Wednesday, August 17, 2016

Low-Tar Cigarettes Had Merit, Said American Cancer Society; So Do E-Cigarettes

E-cigarette opponents routinely claim that e-cigarettes benefit from industry-promoted consumer health misconceptions in the same manner that so-called light cigarettes soared in popularity years ago, when, it is alleged, marketers created a mythology about the relative safety of “reduced tar.”  In reality, there is more truth in those light claims than people suspect.

According to one heavily cited account (here), “In the late 1960s, tobacco manufacturers introduced ‘light’ or ‘low tar’ brands that yielded 7–14 mg tar per cigarette, compared to the 22 mg tar of the average cigarette sold at that time.   Later, ‘ultralight’ brands appeared, with tar yields below 7 mg per cigarette.  Today [in 2004], almost 90% of cigarettes sold in the United States are in these categories.  Better taste is not the reason why smokers buy light cigarettes.  They buy them because they have the misconception that smoking lower tar products reduces their risk of lung cancer and other tobacco-related diseases.  Advertisements for these brands carry the implicit and tempting message that switching to a light brand is an alternative to quitting smoking.”

This line – that safer cigarettes are a deception perpetrated by the tobacco industry -- has been repeated so often that it is considered gospel by the American public.  In fact, the scientific literature supports the relative safety claim and debunks the popular myth.

Research published in the 1970s documented that low-tar low-nicotine cigarettes were less hazardous than others.  Articles from the American Cancer Society in respected medical journals played a prominent role in shaping consumers’ positive perception of these products. 

In 1976 the Cancer Society published research (here) showing that light cigarettes were safer.  In 1959-60, over a million people were enrolled by the Cancer Society in a prospective epidemiological study of cancer risk factors.  Smokers were classified according to nicotine-tar content, high (2.0-2.7 milligrams nicotine and 26-36 mg tar) or low (less than 1.2 mg nicotine and less than 18 mg tar); detailed records were obtained for death rates and dates. 

The study revealed that the death rate from all causes was 16% lower among smokers of low nicotine-tar cigarettes than among smokers of high nicotine-tar cigarettes.  Similarly, low nicotine-tar smokers had a 14% lower death rate from heart attacks and a 26% lower rate from lung cancer.  The authors concluded that “total death rates, death rates from coronary heart disease, and death rates from lung cancer were somewhat lower for those who smoked ‘low’ tar-nicotine cigarettes than for those who smoked ‘high’ tar-nicotine cigarettes.”

The research findings were extensively reported on by the media (example here).

In 1979, Cancer Society investigators published a study in the New England Journal of Medicine, confirming the 1976 lung cancer findings (abstract here).  This study examined the lungs of 211 men who died in 1955-60 and 234 men who died in 1970-77.  Researchers looked for microscopic changes indicating that a cancerous tumor might have eventually developed if these men had lived longer.

Percentage (%) of Smokers Who Had Pre-Cancerous Lung Changes At Autopsy, According to the American Cancer Society
Smoking CategoryFull-Tar Smokers, 1955-60Light-Tar Smokers, 1970-77
Less than 1 pack per day2.60.1
1-2 packs per day13.20.8
2+ packs per day22.52.2

The results from this study are shocking.  In 1955-60, when most smokers consumed full-tar cigarettes, 2.6% of men who smoked less than a pack per day had pre-cancerous changes in their lungs.  Among men smoking 1-2 packs per day, 13% had changes; this increased to 23% among those smoking over 2 packs per day.  But in 1970-77, when, according to the report, “a large proportion of smokers have deliberately selected brands with reduced tar and nicotine,” the percentage of smokers in every category who had pre-cancerous lung changes was very small.

Cancer Society researchers concluded: “The evidence from this study is consistent with evidence from epidemiologic studies indicating that death rates from lung cancer are lower among men who smoke low tar/nicotine cigarettes than among men who smoke the same number of high tar/nicotine cigarettes per day…”

Again, the results were widely reported by the national media, including the Wall Street Journal (here).  Cancer Society president LaSalle D. Leffall, Jr., issued a harm reduction message, saying that “findings of the new study suggest a way for smokers to reduce their lung cancer risk by switching to low tar-nicotine cigarettes if they find it impossible to quit entirely.”  Leffall noted that “the best way to escape the risk of lung cancer ‘is not to smoke at all…There is no safe cigarette.’”

