Tag Archives: ST variants

This is what local public health looks like, Iowa edition

by Carl V Phillips

Granted, the position statement on dissolvable tobacco products by the Iowa Counties Public Health Association matters very little to the world (though at CASAA we do like to highlight absurdities from Iowa, the new home of one of our directors).  But it tells us a lot about how phenomenally clueless “public health” people on the ground are. They should really stick with practical matters they understand, like restaurant inspections — and you do not want to think too hard about the implications if their understanding of how to do restaurant inspections is as poor as their understanding of tobacco.

Keep in mind that this statement was published this month (h/t Jan Johnson for reporting it), not two years ago.

Background: In response to increasing restrictions on the use of cigarettes and other products limited by the implementation of smoke-free air acts in multiple states, the tobacco industry has produced and begun to distribute new dissolvable products including Orbs, Strips, and Sticks, and Ariva and Stonewall tablets. Flavored tobacco products are considered the potential third wave of tobacco addiction.

Notice that they lead with the top-down “it is all about us” presumption that I analyzed in detail recently.  They then go on to mention five products.  The first three, from RJR, have been dismal failures (which is 1/3 a shame:  the Strips and Orbs are as unappealing as NRT, but the Sticks were a good product, and smokers who tried them often found them a very good substitute; I have suggested to RJR, only half-joking, that they re-launch the Sticks as “battery-free eco-friendly e-cigarettes” or something).  The other two lozenge products, from Star Scientific — very much not part of “the tobacco industry” — have been off the market for more than a year.

I have no idea what the “third wave of tobacco addiction” even means.  Despite their passive voice assertion, I have never heard that phrase before.  But I suspect it is not compatible with “all of these products sunk beneath the waves because they never caught on with consumers.”

I could probably just stop there and observe just how amazingly clueless the anti-harm-reduction industry’s local useful idiots are.  But a bit more…

Concerns regarding the potential health impacts of these products include the following.  These products are not FDA-approved cessation products. They do not help people end their addiction to nicotine.

Um, how is either one of those a health impact?  And, actually, they kind of are/were FDA approved, in the sense that FDA has jurisdiction over them but has not quashed them.  They may or may not help people end their “addiction” — given their minimal sales, it is hard to argue that there is evidence that they do, but clearly there is no evidence that they do not, as is asserted.

Dissolvable tobacco contains higher levels of nicotine than cigarettes. The typical cigarette will give the smoker a dose of between 1 and 2 milligrams of nicotine over the time it takes to smoke the cigarette (10 min or so). These products are designed to dissolve in the mouth in 3 (strips) to 10 (tablets) minutes but they can also easily be chewed or swallowed whole. Arriva delivers about a 1.5 mg dose, Stonewall delivers about 4mg.

Seriously, these are the people who presume to be offering advice to others. Swallow nicotine and very little of it gets absorbed.  The numbers for those (non-existent) products are — or, rather, were —  the nicotine content of the objects, not how much gets absorbed.  They cannot even get the time periods right (e.g., the strips dissolve in less than a minute and so give a bit of a kick, though not nearly as much as a couple of puffs on a cigarette; the lozenges, if you can stand them, last a lot longer than a cigarette).  Do you think anyone involved with this report even talked to someone who had used one of these products?

These products are intentionally marketed in colorful packages, sweet flavors, and convenient sizes that are very attractive to youth and are very easy to hide. Kids can use them at school, at home–anywhere. Their discreet form, candy-like appearance, and added flavorings may make them very attractive to children, and increase the risk of unintentional ingestion of toxic levels of nicotine. Further, access to these products may increase youth initiation and addiction to tobacco products.

Yes, that has always seemed like a concern ANTZ should have about NRT (except for that “toxic” bit — you would have to consume more product than you could shove into your mouth to get to toxic levels).  Oh, wait, you say, they were not talking about NRT?  No, they must have been, because those dissolvables had about the least appealing packaging I have ever seen, whereas NRT is pretty much packaged to look like candy.  (Btw, if you have never read the “study” at that link, you really should — I think it is the funniest thing I have ever written.)

