "new statistics" is the British Heart Foundation referring to which purportedly demonstrate that the smoking ban in Wales resulted in a reduction in heart attacks?
Once again, it turns out that the British Heart Foundation is referring to the cherry-picked data from October through December of 2007 which reveal a 13% decline in heart attacks during these months compared to the corresponding period in 2006. But a broader look, which includes all 9 months following the smoking ban, confirms that there actually was no change in heart attack admissions. Apparently, these three months were cherry-picked in order to show an effect.
Implications of the Rest of the Story
First, these data cast doubt on the conclusion of studies - such as the report from Scotland published last week - that smoking bans result in a dramatic, immediate drop in heart attacks. There seems little doubt that such a decline was not observed in Wales, a result which seems inconsistent with the conclusion of these other studies.
Second, it will be interesting to see whether anti-smoking groups acknowledge these data or ignore them. Are anti-smoking groups interested in the truth, or are they only interested in results which support their pre-determined conclusions?
Third, this story demonstrates that anti-smoking groups are not relying on solid science to draw their conclusions about the effects of smoking bans on heart attacks. They are willing to rely on cherry-picking of a fraction of the relevant data to draw their conclusions and make their pronouncements to the public.
It's quite clear that anti-smoking groups are prepared to rally around and tout the results of any study that draws favorable conclusions, regardless of the quality of the science. But what's most interesting to me is that we in tobacco control have denounced smoking ban opponents for relying on studies with exactly the same tactics - cherry-picking of data - in order to "demonstrate" that smoking bans result in a decline in restaurant sales. How can we on the one hand denounce studies that do not consider all relevant data and come to unfavorable conclusions and then on the other hand tout the results of studies using the same methodology which come to favorable conclusions?
Will the British Heart Foundation and ASH now retract their earlier statements and apologize to the public for drawing and disseminating premature conclusions? I doubt it. This is why it is essential that we get it right the first time around.
But when your sole criterion for scientific quality is whether the study results support your pre-determined conclusion, it is going to be difficult to get it right the first time, or any time.
Monday, August 04, 2008
IN MY VIEW: Another Reason Why Conclusion of Scottish Smoking Ban Study is Invalid - Effect May Have Been Due to Diagnostic and Treatment Changes
I have already explained why I think the conclusion of the study which reported a 17% decline in acute coronary syndrome admissions in 9 Scottish hospitals following implementation of the national smoking ban is invalid. In that previous post, I focused on the failure of the study to establish a valid baseline of acute coronary syndrome admission in these 9 hospitals, and therefore, its inability to be able to comment on whether the observed 17% reduction is something different from that seen in the past.
The study reported a decline in acute coronary syndrome admissions from 3235 to 2684, comparing the ten-month period preceding the smoking ban with the corresponding period after the smoking ban. Now suppose that the number of acute coronary syndrome admissions in the corresponding period of the previous year was about 3300. Then, it would be clear that this 17% reduction represents something very different - there was basically no decline in the previous year.
However, suppose the number of acute coronary syndrome admissions in the previous year was about 3800. Then, the observed 17% reduction associated with the smoking ban would no longer be so impressive, since there was a 14% reduction during the previous year.
Well - which of these scenarios is the true one? The validity of the study conclusions rests entirely on the answer.
Unfortunately, the answer is unknown. The study does not report the number of admissions for acute coronary syndrome - using the same diagnostic criterion of an elevated cardiac troponin level - during the previous year. Thus, there is no way to know whether the 17% reduction is something new and different, or whether there already was a trend of sharply declining admissions.
As a result, the study findings simply are not enough to support the study conclusions. The research can surely conclude that there was a sharp decline in acute coronary syndrome admissions associated with the smoking ban, but the research cannot conclude that the decline was attributable to the smoking ban.
Here, I present another reason why the study conclusion is not valid: there is a very plausible alternative explanation for the observed decline in acute coronary syndrome admissions.
The Rest of the Story
What seems to have gone largely unnoticed in the article and the news coverage around it is the fact that another major heart disease intervention took place in these 9 Scottish hospitals around the time of the smoking ban: these hospitals used a relatively new system for diagnosing heart disease -- cardiac troponin assays.
Previously, the diagnosis of unstable angina and silent heart attacks (those without any symptoms) was problematic because of the lack of a sensitive laboratory test. Creatine kinase (CK) - the test previously used - is not sensitive enough to be able to pick up all cases of unstable angina and it may not pick up silent heart attacks that occurred in the recent past. However, cardiac troponin is a much more sensitive test, and it is able both to pick up very small areas of myocardial ischemic injury as well as injury that occurred in the recent past. For this reason, the use of cardiac troponin brings with it the ability to diagnose many more cases of severe cardiac disease that might not have been recognized in the past.
When physicians know about the presence of ischemic injury, they can take a more aggressive treatment approach. Ultimately, this is expected to reduce the incidence of future heart attacks in these patients.
This is all explained rather nicely in this article on Emax Health:
The bottom line is that a plausible explanation for the observed 17% reduction in acute coronary syndrome admissions in the 9 Scottish hospitals in the study is that the intervention (that is, the use of cardiac troponin testing for all patients with chest pain or suspected heart disease), rather than the smoking ban, caused this reduction.
Without knowing the effect on acute coronary syndrome admissions of using this new diagnostic system, it is impossible to conclude that the 17% reduction was due to the smoking ban, rather than to this important diagnostic and therapeutic change.
It is not clear exactly when the intervention was implemented in these 9 hospitals. Presumably, it was not in place in all 9 hospitals until 10 months prior to the smoking ban - this is presumably why the researchers included only data for this 10 month period in the study. If the intervention was in place in all 9 hospitals well prior to that, then the obvious question would become: why does the paper not present the data on admissions for acute coronary syndrome during the entire period in which the intervention was in place in these hospitals?
It is important to emphasize that I am not questioning here the validity of the study's conclusion that there was a 17% decline in acute coronary syndrome admissions. What I am questioning is the attribution of that decline - in its entirety - to the smoking ban, rather than to improved diagnosis and treatment, which is precisely the reason that the cardiac troponin system was put in place in these hospitals.
The study reported a decline in acute coronary syndrome admissions from 3235 to 2684, comparing the ten-month period preceding the smoking ban with the corresponding period after the smoking ban. Now suppose that the number of acute coronary syndrome admissions in the corresponding period of the previous year was about 3300. Then, it would be clear that this 17% reduction represents something very different - there was basically no decline in the previous year.
However, suppose the number of acute coronary syndrome admissions in the previous year was about 3800. Then, the observed 17% reduction associated with the smoking ban would no longer be so impressive, since there was a 14% reduction during the previous year.
Well - which of these scenarios is the true one? The validity of the study conclusions rests entirely on the answer.