By the 1980s, public health experts and cigarette manufacturers alike were optimistic about the prospects of a safer cigarette.  Manufacturers introduced products with even lower levels of tar, which they called ultra-lights. 

In 2004, Cancer Society researchers confirmed that smoking ultra-lights resulted in lower lung cancer rates than the full-tar cigarettes, but the rates for ultra-lights were the same as those for low-tar cigarettes (here).

The health advantages of light cigarettes over full-flavor brands were documented and promoted by the American Cancer Society in 1976 and 1979.  Optimism about low-tar brands was later reversed by another Cancer Society report, which did not acknowledge or cite the earlier studies. 

One fact is not debatable: The public health community conducted research that led to the promotion of light cigarettes as safer alternatives.  Therefore, there is no industry conspiracy template for anyone to employ against e-cigarettes.

Wednesday, August 10, 2016

A Smokeless History Lesson For Vaping Advocates

E-cigarettes are under siege by federal health authorities and NGOs, aided and abetted by countless university researchers funded generously by the National Institutes of Health (here).  Many of their tactics were introduced 35 years ago.  Here, in brief, is the story of smokeless. 

The American anti-smokeless campaign started on March 26, 1981, when Deborah Winn, Ph.D., reported in the New England Journal of Medicine that the relative risk for oral cancer among powdered dry snuff users was 4, a risk she described as "exceptionally high".  In reality, that risk translated to a mere 12 deaths per year among 100,000 long-term users (For perspective, compare this with the contemporary annual U.S. death rate of 10 per 100,000 users of automobiles, here).  Winn studied only the use of powdered dry snuff, not the moist snuff and chewing tobacco that the vast majority of American smokeless tobacco consumers prefer.  She later acknowledged in two obscure scientific publications – a 1983 IARC report (here) and the 1986 Banbury Report 23 from Cold Spring Harbor Laboratory – that her study involved only dry powdered snuff, but her omission of that critical detail in the initial article set the stage for condemnation of all smokeless products as health hazards (discussed in detail here). 

Winn also falsely inflated the moderate relative risk of 4 to a startling and unsubstantiated 50 (explained in detail here).  The fifty fabrication was adopted by public health agencies and associations worldwide, and continues to pollute the web sites of the American Cancer Society (here) and the State of Kentucky (here), among many others.

The office of the Surgeon General of the United States has been tarnished by the campaign to demonize smokeless products.  Surgeon General Richard Carmona grossly distorted the facts when he testified before Congress in 2003, saying “there is no significant evidence that suggests smokeless tobacco is a safer alternative to cigarettes.”  I also testified at that hearing (here) and published in the Washington Times the following week an op-ed dismantling Dr. Carmona’s testimony (here).  It was another Surgeon General, Antonia Novello, whose 1994 false claim, “The majority of our experts predict an oral cancer epidemic if the current trends in spit tobacco use continue,” (here) prompted me to enter the field of tobacco harm reduction. There was never any basis for that prediction, and it was never realized. 

Major medical institutions have damaged their credibility by spreading misinformation about smokeless tobacco.  These include the Mayo Clinic, the Legacy Foundation, the National Cancer Institute (here) and others.  Other examples of this scientific travesty were described in a comprehensive review of tobacco harm reduction penned by William Godshall and me in 2006 (here).

Today, e-cigarettes are attracting growing support from public health proponents who recognize their value as safer alternatives for cigarette smokers.  It is consternating, however, that some of these experts persist in demonizing smokeless tobacco products whose relative safety is supported by dozens of irrefutable epidemiologic research studies. 

Thursday, August 4, 2016

New Risk Factor for Mouth & Throat Cancer: Hepatitis C Virus

Hepatitis C is a risk factor for mouth and throat cancer, say researchers from the University of Texas MD Anderson Cancer Center (abstract here).