Of course, what is most clueless about this whole 2014 position statement is that they obsess about products that were removed from the market in 2012 and yet fail to mention that the currently most interesting existing product in this whole NRT/dissolvable tobacco sector (they are basically the same niche) is RJR’s Zonnic.  They are strangely silent about the evils of the tobacco industry selling an NRT product.  It makes the tortured distinction between NRT and dissolvables a little too obvious.

Dissenters argue that tobacco products already cannot be legally sold to anyone under the age of 18; however, these products are being aggressively marketed to youth via social media channels. Youth will access these products in many ways, including from legal purchasers, just as they have done with other illicit products in the past.

Once you stop laughing (remember, this was published this month), consider that this is something we do not make a big enough deal about:  These same people who predict that e-cigarettes, etc., are going to have some horrible impact also claimed the same thing about dissolvables, which basically no one consumed.  I suspect there are more kids using meth in Iowa than ever used dissolvables.  We need to point out that they use the same dire language about everything, regardless of being proven wrong in the past.

Policy Recommendations:  To prevent tobacco-related disease and death, ICPHA recommends three measures designed to control the sale and distribution of these products within Iowa based on ordinances that were recommended by the Linn County Board of Health to the Linn County Board of Supervisors:

Read:  The biggest clueless obsessives in the word, re this issue, live here in Iowa. Thus we should defer to them.

Prohibit the sale of Dissolvable Tobacco Products;
Prohibit the sale of Buy One Get One Free Tobacco Product Offers; and Prohibit the Distribution of Smokeless Tobacco Samples at Qualified Adult-Only Facilities.

Did you catch their analysis of the dangers of BOGO and ST samples in their claims?  Neither did I.  (I left out a bit because it is tiresome to respond to the same lies all the time, but nothing about those.)  This is what public health looks like:  Write the conclusions based on whatever personal bias you happen to have; write some words above them; don’t worry if the latter have nothing to do with the former.

Oh, in case you wanted to weigh in on this:

Comments are closed.

Wouldn’t want to risk someone pointing out how clueless they are, would they?

Anti-THR liar of the year #3: The World Health Organization (and a Dishonorable Mention for the Continuumistas)

Continuing the countdown of 2013’s top anti-THR liars, we should not forget that THR is not just about e-cigarettes or people who are rich enough to afford them.  Smokeless tobacco is still the leading method for THR in terms of number of users and proven efficacy and effectiveness.  The World Health [sic] Organization (WHO) — including its International Agency for Research on Cancer (IARC) and Framework Convention on Tobacco Control (FCTC) units — has long been one of the leading liars about smokeless tobacco.  While their lying is not as aggressive as it once was (and thus they rank only third this year in spite of their enormous reach), it is still going strong.

This matters because the lies have some influence on the knowledge of people in rich countries — for example, IARC played an important role in tricking people into believing that snus causes cancer to a measurable degree despite the lack of any such evidence.  But it matters much more because many poor countries simply take their public health marching orders from the WHO.

Among such countries are India and its neighbors, where there is great potential for tobacco harm reduction of a different kind.  Millions of people in South Asia use the dip product gutka and others that are similar to it, and these appear to create so much risk of cancer and other oral diseases that their health impact may be up with smoking.  The potential harm reduction that would come from persuading people to switch to smokeless tobacco — an obvious substitute that is low-risk and can be affordably manufactured locally — is enormous.  The number of users of those products is in the order of a tenth the number of smokers in the world.  Enter the WHO, which erroneously claims that these products are smokeless tobacco (tobacco is one of the ingredients, but clearly not the one that is causing the large health impacts).

Not only does this basically guarantee that there will be no attempt at harm reduction in South Asia, but it then carries back to the rest of the world that is tricked into believing that smokeless tobacco causes risks similar to gutka.  This leads to harmful lies like this, where the claim is that smokeless tobacco is 17% as risky as smoking (the absurdity of making a claim that precise, even beyond the fact that it is wrong by an order of magnitude, is a topic for another day).  This tends to discourage smokers from switching to this proven low-risk alternative.