Unfortunately, the answer is unknown. The study does not report the number of admissions for acute coronary syndrome - using the same diagnostic criterion of an elevated cardiac troponin level - during the previous year. Thus, there is no way to know whether the 17% reduction is something new and different, or whether there already was a trend of sharply declining admissions.
As a result, the study findings simply are not enough to support the study conclusions. The research can surely conclude that there was a sharp decline in acute coronary syndrome admissions associated with the smoking ban, but the research cannot conclude that the decline was attributable to the smoking ban.
Here, I present another reason why the study conclusion is not valid: there is a very plausible alternative explanation for the observed decline in acute coronary syndrome admissions.
The Rest of the Story
What seems to have gone largely unnoticed in the article and the news coverage around it is the fact that another major heart disease intervention took place in these 9 Scottish hospitals around the time of the smoking ban: these hospitals used a relatively new system for diagnosing heart disease -- cardiac troponin assays.
Previously, the diagnosis of unstable angina and silent heart attacks (those without any symptoms) was problematic because of the lack of a sensitive laboratory test. Creatine kinase (CK) - the test previously used - is not sensitive enough to be able to pick up all cases of unstable angina and it may not pick up silent heart attacks that occurred in the recent past. However, cardiac troponin is a much more sensitive test, and it is able both to pick up very small areas of myocardial ischemic injury as well as injury that occurred in the recent past. For this reason, the use of cardiac troponin brings with it the ability to diagnose many more cases of severe cardiac disease that might not have been recognized in the past.
When physicians know about the presence of ischemic injury, they can take a more aggressive treatment approach. Ultimately, this is expected to reduce the incidence of future heart attacks in these patients.
This is all explained rather nicely in this article on Emax Health:
"Patients who test positive for the presence of a specific biochemical marker of heart cell death in their blood but who do not exhibit other risk factors for future heart attack should be treated as higher risk patients, according to a new analysis by cardiologists at Duke University Medical Center.
The researchers found that troponin, a protein that is released into the bloodstream as heart muscle cells die, can be a reliable indicator of future risk even when other traditional measures of heart health are negative. This is important, the researchers say, in light of the recent recasting of the definition of heart attack by the major cardiology organizations to place more emphasis on the results of troponin testing, in addition to the presence of chest pain and electrocardiogram abnormalities.
When a patient comes to the emergency room as a possible heart attack victim, physicians typically measure the heart's electrical activity (EKG) and also look for chemicals in the blood that might indicate if heart muscle is damaged or dead. For years, they have measured the levels of creatine kinase-MB (CK-MB) and, more recently, they also have been testing for troponin. Because the test for troponin can detect even small amounts of heart muscle damage, patients previously testing positive for troponin but negative for CK-MB were not always treated as being at high-risk.
'Our analysis shows that patients who test positive for troponin but not for CK-MB should still be treated as if they tested positive for both,' said Duke cardiology fellow Dr. Sunil Rao. 'This is important because in the past, these patients would usually not be treated aggressively.'"
An article by Drs. Brian Go and H. Vernon Anderson nicely explains how the use of cardiac troponin results in the earlier identification of patients with unstable angina, which can lead to more aggressive treatment. As these cardiologists explain, an elevation of troponin is a risk factor for future heart attacks. Thus, these represent patients who previously may not have been treated as aggressively and therefore would be at high risk for heart attack. With more aggressive treatment, heart attack risk can be reduced, at least in the short-term.The bottom line is that a plausible explanation for the observed 17% reduction in acute coronary syndrome admissions in the 9 Scottish hospitals in the study is that the intervention (that is, the use of cardiac troponin testing for all patients with chest pain or suspected heart disease), rather than the smoking ban, caused this reduction.
Without knowing the effect on acute coronary syndrome admissions of using this new diagnostic system, it is impossible to conclude that the 17% reduction was due to the smoking ban, rather than to this important diagnostic and therapeutic change.
It is not clear exactly when the intervention was implemented in these 9 hospitals. Presumably, it was not in place in all 9 hospitals until 10 months prior to the smoking ban - this is presumably why the researchers included only data for this 10 month period in the study. If the intervention was in place in all 9 hospitals well prior to that, then the obvious question would become: why does the paper not present the data on admissions for acute coronary syndrome during the entire period in which the intervention was in place in these hospitals?
It is important to emphasize that I am not questioning here the validity of the study's conclusion that there was a 17% decline in acute coronary syndrome admissions. What I am questioning is the attribution of that decline - in its entirety - to the smoking ban, rather than to improved diagnosis and treatment, which is precisely the reason that the cardiac troponin system was put in place in these hospitals.
Thursday, July 31, 2008
New Research Article Concludes that Smoking Ban in Scotland Caused a 17% Reduction in Acute Coronary Events; Comparing Apples to Oranges
A study published in the current issue of the New England Journal of Medicine reports that the smoking ban in Scotland resulted in a 17% decline in hospital admissions for acute coronary syndrome (including myocardial infarctions [heart attacks] and unstable angina) (see : Pell JP et al. Smoke-free legislation and hospitalizations for acute coronary syndrome. N Engl J Med 2008; 359:482-491).
The study compared the number of admissions for acute coronary syndrome in nine hospitals in Scotland (representing 63% of admissions for acute coronary syndrome in the country) during the 10-month period prior to the smoking ban and the corresponding 10-month period the following year. The number of admissions declined from 3235 to 2684, a drop of 17%.
This 17% drop was compared to the trend in overall hospital admissions in all of Scotland during the preceding 10 years. According to the study, "the trend during the 10 years before legislation was a 3% mean annual reduction, with a maximum reduction of 9% in 2000."
Because the observed 17% reduction in admissions for acute coronary syndrome was much higher than the annual reduction during the 10 previous years and exceeded the highest annual decline between any two years, the study concludes that the observed reduction is attributable to the smoking ban.
The Rest of the Story
The problem with this article is that its conclusion is based on a comparison of apples to oranges. In order to compare the change in heart attacks in Scotland from 2006-2007 to the trend in heart attacks during the preceding ten-year period, one needs to use the same data source to compare these trends.
In this article, the researchers use one source of data to estimate the change in heart attacks from 2006-2007 (observed changes in admissions for nine hospitals representing a portion of the country) and a different source of data to estimate the trend in heart attacks from 1996-2006 (national data from the Scottish National Health Service).
A critical basis for the article's conclusion is that the year-to-year decline in heart attacks in Scotland never exceeded 10%, while the researchers found a 17% decline in heart attacks during the year following the smoking ban.
However, the relevant question is not what the national health service data show, but what changes in heart attack admissions would have been found using the same methods employed by the researchers to count heart attack admissions for 2006-2007. What would the annual changes have been using the same 9 hospitals and using the same method of counting heart attack admissions?