Hep C is a serious viral infection of the liver, mainly transmitted through infected blood via shared needles and accidental needle sticks or through sexual contact (here).  It can cause liver damage and failure, and it is a risk factor for liver cancer.  Hep C kills 19,000 Americans yearly, but there are effective treatments (here).     

The researchers, led by first author Parag Mahale, had access to 34,500 blood samples from MD Anderson cancer patients treated between 2004 and 2014.  The researchers divided Hep C patients into two groups: those who had cancers of the head and neck region (n = 609) and controls with cancers of the lung, esophagus and bladder (n = 1,143).  They looked for differences in Hep C infection rates.

Mahale and colleagues found that about 14% of people with mouth or throat cancer were infected with Hep C, which is about twice the rate as controls (OR = 2.0, 95% confidence interval, CI = 1.04 – 4.01).  The association was somewhat higher in patients who had mouth or throat cancer and who were infected with human papillomavirus, HPV (OR = 3.0, CI = 1.3 – 6.8). 

I have previously discussed the emerging evidence for HPV as a risk factor for mouth and throat cancer (here and here).  The new research suggests that Hep C may also play a causative role. 


Wednesday, July 27, 2016

Smoking and Using E-Cigarettes? Moffitt Cancer Center Wants You To Be “Forever Free”

“Do e-cigarettes actually help people quit smoking?”  The Moffitt Cancer Center in Tampa, Florida, is recruiting smokers who vape (i.e., dual users) for a clinical trial that, according to spokesman Vani Nath Simmons (here), aims to answer that question.  Researchers will be using federal grants to convince smoker-vapers to quit smoking, and possibly to quit vaping, by sending them self-help booklets.

The researchers, led by Thomas Brandon, Ph.D., have long been interested in providing smokers low-cost self-help interventions for quitting and preventing relapse.  They mail study participants booklets called “Forever Free,” teaching them “how to resist urges to smoke.”  The researchers have published the results of several trials, each of which involved minor variations in design and frequency of booklet mailings.  Here are some results:

Results Of Moffitt-Based Clinical Trials Employing Self-Help Booklets
Publication, dateMain OutcomeMain Result
Addiction, 2015Relapse preventionNo effect
American Journal of Preventive Medicine, 2015AbstinenceBooklets better
Nicotine & Tobacco Research, 2016Relapse preventionNo effect
Journal of Consulting and Clinical Psychology, 2000Relapse preventionBooklets better

The first study was conducted in Britain; the next two, in the U.S., were supported by National Cancer Institute grants totaling about $5 million over the period 2009-2013.  According to the American Journal of Preventive Medicine report, the booklets helped smokers abstain in one cessation trial.  They were mailed to smokers at two rates, standard (8 booklets over 12 months) or intensive (10 over 18 months with other mailings on alternate months).  The control group only received one booklet at the beginning of the trial.  At 24 months, 19% of this group reported that they hadn’t smoked in the past week.  The non-smoking rate was 24% in the control group and 30% (significantly higher) in the intensive group.

In 2000, Dr. Brandon reported that former smokers who received booklets had lower relapse rates than smokers who had access to a telephone hot line (12% vs. 35%). 

Dr. Brandon has been quoted noting the relative merits of e-cigarettes compared to cigarettes (here), and Moffitt spokesman Simmons acknowledged, “We can say that it is very unlikely that they [e-cigarettes] are as harmful as regular tobacco cigarettes because you aren’t being exposed to the tar and the cancer-causing chemicals.” 

In the current trial, the booklets are modified specifically for vapers, as reflected in the title, “If You Vape: Guide to Quitting Smoking”.  However, the formal description of the study, as filed with the NIH (here), includes among its objectives producing tobacco abstinence among subjects and terminating “their e-cigarette use as per traditional nicotine replacement therapy (NRT).”  One hopes that this study will not embrace the disease-treat-cure model for influencing consumer behavior (here and here).

Note: This post was updated with additional information on July 29, 2016.