The WHO has not spared e-cigarettes from its anti-THR lies, though they are a relatively minor player there, in contrast with being singularly devastating in their history of lies about smokeless tobacco.  Hat tip to Clive Bates for compiling this list of tweets, which speaks for itself:

WHO lies about e-cigarettes

Dishonorable Mention:  the Continuumistas

Another tribe of semi-liars are the “continuumistas” (not the best neologism meme ever, but useful), those who persist in mistakenly claiming that there is a “continuum of risk” among tobacco products.  This relates closely to the above points about different products and comparative risks.  The “continuum” claim may have been made more times in 2013 than in all previous history.  However, we did not rank the continuumistas on this list because it not really the same as the other lies:  While this is often an anti-THR tactic, in many cases it is not intentional and, indeed, many pro-THR commentators make this error.  Still, it is important and harmful, so deserves a mention.

Some of us have been pointing out for years why this claim is wrong and harmful.  For more details, read this, but to summarize the key point:  Claiming there is a continuum of risk suggests that tobacco products are spread out across the spectrum from zero up to the risk of cigarettes.  If someone believes that is true, they try to fill in the space, and so they dramatically elevate the claimed risk from some products, as with that 17%.  The reality is that there are basically just two relevant points: cigarettes and “about zero”.  The latter includes smokeless tobacco, NRT, and e-cigarettes, as well as abstinence.  The risks from all of these are so close that we cannot measure any differences, and so if you were to graph these risks versus smoking, they would all occupy the same dot on the graph.

So what explains the continuumistas in light of that distribution being about as far from continuous as is possible?  Some of them are out-and-out anti-THR liars, who are trying to suggest that no one should use the effective and satisfying THR products — or even that such products should be banned — because there is something else that is even lower risk.  Historically it was smokeless tobacco that was inaccurately moved into the empty zone between cigarettes and zero, but increasingly it has been e-cigarettes.  In many cases this involves absurd made-up numbers (e.g., “smokeless tobacco poses 10% the risk of smoking” or “why reduce your risk by half by switching to vaping when you can eliminate it entirely”), though sometimes it is similarly misleading graphical representations.

The claim is also actively perpetuated by industry in an attempt to muddy the waters and distract from the simple message: “combustion = bad for you; all else that currently exists and matters in the marketplace = no measurable risk”.  (In fairness, industry is trying to develop some smoking-like products that might occupy that middle space, with much less risk than smoking but more appeal to many smokers who do not like the smoke-free options; still, this does not make the continuum message accurate.)  Regulators also tend to like the notion because they like complication, and it keeps them from having to admit that the best choices — which they are often not making — are quite obvious and simple.  Finally, many THR supporters who are trying to position themselves as “moderates” seem to like the concept because it lets them avoid stating the highly confrontational implications of the simple message (“we can all agree there is a continuum of risk, right?… aah, good, so we are all on the same page”).

But whether used as intentional manipulation, a highly-toxic compromise between the truth and politics, or mere thoughtless repetition, the continuumista message is harmful for THR as a classic case of “the perfect is the enemy of the good”.  By suggesting that abstinence is perfect and thus “merely” good alternatives are too far away from it, many people are discouraged from taking the good options that are so close to perfect that the difference does not matter.

WHO lying about smokeless tobacco again

by Carl V Phillips

For those who may not know, the World Health Organization is one of the worst anti-THR liars in the world.  The prominence of their role as liars has fallen behind some other players in the Anglophone discourse recently, perhaps because their FCTC process has been largely eclipsed by the FDA, MHRA, and EU processes, because the WHO are slow and plodding so have not managed to become very actively anti-ecig yet.  But they, including their propaganda-science unit, the International Agency for Research on Cancer (IARC), are still trying to keep people smoking.

In this press release (h/t Clive Bates), WHO claims smokeless tobacco causes a huge number of cases of oral cancer and creates a huge health and financial toll in India and other countries in that region.  The announcement includes the news that the governments in that region are embarking on a goal (note: I intentionally did not say “plan”) to reduce use by 30%.  For those who do not know, this really means that WHO set that goal — in this region and in many other poor countries, insult is added to poverty by having a bunch of rich operatives in Geneva act as puppet masters for the national health authorities.

The lie here is that people in that region don’t use smokeless tobacco.  The cheap and ubiquitous causal drugs (filling the same niche that coffee, tea, tobacco, coca, etc. do in other cultures) used by millions of people in that region consist of several ingredients.  Sometimes tobacco is one of them, though sometimes not.  When it is included, it is typically the third ingredient down the list.