It is important to note that:
(1) The diagnosis of acute coronary syndrome in 2006-2007 was based on an assay for cardiac troponin (a component of cardiac muscle which is released into the blood following heart injury), which is a very sensitive test for cardiac injury. For the period 1996-2006, the diagnosis was likely made based on less sensitive measures, since the use of troponin to diagnose coronary syndrome has greatly increased in recent years.
(2) The random variation and secular trends in coronary syndrome for the 10-year period prior to the smoking ban are based on standardized, national data which include the entire country of Scotland. Thus, the variation is likely to be much lower than the variation in the data from a sample of just 9 hospitals.
The correct way to conduct this analysis would be to examine the trends in heart attacks in all of Scotland for the entire ten-year period using a single, standardized and consistent data source and then to examine the degree of random variation in year-to-year changes in heart attacks and see if the observed change associated with the smoking ban is inconsistent with the magnitude of observed year-to-year changes during the years preceding the smoking ban.
Fortunately, the annual data on heart attack admissions in Scotland is available online, so we can examine the magnitude of year-to-year changes in heart attacks in the past decade and see how the change associated with the smoking ban compares.
Remember that the smoking ban was implemented in March 2006, so changes from 2005 to 2006 would reflect the smoking ban, as would changes from 2006 to 2007.
Between 2005 and 2006, the number of heart attack admissions in all of Scotland declined by 4.2%. Between 2006 and 2007, the number of heart attack admissions in Scotland dropped by 8.0%.
That might sound like a big drop, large enough that we would conclude it was due to the smoking ban.
However, look at the year-to-year declines in heart attacks in Scotland in years prior to the smoking ban.
Between 2003 and 2004, heart attack admissions declined by 4.6%. This is greater than the observed heart attack decline from 2005 to 2006.
Between 1999 and 2000, heart attack admissions in Scotland declined by 10.2%. This is much greater than even the 8.0% decline observed from 2006 to 2007.
Even if we look at the 2-year decline in heart attacks from 2005 to 2007, it is about the same as the 2-year decline observed bewteen 1999 and 2001 (11.9% compared to 10.7%).
If I present the data this way, it makes it clear that the observed change in heart attacks associated with the smoking ban is not at all out of the range of normal declines in heart attacks from year to year in Scotland observed in the absence of the smoking ban.
2005-2006: -4.2% 2003-2004: -4.6%
2006-2007: -8.0% 1999-2000: -10.2%
My point here is not that these data prove there was no decline in heart attacks in Scotland attributable to the smoking ban. My point is merely that there is no way one can conclude that the observed decline in the year following the smoking ban was different from the magnitude of the declines observed in previous years.
The analysis in this paper assumes that the entire observed change in heart attacks is attributable to the smoking ban. However, it is clear that a 10.2% decline in Scotland from 1999-2000 occurred in the complete absence of a smoking ban. Clearly, there are other factors which are contributing to a decline in heart attacks, there is a secular trend of substantially declining heart attacks over time, and in fact, the magnitude of the decline associated with the smoking ban is less than the magnitude of the decline observed in some recent years preceding the smoking ban.
In other words, one cannot rule out the very plausible alternative hypothesis that the observed decline in heart attacks is explained by random variation in the data and the already existing secular trend of declining heart attacks in Scotland.
The study compared the number of admissions for acute coronary syndrome in nine hospitals in Scotland (representing 63% of admissions for acute coronary syndrome in the country) during the 10-month period prior to the smoking ban and the corresponding 10-month period the following year. The number of admissions declined from 3235 to 2684, a drop of 17%.
This 17% drop was compared to the trend in overall hospital admissions in all of Scotland during the preceding 10 years. According to the study, "the trend during the 10 years before legislation was a 3% mean annual reduction, with a maximum reduction of 9% in 2000."
Because the observed 17% reduction in admissions for acute coronary syndrome was much higher than the annual reduction during the 10 previous years and exceeded the highest annual decline between any two years, the study concludes that the observed reduction is attributable to the smoking ban.
The Rest of the Story
The problem with this article is that its conclusion is based on a comparison of apples to oranges. In order to compare the change in heart attacks in Scotland from 2006-2007 to the trend in heart attacks during the preceding ten-year period, one needs to use the same data source to compare these trends.
In this article, the researchers use one source of data to estimate the change in heart attacks from 2006-2007 (observed changes in admissions for nine hospitals representing a portion of the country) and a different source of data to estimate the trend in heart attacks from 1996-2006 (national data from the Scottish National Health Service).
A critical basis for the article's conclusion is that the year-to-year decline in heart attacks in Scotland never exceeded 10%, while the researchers found a 17% decline in heart attacks during the year following the smoking ban.
However, the relevant question is not what the national health service data show, but what changes in heart attack admissions would have been found using the same methods employed by the researchers to count heart attack admissions for 2006-2007. What would the annual changes have been using the same 9 hospitals and using the same method of counting heart attack admissions?
It is important to note that:
(1) The diagnosis of acute coronary syndrome in 2006-2007 was based on an assay for cardiac troponin (a component of cardiac muscle which is released into the blood following heart injury), which is a very sensitive test for cardiac injury. For the period 1996-2006, the diagnosis was likely made based on less sensitive measures, since the use of troponin to diagnose coronary syndrome has greatly increased in recent years.
(2) The random variation and secular trends in coronary syndrome for the 10-year period prior to the smoking ban are based on standardized, national data which include the entire country of Scotland. Thus, the variation is likely to be much lower than the variation in the data from a sample of just 9 hospitals.
The correct way to conduct this analysis would be to examine the trends in heart attacks in all of Scotland for the entire ten-year period using a single, standardized and consistent data source and then to examine the degree of random variation in year-to-year changes in heart attacks and see if the observed change associated with the smoking ban is inconsistent with the magnitude of observed year-to-year changes during the years preceding the smoking ban.
Fortunately, the annual data on heart attack admissions in Scotland is available online, so we can examine the magnitude of year-to-year changes in heart attacks in the past decade and see how the change associated with the smoking ban compares.
Remember that the smoking ban was implemented in March 2006, so changes from 2005 to 2006 would reflect the smoking ban, as would changes from 2006 to 2007.
Between 2005 and 2006, the number of heart attack admissions in all of Scotland declined by 4.2%. Between 2006 and 2007, the number of heart attack admissions in Scotland dropped by 8.0%.
That might sound like a big drop, large enough that we would conclude it was due to the smoking ban.
However, look at the year-to-year declines in heart attacks in Scotland in years prior to the smoking ban.
Between 2003 and 2004, heart attack admissions declined by 4.6%. This is greater than the observed heart attack decline from 2005 to 2006.
Between 1999 and 2000, heart attack admissions in Scotland declined by 10.2%. This is much greater than even the 8.0% decline observed from 2006 to 2007.
