From: SMOKEFREE@compuserve.com
Date: Mon, 07/07/08
The lesser of the two
Some experts tout snuff, which is gaining popularity, as a safer
alternative to cigarettes.
By Brian Newsome
The Gazette
July 6, 2008 - 11:22PM
http://www.gazette.com/articles/lesser_37975___article.html/_.html
One group pushes abstinence as the only true way. The other argues that
such thinking is unrealistic and narrow-minded.
At times, passions flare, sometimes to the point of name calling.
It sounds like an argument over the distribution of contraceptives in
schools, but this public health showdown centers on what many people
assumed was a long-settled issue: the dangers of tobacco.
For decades, health experts have been fighting Big Tobacco. In recent
years, however, some of them have been arguing among themselves.
At issue is whether all tobacco should be presented to the public as
equally dangerous, or if statistically safer tobacco products such as
chewing tobacco should be promoted as a less risky alternative for smokers.
In other words, some public health experts argue, if you can't quit
cigarettes, you're better off switching to a smokeless product.
Health experts have quietly debated the idea for years, but their
disagreements have grown from a minor distraction to a major dispute as
smoking bans sprout up across the country and smokeless tobacco sales soar.
The tobacco tussle
Mainstream public-health practice has long treated all tobacco products as
equal and preached a message that a reduction of health risks comes only
with cessation. Since 1986, smokeless products such as snuff and chew have
been required to carry a warning that says "This product is not a safe
alternative to cigarettes."
But research has shown that smokeless tobacco products - while not risk
free - are significantly less deadly than cigarettes, leading some health
experts to pitch them as an alternative for those who can't or won't quit
smoking. The smokeless products might not help people kick the habit, but
it removes the primary dangers associated with cigarettes, the thinking
goes.
The concept, known as harm reduction, is nothing new in the public-health
field. Over the years, it has been put into action in the form of
needle-exchange programs for drug abusers and methadone treatment for
heroin addicts.
In the fight against tobacco, harm reduction was a back-burner discussion
because 90 percent of tobacco sales came from cigarettes.
That's changing.
Sales of moist snuff increased from 800 million cans in 2002 to an
estimated 1.2 billion cans this year, and cigarettes now make up 80 percent
of sales, said Bill Godshall, director of Smokefree Pennsylvania. A number
of new products - electronic cigarettes, tobacco lozenges and even
nicotine-infused skin cream - are being marketed to smokers who can't light
up where they please.
The trend has put the harm reduction debate in the middle of the fight
against tobacco, and there's little room for neutrality.
A case for the spitoon
Godshall, who has a master's degree in public health, has spent more than
two decades fighting smoking. He considers himself a formidable foe of
companies such as Phillip Morris, and says he was one of the first to lobby
for a tobacco tax and the removal of cigarette vending machines from public
places. He's spoken at national and international conferences on tobacco.
He's also a harm-reduction advocate.
"Any time you're using a less hazardous form of nicotine than cigarettes,
my point is you're reducing your risks," he said.
He talks with the passion of a war protester or a radical environmentalist,
speaking fast and spewing well-rehearsed facts and figures. Nicotine, by
itself, isn't all that different from coffee, Godshall says. It is
addictive and elevates the heart rate.
The real damage to smokers' health comes from the dozens of carcinogens in
cigarettes, cigars and pipes - products that are lit and inhaled. Of more
than 45 million people who smoke in the U.S., about 438,000 die each year,
according to the Centers for Disease Control and Prevention. About 40,000
people die because of secondhand smoke, according to some estimates.
Chewing tobacco and snuff contain 28 carcinogens and have been known to
cause oral cancer, but the numbers pale in comparison with smoking. Smoking
is estimated to take an average of eight years off a person's life,
compared with 15 days for smokeless tobacco, say Godshall and others in his
camp. They contend that smokeless tobacco is 98 percent safer than
cigarettes.
True, smokeless tobacco users were four times more likely to get oral
cancer than nontobacco users, but they are still half as likely to get oral
cancer as smokers, research shows.
The Royal College of Physicians of London, a highly regarded medical group
composed of an international team of doctors, issued a report last year
defending harm reduction. In the report's preface the group said:
"The ideas we present are controversial, and challenge many current and
entrenched views in medicine and public health. They also have the
potential to save millions of lives. They deserve serious consideration."