It is true that these products cause lots of oral diseases.  While the formal research on this is terrible quality and barely exists, it is clear from population statistics and product chemistry that there is a serious problem.  (Note that when population statistics and product chemistry show a result that the ANTZ do not like — say that e-cigarettes work and are low risk — they insist that it is of no value.  But when they like the result they embrace it.  Only politics matters to these people; they just make up scientific methods to further their politics.)

But the problem seems to be largely attributable to the other plant ingredients and a caustic chemical that are present (see this post for details), so the lie is not that the dip used by Indians and their neighbors is bad for you.  The lie is that it is smokeless tobacco.  Because, of course, we know that the risks from actual smokeless tobacco are so low that they cannot even be shown to exist.  (A few archaic variants perhaps had a risk that was a few percent that of smoking, but modern popular products have a risk so low it is speculative, based on predicting that nicotine has some adverse consequences.)

Suggesting that tobacco is causing these diseases is basically like claiming that tomato slices are fattening:  Tomato slices are typically the third ingredient in a fast-food burger, after the meat (including the grease it is cooked in) and the bun/wheat flour.  Fast food burgers are fattening.  So blame the tomatoes!  They are from a plant that is closely related to tobacco, after all, which means it must be their fault.  So if you are buying something in the gutka family in India be sure to get the kind without tobacco, and if you eat fast food burgers be sure to hold the tomato.  According to the WHO, that will make the products healthy.

Pretending there is a difference between dissolvables and similar NRT

by Carl V Phillips

A recent paper was ostensibly a research agenda for dissolvable smokeless tobacco products.  It is totally lame and is so devoid of useful content that it would not be worth reading at all, except that it is written by some of the US FDA tobacco unit’s pet consultants, and thus can be seen as either a calculated trial balloon for the FDA or, more likely in this context, an engineered excuse for doing what they were planning to do anyway.  The entire paper is vaguely hostile to dissolvables without actually saying anything concrete (because there is nothing concrete to say).

The glaring omission from the paper — and the definitive evidence that the paper was not trying to provide an honest policy analysis — was the complete lack of mention of pharmaceutical (NRT) nicotine lozenges.  The latter products are so similar to dissolvable ST that only someone who is trying to mislead their readers would fail to draw the comparison.

Clearly there are differences in appeal:  the ST products are made by people who understand what consumers like and are trying to give them what they want, whereas the pharma products are decidedly yucky (personally I do not find any of these products appealing, but the pharma products are more unappealing, an assessment shared by people I have talked to who like the ST products).  There are potential differences in the benefits (all of the psychoactive chemicals in tobacco vs. nicotine alone).  And there are theoretical tiny differences in their health effects, though it is not necessarily obvious which direction that goes in, and in any case it is tiny and unlikely to be measurable unless there is something very strange about dissolvables that makes them unlike snus.

But physically and behaviorally, the products are basically identical, and it is the physical and behavioral aspects that the recent paper (and, thus presumably FDA) is most focused on.  For example, there is the inevitable “look like candy” claim, though the pharma products resemble candy just as closely and, unlike the ST products, are actually packaged in ways that resemble candy (for more on that, read my parody of those claims if you have not done so — I am fairly confident you will find it worth your time).

There are several discussions of how smokers might use these products to deal with smoking place restrictions (with the insinuation that allowing smokers to avoid suffering is a bad thing).  But there is no mention that most people who use pharma nicotine use it for just that purpose.  The authors seem to also be unaware of the existence of snus pouches and e-cigarettes — they suggest that dissolvables are unique in their ability to provide smokers with a comfortable and socially acceptable smoke-free alternative.

Simply ignoring the similarities, while casting insinuations about dissolvable ST that are unaffected by the small differences, is the typical ANTZ strategy.  It seems to be the most definitive evidence that they are consciously endeavoring to protect their friends/patrons in pharma (not that there is not plenty of other evidence, but this is the most blatant).

While the recent paper was not one of the semi-psychotic hatchet jobs that we often see, it definitely had its share of “come up with anything we can say that is negative”:

The packaging of dissolvables also raises important questions. Some current product packages include 12 dissolvables per container. It is unclear if such package size is appropriate for the exclusive dissolvable user, or if it is more suitable for the needs of a dual user seeking to maintain nicotine levels during periods of smoking abstention.