Even if we look at the 2-year decline in heart attacks from 2005 to 2007, it is about the same as the 2-year decline observed bewteen 1999 and 2001 (11.9% compared to 10.7%).
If I present the data this way, it makes it clear that the observed change in heart attacks associated with the smoking ban is not at all out of the range of normal declines in heart attacks from year to year in Scotland observed in the absence of the smoking ban.
2005-2006: -4.2% 2003-2004: -4.6%
2006-2007: -8.0% 1999-2000: -10.2%
My point here is not that these data prove there was no decline in heart attacks in Scotland attributable to the smoking ban. My point is merely that there is no way one can conclude that the observed decline in the year following the smoking ban was different from the magnitude of the declines observed in previous years.
The analysis in this paper assumes that the entire observed change in heart attacks is attributable to the smoking ban. However, it is clear that a 10.2% decline in Scotland from 1999-2000 occurred in the complete absence of a smoking ban. Clearly, there are other factors which are contributing to a decline in heart attacks, there is a secular trend of substantially declining heart attacks over time, and in fact, the magnitude of the decline associated with the smoking ban is less than the magnitude of the decline observed in some recent years preceding the smoking ban.
In other words, one cannot rule out the very plausible alternative hypothesis that the observed decline in heart attacks is explained by random variation in the data and the already existing secular trend of declining heart attacks in Scotland.
Wednesday, July 30, 2008
My Letter to the Editor Criticizes Treatment of Smoking as a Moral Issue
On July 14, I reported on an article in the Daily Freeman (Kingston, NY), a Dutchess County legislative leader is promoting a smoking ban for all county parks and their parking lots because smoking sets a bad example for children. A similar law being considered in neighboring Ulster County would ban smoking on all county-owned property.
According to the article: "''I just feel there shouldn't be tobacco use in county parks,' said Dutchess County Legislature Majority Leader Sandra Goldberg, who led the Dutchess initiative. Goldberg, D-Wappinger, said the county's parks are intended to be a "family place" and the presence of smokers is not only harmful to those forced to breathe second-hand smoke, but it sets a bad example for children. Nearly the entire Democratic caucus in the county Legislature supports the Dutchess measure, Goldberg said."
This trend of promoting widespread outdoor smoking bans not to protect nonsmokers from secondhand smoke but to protect nonsmokers from seeing smokers is picking up momentum; yesterday, I reported the implementation of an ordinance in Loma Linda, California which explicitly states its intention is to prevent children from having to see smokers and thus make the city a family-unfriendly place.
The Rest of the Story
In response to this trend and in particular, to the Daily Freeman article, I submitted a letter to the editor which was published in the Daily Freeman on July 22 (page A5).
The newspaper does not appear to publish its letters to the editor online, but here are some excerpts from my letter:
"You reported (July 13) that a Dutchess County legislative leader is promoting a smoking ban for all county parks and their parking lots because smoking sets a bad example fro children.
According to the article, "Dutchess County Legislature Majority Leader Sandra Goldberg, who led the Dutchess initiative ... said the county's parks are intended to be a 'family place' and the presence of smokers is not only harmful to those forced to breath secondhand smoke, but it sets a bad example for children."
We will be in serious trouble when we start outlawing health behaviors in public merely because they set a bad example. Are we going to outlaw eating french fries in public because it sets a bad example to children regarding a healthy diet? Are we going to outlaw severely overweight people from public parks because they set a bad example for children? ...
The danger here is that Goldberg is turning smoking into a moral, rather than strictly a health issue. It is crossing that line from health into morals, with regard to smoking or any other health behavior, that I find unacceptable, inappropriate, and, frankly, dangerous. ...
To argue that smoking needs to be banned on all county property because we need to protect kids from seeing this morally inappropriate behavior is no longer a public health argument. It is a public morality argument and it has no place in this debate."
According to the article: "''I just feel there shouldn't be tobacco use in county parks,' said Dutchess County Legislature Majority Leader Sandra Goldberg, who led the Dutchess initiative. Goldberg, D-Wappinger, said the county's parks are intended to be a "family place" and the presence of smokers is not only harmful to those forced to breathe second-hand smoke, but it sets a bad example for children. Nearly the entire Democratic caucus in the county Legislature supports the Dutchess measure, Goldberg said."
This trend of promoting widespread outdoor smoking bans not to protect nonsmokers from secondhand smoke but to protect nonsmokers from seeing smokers is picking up momentum; yesterday, I reported the implementation of an ordinance in Loma Linda, California which explicitly states its intention is to prevent children from having to see smokers and thus make the city a family-unfriendly place.
The Rest of the Story
In response to this trend and in particular, to the Daily Freeman article, I submitted a letter to the editor which was published in the Daily Freeman on July 22 (page A5).
The newspaper does not appear to publish its letters to the editor online, but here are some excerpts from my letter:
"You reported (July 13) that a Dutchess County legislative leader is promoting a smoking ban for all county parks and their parking lots because smoking sets a bad example fro children.
According to the article, "Dutchess County Legislature Majority Leader Sandra Goldberg, who led the Dutchess initiative ... said the county's parks are intended to be a 'family place' and the presence of smokers is not only harmful to those forced to breath secondhand smoke, but it sets a bad example for children."
We will be in serious trouble when we start outlawing health behaviors in public merely because they set a bad example. Are we going to outlaw eating french fries in public because it sets a bad example to children regarding a healthy diet? Are we going to outlaw severely overweight people from public parks because they set a bad example for children? ...
The danger here is that Goldberg is turning smoking into a moral, rather than strictly a health issue. It is crossing that line from health into morals, with regard to smoking or any other health behavior, that I find unacceptable, inappropriate, and, frankly, dangerous. ...
To argue that smoking needs to be banned on all county property because we need to protect kids from seeing this morally inappropriate behavior is no longer a public health argument. It is a public morality argument and it has no place in this debate."
Tuesday, July 29, 2008
Ban on Smoking Just About Everywhere Outdoors in Loma Linda Goes Into Effect
Last Friday, what is perhaps the nation's most restrictive smoking ban went into effect in the city of Loma Linda, California. The ordinance, adopted by the City Council on June 24, bans smoking practically everywhere outdoors in the city, with the exception of private residential property and outdoors smoking outposts at shopping centers.
Other than private residential property or approved smoking areas at shopping centers, the ordinance bans smoking in every outdoor area in the entire city. The only exception is a privately owned outdoor area if no nonsmoker is present and "due to the time of day or other factors, it is not reasonable to expect another person to arrive." On publicly owned property, there is no smoking outdoors allowed, without exception.
This means that there is no smoking in any street, in any alleyway, on any sidewalk, in any public parking lot, or anywhere else outdoors in Loma Linda, unless it is private property and there is no expectation of another person arriving (which amounts to a ban on smoking except in the wee hours of the night).