Picking your poison
But most public health professionals and physicians aren't swayed by such
statistics and arguments.
"We're talking about a theory that's being presented as a fact," said Alan
Blum, a family physician and director of the University of Alabama Center
for the Study of Tobacco and Society.
The American Cancer Society, American Heart Association, and virtually all
publichealth departments oppose all tobacco and nicotine products, except
cessation tools, such as the patch or gum, that are produced by
pharmaceutical companies.
The numbers, they say, tell only part of the story.
Stephen Telatnik is a pulmonologist for Memorial Health System who oversees
a smoking-cessation program and helped implement the hospital's smoke-free
campus. A practicing doctor for 40 years, he's seen too many patients
suffering from head and neck cancer to ever defend smokeless tobacco.
"There's just no excuse for that type of approach, regardless of the
research," he said. "I've seen the disasters, and it only takes one of
those disasters."
For Dan Martindale, health promotion division director for the El Paso
County Department of Health and Environment, it is a matter of picking
poisons. "From a public-health perspective, you're just playing Russian
roulette," he said.
Blum is well-versed in the harm-reduction argument but dismisses the idea
as a "pitiful way to reduce death and disease."
The concept is based on assumptions that people will go from one product to
the other, and then might eventually quit. "They wind up doing both or
can't get off the smokeless (tobacco)," Blum said. CDC data show that teens
who take up smokeless tobacco are more likely to start smoking.
And, as with any public awareness push, he said, there's the message to
think about. A relaxed stance on certain types of tobacco might give
children the confidence to try it.
The risks of a wrong message are significant, he said. Cigarette filters
were once touted as a way to reduce the harmful effects of smoking. Their
effectiveness has been debunked, Blum said, but people still smoke them,
thinking they are safer than unfiltered ones.
And there's a lack of research on nicotine and smokeless-tobacco products..
Nicotine affects blood pressure and heart rate, but how that affects heart
disease and the brain has not been studied in isolation. While a
theoretical switch might take away one risk - lung cancer - it might
introduce new ones, Blum suggested.
Digging trenches
The impasse over harm reduction has led to pointed accusations, newspaper
editorials and a war of words. The American Cancer Society has been accused
of a conflict of interest and hypocrisy because it supports and is paid to
endorse pharmaceutical products such as the patch or gum but goes after
similar tobacco products.
Harm-reduction activists, in turn, are accused of being too friendly with
the enemy.
Godshall, the harm-reduction advocate, is clearly in a minority among
health professionals, and he said speaking engagements at conferences have
been hard to come by in recent years as he's become more vocal about his
stance. People have called him "crazy," he said, and panelists dismiss his
questions when he breaches the subject at conferences.
He, in turn, calls his critics "abstinence moralists" and "prohibitionists"
who want people to "quit or die."
"I don't need the permission of the American Cancer Society to save lives,"
he said.
Blum says Godshall and others on the side of harm reduction act as if
they'd found "the true religion." He called Godshall "brilliant," but
accused him of not seeing clearly on this issue.
"I don't know how to resolve this," Blum said. "I really don't.
CONTACT THE WRITER: 636-0198 or brian.newsome@gazette.com
BY THE NUMBERS
- 800 million cans of snuff sold in 2002. Estimated 1.2 billion cans sold
in 2008.
- 8 percent of high school students use smokeless tobacco.
- Smokeless tobacco contains 28 cancercausing agents.
SOURCES: CENTERS FOR DISEASE CONTROL AND PREVENTION; BILL GODSHALL OF
SMOKEFREE PENNSYLVANIA
STATES WITH FULL STATEWIDE SMOKING BANS
Arizona 2006
Arkansas 2006
California 1994
Colorado 2006
Connecticut 2004
Delaware 2002
Hawaii 2006
Illinois 2008
Iowa 2008
Maine 2004
Maryland 2007
Massachusetts 2004
Minnesota 2007
Montana 2005
Nebraska 2008
New Jersey 2006
New Mexico 2007
New York 2003
Ohio 2006
Oregon 2007
Rhode Island 2005
Utah 2006
Vermont 2005
Washington 2005
STATES WITH PARTIAL SMOKING BANS
Florida 2003
Georgia 2005
Idaho 2004
Louisiana 2007
Nevada 2006
New Hampshire 2007
North Dakota 2005
Oklahoma 2006
Pennsylvania 2008
South Dakota 2002
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