I realize that ANTZ do not always seem to be a part of the same humanity as the rest of us, but how have they overlooked the fact that manufacturers often introduce a new product with a limited quantity, rather than demanding consumers pay for a large quantity to try the product.  I suspect consumers still can figure out how to buy a larger quantity at one time if they wanted — tobacco users are not as dumb as the ANTZ apparently think.  But beyond that, the claim is just moronic on its face:  Exactly how many smokers find themselves saying “well shoot, this only comes in a 24 pack, but I only expect that I will find myself needing to be temporarily smoke-free 12 more times in my life, so I guess I will not buy it”?

Of course, were the 24 pack were the norm, Greg Conley cleverly observed that the paper would have instead read:

Some current product packages include 24 dissolvables per container. It is unclear if such package size is appropriate due to the extremely high risk of child poisonings.

(Note: There is no evidence of particularly high risk — this is parody.)

Finally, as is practically mandatory for these papers:

This increase in the marketing of dissolvables has sparked controversy because the design of these products could conceivably contribute to an overall increase in tobacco consumption, thus leading to an increase in morbidity and mortality.

Apparently they have not read me and others pointing out that this claim is absurd (mentioned here recently), and that any substitute for smoking cannot help but lead to a decrease.  Apparently also they are incapable of performing the simple arithmetic that it takes to independently derive that conclusion.  Of course, they do not really have to have such analytic skills because they have figured out how to make a living writing content-free papers and then cashing their huge checks from the US taxpayer.

[Minor Update:  After some discussion, I have conceded that the neologism has standardized as the plural of the noun-ification of the adjective “dissolvable” — that is, without the “e” that was toyed with as a way to create a distinct word.  I will further concede that I should have at least been consistent :-) — so all the appearances are now standardized.  If nothing else, this is a nice lesson in how language usage evolves based on utility rather than following arbitrary rules like to not split infinitives or that a preposition is not good to end a sentence with.  After all, the rules say that the word is dissoluble.]

American Cancer Society are liars

by Carl V Phillips

As I have documented, the American Cancer Society (ACS) was one of the most aggressive anti-THR liars of the 2000s, actively campaigning to convince people that smokeless tobacco use was as harmful as smoking.  They have continued to be solidly a part of the anti-THR cabal in the 2010s, but they have not been so aggressive about the propaganda.  So in “honor” of today being the ACS’s “Great American Smokeout”, I thought I would see how much they might have corrected their lies.  It took me about five seconds to figure out the answer was “not much at all”.

Take just this one page, with about one screen’s worth of information.  (Archived here in case they try to memory-hole it, though they do not seem particularly concerned about being caught perpetuating stupid lies.)  It was the top hit from their own search engine, so I cannot be accused of digging through their archives to find obscure, non-prominent lies.

There is nothing here that they have not been corrected on numerous times.  So an intention to mislead people — blatant intentional lying — is the only way to interpret their behavior.  Let’s step through the entire content:

Are spit tobacco and snuff safe alternatives to smoking?

Can the question itself be a lie?  It turns out yes.  Many questions are intentionally designed to distract from the truth.  In this case, “safe alternative” is a strawman to distract the reader away from the relevant question, “is smokeless tobacco use an enormously safer low-risk alternative to smoking”.  No one seriously claims that ST is safe.  Nothing is 100% safe, so they could ask the same question and get the same answer about whether eating apples is a safe alternative to smoking.  People with a poor understanding of risk often think there is some dichotomy between the risky and the safe, which is obviously false, and ACS is blatantly taking advantage of this flaw in our national education, and perpetuating it rather than trying to help correct it.

As for “spit tobacco”, it is not a lie, but it is morally rather similar.  This is a term that was made up by anti-THR activists to try to denigrate ST users.   Can you imagine if they used similar derogatory unprofessional phrasing to describe, say, gay sex acts that increase cancer risk.  It would be a scandal.  Luckily for them, being tobacco-user-phobic is allowed.

Many terms are used to describe tobacco that is put in the mouth, such as spit, oral, smokeless, chewing, and snuff tobacco. Using any kind of spit or smokeless tobacco is a major health risk. It is less lethal than smoking tobacco, but less lethal is a far cry from safe.