The Rest of the Story
Before getting to the draconian nature of this law, I need to comment on the hypocrisy of the Loma Linda City Council (other than the one councilor who voted against the ordinance).
The city council declared that it needed to ban smoking everywhere in the city, even in remote outdoor locations where no nonsmoker was present, because in its own words, it desired to:
Well ... if smoking is such an affront to the family-friendly atmosphere of the city, then why was there a need to allow smoking in what are probably the two places that are most crowded and where children are most likely to see smokers: the Loma Linda Plaza Shopping Center and Mountain View Plaza Shopping Center?
I think the answer is obvious: because the city council has no integrity or willingness to stand up for a principle, especially when it perceives that standing up for that principle may interfere with the money that the city brings in.
Ironically, if you are in a remote public alleyway with no person present within hundreds of feet, you cannot smoke; however, if you are at a crowded shopping plaza with hundreds of children and families milling around, you are allowed to smoke in a designated area.
Interestingly, city councilors determined that smoking is a bad influence on children in all public places in the city with the exception of shopping centers.
One other comment before I get to the draconian nature of this law. I reject the city council's three justifications for this ordinance's prohibition of smoking in virtually all outdoors areas of the city. I don't think that preventing children from seeing smokers is a valid justification for a smoking ban. I think the reason to enact smoking bans is to protect nonsmokers from secondhand smoke exposure.
The same justification that the city council used to ban smoking in virtually all outdoors locations could also be used to ban the consumption of fatty foods in public, or even to ban obese people from public places.
This is why I find the ordinance to be draconian in nature: because it goes beyond the desire to protect nonsmokers from secondhand smoke exposure. There is clearly no need to ban smoking in every outdoor location in a city in order to protect nonsmokers from the hazards of tobacco smoke exposure. Banning smoking on every street and in every sidewalk, alley and parking lot is simply not justified by any science which demonstrates that exposure to secondhand smoke in these locations represents a significant public health problem.
Even worse, by banning smoking virtually everywhere outdoors, this ordinance might just succeed in pushing smokers to where they city apparently wants them: indoors. And with that comes an even worse public health problem than this ordinance is intended to solve -- exposure of children to secondhand smoke in the home.
What the city is basically saying is that if you are a smoker, we don't want to see you smoking outside. Keep it inside, where you can expose your children to the smoke in the privacy of your own home.
Is it really better for smokers to expose their children to secondhand smoke than to smoke in outdoors locations where their children are not exposed, but people might see them smoking?
The penalties in the ordinance for failure to enforce its provisions are also draconian, in my opinion. According to this ordinance, if you own a hardware store and a guy is smoking in a remote area of your parking lot, with no one within sight, you are guilty of violating this ordinance if you don't accost him and stop him from smoking. Does that really make any sense?
It's interesting to me how the goalposts have changed during the time I have been involved in advocacy for smoke-free public places. Initially, the purpose was to protect nonsmokers from tobacco smoke. Now, the purpose is apparently to protect people from having to see smokers.
Other than private residential property or approved smoking areas at shopping centers, the ordinance bans smoking in every outdoor area in the entire city. The only exception is a privately owned outdoor area if no nonsmoker is present and "due to the time of day or other factors, it is not reasonable to expect another person to arrive." On publicly owned property, there is no smoking outdoors allowed, without exception.
This means that there is no smoking in any street, in any alleyway, on any sidewalk, in any public parking lot, or anywhere else outdoors in Loma Linda, unless it is private property and there is no expectation of another person arriving (which amounts to a ban on smoking except in the wee hours of the night).
The Rest of the Story
Before getting to the draconian nature of this law, I need to comment on the hypocrisy of the Loma Linda City Council (other than the one councilor who voted against the ordinance).
The city council declared that it needed to ban smoking everywhere in the city, even in remote outdoor locations where no nonsmoker was present, because in its own words, it desired to:
- protect children from exposure to smoking and tobacco;
- reduce the potential for children to associate smoking and tobacco with a healthy lifestyle; and
- affirm and promote the family-friendly atmosphere of the City’s public places."
Well ... if smoking is such an affront to the family-friendly atmosphere of the city, then why was there a need to allow smoking in what are probably the two places that are most crowded and where children are most likely to see smokers: the Loma Linda Plaza Shopping Center and Mountain View Plaza Shopping Center?
I think the answer is obvious: because the city council has no integrity or willingness to stand up for a principle, especially when it perceives that standing up for that principle may interfere with the money that the city brings in.
Ironically, if you are in a remote public alleyway with no person present within hundreds of feet, you cannot smoke; however, if you are at a crowded shopping plaza with hundreds of children and families milling around, you are allowed to smoke in a designated area.
Interestingly, city councilors determined that smoking is a bad influence on children in all public places in the city with the exception of shopping centers.
One other comment before I get to the draconian nature of this law. I reject the city council's three justifications for this ordinance's prohibition of smoking in virtually all outdoors areas of the city. I don't think that preventing children from seeing smokers is a valid justification for a smoking ban. I think the reason to enact smoking bans is to protect nonsmokers from secondhand smoke exposure.
The same justification that the city council used to ban smoking in virtually all outdoors locations could also be used to ban the consumption of fatty foods in public, or even to ban obese people from public places.
This is why I find the ordinance to be draconian in nature: because it goes beyond the desire to protect nonsmokers from secondhand smoke exposure. There is clearly no need to ban smoking in every outdoor location in a city in order to protect nonsmokers from the hazards of tobacco smoke exposure. Banning smoking on every street and in every sidewalk, alley and parking lot is simply not justified by any science which demonstrates that exposure to secondhand smoke in these locations represents a significant public health problem.
Even worse, by banning smoking virtually everywhere outdoors, this ordinance might just succeed in pushing smokers to where they city apparently wants them: indoors. And with that comes an even worse public health problem than this ordinance is intended to solve -- exposure of children to secondhand smoke in the home.
What the city is basically saying is that if you are a smoker, we don't want to see you smoking outside. Keep it inside, where you can expose your children to the smoke in the privacy of your own home.
Is it really better for smokers to expose their children to secondhand smoke than to smoke in outdoors locations where their children are not exposed, but people might see them smoking?
The penalties in the ordinance for failure to enforce its provisions are also draconian, in my opinion. According to this ordinance, if you own a hardware store and a guy is smoking in a remote area of your parking lot, with no one within sight, you are guilty of violating this ordinance if you don't accost him and stop him from smoking. Does that really make any sense?
It's interesting to me how the goalposts have changed during the time I have been involved in advocacy for smoke-free public places. Initially, the purpose was to protect nonsmokers from tobacco smoke. Now, the purpose is apparently to protect people from having to see smokers.