Not too long ago, ACS would have said, in one way or another, that the risk is the same.  But the liars have been called on that enough times that only the most clueless still say it.  But instead of changing to the truth that encourage people to quit smoking, they just came up with another version of the anti-THR lie.  While there is no bright-line definition of “major health risk”, I suspect that no one would consider that phrase to include what we know about ST: “risk so small that it is not measurable, and there is no definitive link with any disease”.  This is a rather close cry from safe, it turns out.

More nicotine is absorbed from spit tobacco than is absorbed from one cigarette. Overall, people who dip or chew get about the same amount of nicotine as regular smokers.

Lying with literal truth, one of the classics.  The page is about health effects.  Since nicotine causes very very little or perhaps even none of the health risk from smoking, this is a red herring, meant to trick the average reader (who does not understand about nicotine).  What they say is actually not true because it is nonsense:  users of all products get as much nicotine as they choose to get, so it makes no sense to even make the comparison.

The most harmful cancer-causing substances in spit tobacco are tobacco-specific nitrosamines (TSNAs) which have been found at levels 100 times higher than the nitrosamines that are allowed in bacon, beer, and other foods. These carcinogens cause lung cancer in lab animals, even when injected rather than inhaled.

Another classic, the scary, scary chemicals.  Even if ST use does cause cancer, there is no way anyone can definitively claim what chemicals are responsible, let alone most harmful.  And, yes, mega-doses of those chemicals when injected in particular ways can be used to torture animals to death via cancer.  You know what else that is true of?  Basically everything.

Notice also that clever little “have been found”.  This is designed to distract from what is typical of products that are on the shelf today, with much lower concentrations of these chemicals than what has occasionally been found in the past.  It turns out that acetaminophen capsules have been found with lethal doses of poison in them.  Is that useful to know?

Of course, apart from all of that, the real key is that if the exposure does not cause a measurable level of cancer, then talk about cancer causing chemicals is meaningless.  It is intended to distract the reader from the truth.

The juice from smokeless tobacco is absorbed directly through the lining of the mouth. This causes sores and white patches (called leukoplakia) that often lead to cancer of the mouth.

Actually, if there is any dysplasia (pre-cancerous cellular changes), then the term leukoplakia does not apply.  But the terminology does not matter.  (So why did they include it? Because it sounds scary!)  What matters is that the superficial lesions from ST use do not often cause to cancer of the mouth.  Indeed, based on the science we have, there is not evidence that they ever do so.

People who use spit and other types of smokeless tobacco greatly increase their risk of other cancers, including those of the mouth, pharynx (throat), esophagus (the swallowing tube that connects the mouth and the stomach), stomach, and pancreas. Other effects of using spit tobacco include chronic bad breath, stained teeth and fillings, gum disease, tooth decay, tooth loss, tooth abrasion, and loss of bone in the jaw. Users may also have problems with high blood pressure and may be at increased risk for heart disease.

Should I be petty and point out that their list of “other [than mouth] cancers” starts out with mouth cancer.  Nah.  I will just repeat that none of that sentence is true.  It is not even remotely defensible.  There is no detectable risk for any of those cancers, let alone all of them.  Also unsupported by the science are the tooth and gum disease claims.  (I am not sure there is any research on bad breath, but it actually seems likely that using some mint snus reduces bad breath in much the same way that chewing gum does.)

The last sentence is another classic lie via a truthful statement.  ST users might have high blood pressure and above average risk.  Who else might have these problems?  Non-users.  (“Warning:  If you do not use smokeless tobacco, you may be at increased risk for heart disease and are at risk of high blood pressure.  Half of all non-users have elevated risk for heart disease.”   All true!)

What is snus? Is it safe?  Snus (sounds like “snoose”) is a type of moist snuff first used in Sweden. It’s often flavored with spices or fruit, and is usually packaged like small tea bags. It’s also sold loose, as a moist powder. Like snuff and other spit tobaccos, snus is held between the gum and mouth tissues where the juice is absorbed into the body.

No real health claims here.  But geez, how sloppy can you get and still be allowed to have a website?   (I will leave it as an exercise for the reader to spot the errors.)

Because it’s steam-heated rather than fermented, Swedish snus has fewer tobacco-specific nitrosamines that are known to cause cancer (see above). But this doesn’t mean snus is safe.  Snus users may have a higher risk of cancer of the pancreas than non-users. They also get sores or spots in the mouth (lesions) where the snus is held. It appears that snus users may have mouth cancer more often than non-users, though more studies need to be done to confirm this.

The only part that is correct is the “see above” — as in, see what I wrote about every bit of this being wrong, so I do not have to repeat myself.

Last Medical Review: 11/08/2012
Last Revised: 11/08/2012

In some ways this is the worst bit of all.  The page is current.  These zombie lies are not just some old leftovers.  They claim it was revised and reviewed this month.  Perhaps they should get someone who knows something about science, rather than a medic, to do their reviewing.

So, as the 2012 Great American Smokeout draws to a close, with almost everyone who quit for the day soon to start smoking again, the American Cancer Society can congratulate themselves for doing their part to make sure that those smokers did not switch to a low risk alternative.  After all, if they switched, they would dramatically reduce their cancer risk, and then ACS would not be able to keep using them to bolster its own wealth and importance.

Gutka is not smokeless tobacco

by Carl V Phillips

There is a popular oral dip product in India called gutka.  It was recently banned, in one way or another, across much of India, though it appears that this has had relatively little impact (other than perhaps raising the price to the extremely poor people who are most of the users).  Gutka is more popular in that country than is smoking, and is used by an absolutely enormous number of people.

Gutka, and the somewhat similar paan that is popular in Pakistan, appears to pose a very serious risk for oral cancer and other oral diseases, and perhaps other serious diseases.  The health consequences appear comparable to those from smoking, and might even be worse — in particular because, unlike with smoking, many of the serious effects appear to occur before old age.  (The “appear” caveats I keep repeating reflect the fact that most of the epidemiology about these products is so utterly lousy that precision is impossible — we had better quality information about smoking half a century ago.  But there is enough information that it is difficult to doubt that there are serious and high risks.)

So, gutka and paan are, indeed, nasty.  But what they are not — contrary to the typical portrayal — is tobacco.  Gutka does contain tobacco, and paan sometimes does (but not always), but it is not the first ingredient and may not even be the second.  The first ingredient in gutka is areca nut (also known as betel nut), and other ingredients include catechu (a derivative of the acacia tree), various flavorings, and calcium hydroxide (aka slaked lime, or just lime).  The ingredients in the one packet of it that I have that lists the ingredients (most do not) are “betelnuts, tobacco, catechu, cardamom, lime, menthol, natural & artificial flavors”.

So this is tobacco only in the sense that a Big Mac, fries, and Coke is lean beef, potatoes, and water.  The latter are major components of those products, of course.  But if they were all that was consumed, while it would not exactly be healthy eating, but it would not be all that bad.  But a funny thing happens when you consider everything in the foods (various unhealthy fats, high glycemic carbohydrates, carcinogenic products from cooking, etc.) — the meal becomes rather unhealthy.  This is a nearly perfect analogy to the deadly implications of calling gutka “tobacco”.

Something in gutka is pretty clearly quite unhealthy.  Lime is a good candidate — it is quite caustic on your skin, as you might have experienced, and is even worse for your oral mucosa.  It has fairly obvious and rapid negative effects.  But it might be that holding areca nut or catechu in your mouth for a long time is quite harmful too.  The one thing that we can be pretty sure is not causing most of the harm is tobacco.  Why?  Because it is the one of the ingredients that has been extensively studied, as an oral dip exposure, and has been found to produce minimal risk.

To be precise and careful (quite unlike most of those who write about this topic), it is possible that the interaction of tobacco with the other ingredients causes more harm than the other ingredients would cause if the tobacco were absent.  It is also possible that because of the way this particular tobacco is processed, it causes harms that American and Swedish style smokeless tobacco do not.  (There is a plausible but unsubstantiated hypothesis that the much higher concentrations of nitrosamines in some non-Western and archaic products could make them much more hazardous, though there is no evidence that it would be anywhere close to as bad as gutka is.)  Thus, we cannot conclude that the role of the tobacco is benign, but it is clearly wrong to suggest it is the main source of the problem.