Monday, July 28, 2008
IN MY VIEW: The Increasingly Aggressive War on Smokers -- Why We are Headed in the Wrong Direction
The proclamation by the New York State chapter of the American Cancer Society that smokers are poor role models for their children and its seeming acceptance by anti-smoking groups got me thinking about the drawbacks of what I see as an increasing war on smokers, rather than a battle against smoking, cigarettes, or the tobacco industry.
First, it strikes me as odd that we would be declaring war against smokers, since I am in this business in the first place specifically because I saw the suffering of my smoking patients. My inclination was not to attack them, but to try to help them. The goal, I thought, was to try to reduce future suffering due to tobacco-related diseases, not to try to make the lives of smokers miserable and to marginalize them out into the periphery of society.
But there is no question in my mind that the tobacco control movement has now crossed the line from being anti-smoking to being anti-smoker. In the past months on this blog, I have brought forth numerous stories about tobacco control actions that I believe have no health justification, but which do make the lives of smokers more difficult, make it harder for them to obtain jobs and support their families, or which strip them of their rights. All of these lead to the marginalization of smokers, which unfortunately has adverse health consequences in its own right.
The anti-smoking group's comments about the lack of value of smokers as role models for their children demonstrates the important, although perhaps subtle to anti-smoking advocates, distinction between a perspective that is appropriate and one that is not. The American Cancer Society's comment demonstrates the line that separates public health from bigotry.
Smoking, like eating Vienna Fingers, drinking alcohol, watching violent movies, and eating lots of fatty foods, is certainly not setting a good example for children. That is - the behavior does not set a good example. But this is different from saying that the person - the smoker - is a poor role model. Just like the father who eats Vienna Fingers and lots of other fatty foods may very well be an excellent role model for his kids, so may be the smoker. The point is, it is not health-related behaviors that determine whether one is a good role model for children. We do not ascribe moral value or attribute character or integrity to most health behaviors.
Would the American Cancer Society also say that a fat person is a poor role model for children? Suppose that fat person doesn't get enough exercise and consumes too many calories (which, by definition, is almost always the case). Would the Cancer Society also say that this individual is a poor role model for children?
Are fat people poorer parents than normal-weight ones?
For public health practitioners, the answer is clearly no. For physicians, the answer is also no. For bigots, the answer is yes.
The same is true of smoking. While the behavior of smoking does not set a good example, stating that smokers are poor role models for their children is an example of bigotry.
If the American Diabetes Association came out and stated in a newspaper article that fat people were poor role models for children, I would bet that there would be widespread condemnations of the statement for its bigotry, intolerance, and insensitivity. The same should be the case for the American Cancer Society's statement that people who smoke are poor role models for children.
In addition to the kinds of comments offered by the American Cancer Society, there are numerous aspects of the modern-day anti-smoking agenda which are intended to marginalize smokers:
1. The promotion of policies that restrict employment to nonsmokers -- As I have documented on this blog, a number of tobacco control groups are supporting policies that restrict employment to nonsmokers. The World Health Organization, Cleveland Clinic, Weyco, Scotts Miracle-Gro, and Truman Medical Centers are just a few examples of companies that refuse to hire smokers.
2. The advocacy for policies that treat smokers as child abusers -- A number of anti-smoking advocates have called for smokers who expose their children to secondhand smoke to be treated as child abusers.
3. Support for the refusal of physicians to treat or operate on patients who smoke -- This trend continues to grow. Just this past Thursday, the BBC reported that experts are considering denying IVF treatment to smokers.
4. Support for the refusal to allow smokers to adopt children or serve as foster parents -- Some anti-smoking groups are pushing for smokers to be ineligible to adopt children or to serve as foster parents.
5. Support for, and promotion of efforts to ban all smoking on college campuses -- This is a growing trend, and has no relevance to protecting nonsmokers from secondhand smoke. The aim is to prevent anyone from merely seeing anyone smoking on campus.
6. Support for policies that ban smoking entirely outdoors, including parking lots, streets, and sidewalks -- An example of this trend is the recently enacted policy in Hayward, California which bans smoking on streets and sidewalks. These policies are not necessary to protect people from secondhand smoke, but do give police a legal mechanism to get rid of "undesirable" smokers.
All of these policies are intended to, and have the effect of, marginalizing smokers. What public health advocates need to realize is that the marginalization of a group of people has its own set of adverse effects on health. Not the least important of these is that it makes it much less likely that these people are going to want to quit smoking. When people feel that their lives are being controlled, they are less likely to feel a sense that they can control those aspects of their lives and less likely to have such a desire. Marginalization creates a self-fulfilling prophecy, if you will, that supports the maintenance of the behavior in question.
In addition, marginalization of a group of people has been well-documented to have adverse health consequences. People who are stigmatized may internalize society's hateful feelings, resulting in emotional stress and turmoil and a number of adverse health consequences.
I think that it is time to return the tobacco control movement to being an anti-smoking movement, rather than an anti-smoker movement. We need to abandon workplace smoker policies in a return to workplace smoking policies. We need to ensure that in all of our interventions, we are respecting the autonomy, freedoms, and rights of smokers and not casting moral judgment upon them.
In closing, one of the most important tenets of medicine and public health is that we do not cast moral judgment about our patients (in the case of physicians) or the public (in the case of public health practitioners). We view smoking as an unhealthy behavior, but we do not cast moral judgment on the smoker. We do not refuse to treat smokers or to allow smokers to enjoy privileges and advantages that other members of society enjoy simply on the basis of their having chosen to smoke, unless there are direct medical contraindications.
The tobacco control movement is increasingly violating this tenet of public health practice, and in my opinion, crossing the line from public health to bigotry.
First, it strikes me as odd that we would be declaring war against smokers, since I am in this business in the first place specifically because I saw the suffering of my smoking patients. My inclination was not to attack them, but to try to help them. The goal, I thought, was to try to reduce future suffering due to tobacco-related diseases, not to try to make the lives of smokers miserable and to marginalize them out into the periphery of society.
But there is no question in my mind that the tobacco control movement has now crossed the line from being anti-smoking to being anti-smoker. In the past months on this blog, I have brought forth numerous stories about tobacco control actions that I believe have no health justification, but which do make the lives of smokers more difficult, make it harder for them to obtain jobs and support their families, or which strip them of their rights. All of these lead to the marginalization of smokers, which unfortunately has adverse health consequences in its own right.
The anti-smoking group's comments about the lack of value of smokers as role models for their children demonstrates the important, although perhaps subtle to anti-smoking advocates, distinction between a perspective that is appropriate and one that is not. The American Cancer Society's comment demonstrates the line that separates public health from bigotry.
Smoking, like eating Vienna Fingers, drinking alcohol, watching violent movies, and eating lots of fatty foods, is certainly not setting a good example for children. That is - the behavior does not set a good example. But this is different from saying that the person - the smoker - is a poor role model. Just like the father who eats Vienna Fingers and lots of other fatty foods may very well be an excellent role model for his kids, so may be the smoker. The point is, it is not health-related behaviors that determine whether one is a good role model for children. We do not ascribe moral value or attribute character or integrity to most health behaviors.