Who suggests that?  Pretty much everyone.  The impetus for me writing this post was running across this newspaper story about how the gutka ban is failing due to the black market, with a headline that refers to it as “chewing tobacco”.  But it is not just bad reporters and casual observers who make the mistake.  The packets of gutka I have all display the mandated statements “tobacco kills” and “tobacco causes cancer” and what I assume are their Hindi equivalents.  I do not know whether current products still have those statements (once you ban something, it is difficult to enforce labeling regulations, after all), but the point is that the government’s official statements describe the product as “tobacco”.  This is probably the fault of the World Health Organization, since India’s policy is pretty much “do whatever WHO tells us to do”, but I actually do not know the story.  (Anyone know?  Please let me know.)

But it gets even worse than that.  The anti-THR liars have made a concerted effort to trick Westerners into believing that the apparent harms from Indian “tobacco” are relevant to Western products.  The classic example of this IARC Monograph 89, from the International Agency for Research on Cancer — a unit of WHO that primary is known for its science-by-committee declarations, and is mistakenly seen to be an authoritative and apolitical research organization.  The authors of that document — including longtime professional anti-THR activists like Stephen Hecht (already represented in this blog), Scott Tomar (who got a passing mention but seems to have disappeared), and Deborah Winn (who will likely make an appearance) — tried to bury the fact in their 626 pages that their conclusion that smokeless “tobacco” causes cancer was basically based just on studies of gutka and paan along with a single old study of an archaic American product.

I realize that this post leaves the reader with many points of curiosity that call for more information.  I will try to circle back to these sometime.  But I will conclude by creating one more:

Why did I say it was deadly to refer to gutka as tobacco?  THR in the West is about replacing smoking with smoke-free alternatives.  But in South Asia, there is a lot of room for something else that could be called THR:  The replacement of gutka and paan with smokeless tobacco (snus).  Western-style smokeless tobacco could be made domestically (and thus be affordable, though perhaps more expensive than the current products — I am not sure) and it would presumably have about the same unmeasurably low risk as snus.  Given that the impact of the local dip products is similar to that from smoking, this has similar potential to Western THR.  But — as with Westerners who think that “tobacco” or nicotine is the problem rather than smoking — this is very unlikely to be pursued so long as everyone thinks that it is the tobacco that is the problem.

Big government lies, EU-style

Outsourcing today, to Clive Bates’s blog.  He, in turn, was outsourcing to an investigation by a Swedish newspaper that discovered the European Commission (basically, the executive bureaucracy of the European Union) altered a consultant’s 2003 report about the minimal risks from smokeless tobacco, which recommended lifting the ban that prevented Swedish smokeless tobacco product sales elsewhere in Europe.  This was clearly done for political reasons, because the EU was committed to the ban and did not want any inconvenient facts about saving lives via THR to get in the way of their neat little plans.

(For those who may not know, this is pretty clearly a salvo in the simmering fight between Sweden and the rest of the EU, with the former wanting to promote THR — or at least their smokeless tobacco industry — and the latter seeking to renege on the promise that Swedes could continue to sell snus even though it is moronically banned elsewhere.)

The grossest bits of this became apparent because they literally used “Tipp-Ex” (which goes by the much more intuitive name, “Whiteout”, over here).  The original report suggested minimal risk from snuff/snus use, whereas the altered version claimed otherwise.  The key bit (translated from the Swedish):

If one holds up the document to a source of light, it’s easy to read the original line:

“An increased frequency of cancer in the oral cavity has been seen among snuff users in North America, but not unequivocally in Sweden.”

After being painted with Tipp-ex, the sentence reads: “An increased frequency of cancer in the oral cavity has been seen among snuff users.”

It is worth noting that even the original claim is wrong, though whether that was the original author falling victim to a common misconception or lying is difficult to determine.  It was clear in 2003, and still is, that the evidence does not support the claim there is a measurable difference in risk between popular American smokeless tobacco products compared to Swedish products.  (The details are a topic for another day.)

The main point for today is that the EU government is not far behind the US government in lying about THR.  They are, however, arguably solidly ahead in terms of the deaths they have caused by doing so, with their ban Swedish-style products.  There is little doubt that the ban and associated lying is responsible for millions more Europeans smoking today than otherwise would.