Would the American Cancer Society also say that a fat person is a poor role model for children? Suppose that fat person doesn't get enough exercise and consumes too many calories (which, by definition, is almost always the case). Would the Cancer Society also say that this individual is a poor role model for children?
Are fat people poorer parents than normal-weight ones?
For public health practitioners, the answer is clearly no. For physicians, the answer is also no. For bigots, the answer is yes.
The same is true of smoking. While the behavior of smoking does not set a good example, stating that smokers are poor role models for their children is an example of bigotry.
If the American Diabetes Association came out and stated in a newspaper article that fat people were poor role models for children, I would bet that there would be widespread condemnations of the statement for its bigotry, intolerance, and insensitivity. The same should be the case for the American Cancer Society's statement that people who smoke are poor role models for children.
In addition to the kinds of comments offered by the American Cancer Society, there are numerous aspects of the modern-day anti-smoking agenda which are intended to marginalize smokers:
1. The promotion of policies that restrict employment to nonsmokers -- As I have documented on this blog, a number of tobacco control groups are supporting policies that restrict employment to nonsmokers. The World Health Organization, Cleveland Clinic, Weyco, Scotts Miracle-Gro, and Truman Medical Centers are just a few examples of companies that refuse to hire smokers.
2. The advocacy for policies that treat smokers as child abusers -- A number of anti-smoking advocates have called for smokers who expose their children to secondhand smoke to be treated as child abusers.
3. Support for the refusal of physicians to treat or operate on patients who smoke -- This trend continues to grow. Just this past Thursday, the BBC reported that experts are considering denying IVF treatment to smokers.
4. Support for the refusal to allow smokers to adopt children or serve as foster parents -- Some anti-smoking groups are pushing for smokers to be ineligible to adopt children or to serve as foster parents.
5. Support for, and promotion of efforts to ban all smoking on college campuses -- This is a growing trend, and has no relevance to protecting nonsmokers from secondhand smoke. The aim is to prevent anyone from merely seeing anyone smoking on campus.
6. Support for policies that ban smoking entirely outdoors, including parking lots, streets, and sidewalks -- An example of this trend is the recently enacted policy in Hayward, California which bans smoking on streets and sidewalks. These policies are not necessary to protect people from secondhand smoke, but do give police a legal mechanism to get rid of "undesirable" smokers.
All of these policies are intended to, and have the effect of, marginalizing smokers. What public health advocates need to realize is that the marginalization of a group of people has its own set of adverse effects on health. Not the least important of these is that it makes it much less likely that these people are going to want to quit smoking. When people feel that their lives are being controlled, they are less likely to feel a sense that they can control those aspects of their lives and less likely to have such a desire. Marginalization creates a self-fulfilling prophecy, if you will, that supports the maintenance of the behavior in question.
In addition, marginalization of a group of people has been well-documented to have adverse health consequences. People who are stigmatized may internalize society's hateful feelings, resulting in emotional stress and turmoil and a number of adverse health consequences.
I think that it is time to return the tobacco control movement to being an anti-smoking movement, rather than an anti-smoker movement. We need to abandon workplace smoker policies in a return to workplace smoking policies. We need to ensure that in all of our interventions, we are respecting the autonomy, freedoms, and rights of smokers and not casting moral judgment upon them.
In closing, one of the most important tenets of medicine and public health is that we do not cast moral judgment about our patients (in the case of physicians) or the public (in the case of public health practitioners). We view smoking as an unhealthy behavior, but we do not cast moral judgment on the smoker. We do not refuse to treat smokers or to allow smokers to enjoy privileges and advantages that other members of society enjoy simply on the basis of their having chosen to smoke, unless there are direct medical contraindications.
The tobacco control movement is increasingly violating this tenet of public health practice, and in my opinion, crossing the line from public health to bigotry.
Wednesday, July 23, 2008
Anti-Smoking Advocate Says Smokers are a Bad Role Model for their Children
Russell Sciandra, a leading lobbyist with the New York State chapter of the American Cancer Society, is quoted in the Boston Herald Wednesday as calling smokers poor role models for their children.
According to the article, Sciandra stated: "Parents who smoke are a poor role model for their children."
The quote was apparently in response to a media inquiry related to the all-important story of Britney Spears and her parenting skills. The latest in the saga: Britney was apparently caught on camera smoking in the presence of young Sean Preston. Spears has lost primary custody of her 2 1/2 year-old son and has been criticized in the media for a number of poor parenting episodes, including driving with her son on her lap without a seatbelt, and for his fall from a high chair requiring an emergency room visit.
The Rest of the Story
This was an unnecessary cheap shot. Well ... that's how I see it.
You see ... I actually thought about what I might say to the reporter if she had called me instead. The reason? I got a call from the Boston University media office during the day yesterday. The reporter had wanted to speak to me to get a quote for this story. Unfortunately (or perhaps fortunately for me), I was busy and unable to provide a quote so instead she relied on this quote from Russ Sciandra.
Had the reporter talked to me, I would have stated that what Britney Spears, or any other parent, does in terms of raising their children is their own business (as long as it does not involve abuse or neglect) and that there are probably more serious threats to Sean Preston's well-being than his being exposed to tobacco smoke.
It appears that Russ used the opportunity, instead, to take a pot shot at all smokers.
Now I take issue with his statement, because while I think that smoking (the behavior) certainly does not set a great example, smokers (the parents themselves) are by no means poor role models for their children simply because they smoke. There are a heck of a lot of more important factors in whether parents are good role models for their children than whether or not they smoke.
To name just a few, I would say that how much the parents love their kids and show them love, the values they teach their kids, and the example they set for them in terms of morals such as compassion, kindness, honesty, respect, and tolerance are perhaps some of the most important factors in terms of whether I would consider a parent to be a good role model for their children.
To look only at smoking and state that if someone smokes, they are a poor role model for their child, regardless of all these other factors, seems to me to be narrow-minded and self-righteous.
And once again, it is making a moral issue out of what is merely a health issue.
Are parents who eat hamburgers bad role models for their children? What about parents who are fat? Those who often forget to take their medication? Those who aren't screened regularly for cancer? How about those who do not get enough physical activity? Those who watch movies that have violence in them?
If parents who smoke are categorically poor role models for their kids, then so are parents who engage in all these other unhealthy activities.
But to call a parent a poor role model because of these other activities seems absurd. That's because we don't ascribe moral value to most health behaviors. But for some reason, anti-smoking advocates are now trying to ascribe moral value to the decision whether or not to smoke.
How can we possibly do that? The decision is usually made not in adulthood, but in childhood. As anti-smoking advocates, we ourselves emphasize that these decisions are usually not based on informed, adult, rational decision-making processes, but instead occur during childhood - at least the decision to initiate smoking. Then we argue that the decision to continue smoking is largely influenced by nicotine and addiction. So how can we then turn around and say that smoking is a moral issue and the decision to smoke is an immoral one?
I reject this anti-smoking advocate's view of the smoker because I reject the notion that someone who smokes is automatically a poor role model for children. Some of the best role models for children happen to be smokers. I don't think the smoking or not smoking has anything to do with it. It's a health issue, not one of character or integrity.
I don't understand why this anti-smoking advocate, and many others like him, insist upon portraying smoking as an issue of integrity and character, rather than as simply a health-related behavior.
Now I regret that I wasn't available to speak to the reporter. Because I would have preferred that a message of tolerance and respect be delivered rather than one of moral condemnation. Plus, it would have been awesome to tell my friends that when the media need an expert to comment about the Britney Spears saga, they turn to me for answers.
According to the article, Sciandra stated: "Parents who smoke are a poor role model for their children."
The quote was apparently in response to a media inquiry related to the all-important story of Britney Spears and her parenting skills. The latest in the saga: Britney was apparently caught on camera smoking in the presence of young Sean Preston. Spears has lost primary custody of her 2 1/2 year-old son and has been criticized in the media for a number of poor parenting episodes, including driving with her son on her lap without a seatbelt, and for his fall from a high chair requiring an emergency room visit.
The Rest of the Story
This was an unnecessary cheap shot. Well ... that's how I see it.
You see ... I actually thought about what I might say to the reporter if she had called me instead. The reason? I got a call from the Boston University media office during the day yesterday. The reporter had wanted to speak to me to get a quote for this story. Unfortunately (or perhaps fortunately for me), I was busy and unable to provide a quote so instead she relied on this quote from Russ Sciandra.
Had the reporter talked to me, I would have stated that what Britney Spears, or any other parent, does in terms of raising their children is their own business (as long as it does not involve abuse or neglect) and that there are probably more serious threats to Sean Preston's well-being than his being exposed to tobacco smoke.
It appears that Russ used the opportunity, instead, to take a pot shot at all smokers.
Now I take issue with his statement, because while I think that smoking (the behavior) certainly does not set a great example, smokers (the parents themselves) are by no means poor role models for their children simply because they smoke. There are a heck of a lot of more important factors in whether parents are good role models for their children than whether or not they smoke.
To name just a few, I would say that how much the parents love their kids and show them love, the values they teach their kids, and the example they set for them in terms of morals such as compassion, kindness, honesty, respect, and tolerance are perhaps some of the most important factors in terms of whether I would consider a parent to be a good role model for their children.
To look only at smoking and state that if someone smokes, they are a poor role model for their child, regardless of all these other factors, seems to me to be narrow-minded and self-righteous.
And once again, it is making a moral issue out of what is merely a health issue.
Are parents who eat hamburgers bad role models for their children? What about parents who are fat? Those who often forget to take their medication? Those who aren't screened regularly for cancer? How about those who do not get enough physical activity? Those who watch movies that have violence in them?
If parents who smoke are categorically poor role models for their kids, then so are parents who engage in all these other unhealthy activities.
But to call a parent a poor role model because of these other activities seems absurd. That's because we don't ascribe moral value to most health behaviors. But for some reason, anti-smoking advocates are now trying to ascribe moral value to the decision whether or not to smoke.
How can we possibly do that? The decision is usually made not in adulthood, but in childhood. As anti-smoking advocates, we ourselves emphasize that these decisions are usually not based on informed, adult, rational decision-making processes, but instead occur during childhood - at least the decision to initiate smoking. Then we argue that the decision to continue smoking is largely influenced by nicotine and addiction. So how can we then turn around and say that smoking is a moral issue and the decision to smoke is an immoral one?
I reject this anti-smoking advocate's view of the smoker because I reject the notion that someone who smokes is automatically a poor role model for children. Some of the best role models for children happen to be smokers. I don't think the smoking or not smoking has anything to do with it. It's a health issue, not one of character or integrity.
I don't understand why this anti-smoking advocate, and many others like him, insist upon portraying smoking as an issue of integrity and character, rather than as simply a health-related behavior.
Now I regret that I wasn't available to speak to the reporter. Because I would have preferred that a message of tolerance and respect be delivered rather than one of moral condemnation. Plus, it would have been awesome to tell my friends that when the media need an expert to comment about the Britney Spears saga, they turn to me for answers.
Tuesday, July 22, 2008
Mike Running Half Marathon to Raise Money for the Leukemia & Lymphoma Society
On August 17, I will be running (attempting to run) 13.1 miles in the San Diego Half Marathon to benefit the Leukemia & Lymphoma Society.
I am running in memory of my mom, who was killed in a tragic car accident when I was 17 years old.
I am also running in memory of my friend Alex Ortiz, who died two weeks ago from lymphoma. Alex was a medical school friend of mine. In addition to being a fine physician, he was one of the most tolerant, respectful, and compassionate people whom I have met. Alex and I spent many difficult times together during our very first medical school rotation, which ironically was in the oncology wards at Yale-New Haven Hospital. Alex and I spent hours of time after work talking to patients, getting to know them and their families, watching television and just hanging out with them. Much of what I learned from Alex I carried with me during my later medical training in terms of my caring for patients.
Anyone who wishes to sponsor me in my run - your donations, no matter how small, would be appreciated.
If you are interested in sponsoring me, pleases make a check directly to The Leukemia & Lymphoma Society and mail it to me at the address below:
Dr. Michael Siegel
Social and Behavioral Sciences Department
Boston University School of Public Health
801 Massachusetts Avenue, 3rd Floor
Boston, MA 02118
I am running in memory of my mom, who was killed in a tragic car accident when I was 17 years old.
I am also running in memory of my friend Alex Ortiz, who died two weeks ago from lymphoma. Alex was a medical school friend of mine. In addition to being a fine physician, he was one of the most tolerant, respectful, and compassionate people whom I have met. Alex and I spent many difficult times together during our very first medical school rotation, which ironically was in the oncology wards at Yale-New Haven Hospital. Alex and I spent hours of time after work talking to patients, getting to know them and their families, watching television and just hanging out with them. Much of what I learned from Alex I carried with me during my later medical training in terms of my caring for patients.
Anyone who wishes to sponsor me in my run - your donations, no matter how small, would be appreciated.
If you are interested in sponsoring me, pleases make a check directly to The Leukemia & Lymphoma Society and mail it to me at the address below:
Dr. Michael Siegel
Social and Behavioral Sciences Department
Boston University School of Public Health
801 Massachusetts Avenue, 3rd Floor
Boston, MA 02118
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