Tag Archives: conjunction

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. If they were all that was consumed it would not exactly be healthy eating, but they are not all that bad for you.  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.

See also: WHO lying about smokeless tobacco again and The biggest victims of WHO’s anti-harm-reduction efforts are in India


“Tobacco” is still not a useful category

posted by Carl V Phillips

After two weeks and many meetings, I have a lot I want to debrief here and at EP-ology.  But right now I face a long flight and accumulated exhaustion, so a simple post to fill the gap — tempting fate by criticizing the US government just before arriving at immigration.

Starting to smoke has immediate effects on oxygen delivery and lung function, and some upper airway effects do not require much accumulated damage.  “Greatly”?  Well that is perhaps a bit strong, but it does not have a precise meaning, so just call it typical advertising hype.

However, smokeless tobacco use has no such immediate effects.  This is obviously true since it is not clear whether it has any serious health effects ever.  This is not to say that a child ought to be free to decide to use any of these products.  But since — as is the message of the original post — “children” (meaning c.17-year-olds, though the word choice is clearly intended to evoke images of 10-year-olds) are using tobacco products, there are numerous benefits from choosing smokeless rather than smoking.  Telling them that they might as well smoke is no better than directing that lie at adults.

In general, any use of the term “tobacco” to refer to an exposure is wrong.  Tobacco is the name of a plant.  It does not describe any particular exposure and indeed, there are several potentially health-affecting exposures to tobacco that are quite different from one another.  It is basically like saying “poplar trees instantly cause your health to decline greatly” — there are ways in which this is true, but it is pretty obviously a dumb thing to say without actually specifying the exposure.

Moreover, many (perhaps most) uses of the term “tobacco” to describe an exposure are not just wrong, but are lies.  They are intended to make the reader to falsely believe that (possibly true) statements about the effects of smoking apply equally to THR products.  The above statement is pretty clearly an example of that.  After all, it does not take any more effort to type “smoking” than “tobacco”.  (Yes, the term “smoking” is not technically limited to cigarette smoking.  But with absent any modifiers, that is the understood meaning, and that is a useful meaning.  That contrasts clearly with use of “tobacco”.)

It is a simple point, but no one is more in need of remedial lessons than the high school intern who writes the embarrassing @FDATobacco twitter feed.

Classic lie: US Surgeon General, 2003

posted by Carl V Phillips

Despite the temptation to focus this blog on the latest and most clever lies, we realize that there is probably more practical value in writing about some of the classic and really stupid lies.  It is painful to deal with the stupidest claims, over and over again, but not everyone has seen responses to them, so it is useful.

As a first foray into that, I will address the testimony of US Surgeon General Richard Carmona before the a House of Representatives subcommittee hearing on smokeless tobacco in 2003.  That is the one that came up in a recent post because it was used as an especially stupid source citation.

The US government was the dominant anti-THR liar when I first started documenting anti-THR lies a decade ago, and they currently hold that position.  The United Nations might or might not have edged them out for a while during the years in between, but the FDA has put them solidly in the lead again.  Long before the lies about e-cigarette chemistry research from FDA, Samet, at al. became the most-cited anti-THR lie, it was Carmona lying about smokeless tobacco.

There was good testimony given to that subcommittee too (that by Brad Rodu, John Kalmar, me, in particular), but no one cites that anymore.  And they should not cite it, unless they are interested in documenting historical thinking.  Research study results do not necessarily lose value over time, but old summaries and expert opinions cease to be relevant because knowledge changes over time.

Not that Carmona’s opinion was expert.  Far from it.  The core claim was:

No matter what you may hear today or read in press reports later, I cannot conclude that the use of any tobacco product is a safer alternative to smoking.

Someone really has to be clueless to make a claim like this.  Even the preamble clause is an embarrassment, saying, “no matter what evidence I hear, my conclusion will not change”.  But deadly lie is the rest.

It is rather difficult to believe that Carmona was actually so stupid as to believe that smokeless tobacco was not less harmful than cigarettes.  Realizing the truth did not take an expert, a genius, or even education about health science (and you might expect a Surgeon General testifying about a topic to have one or two of those characteristics).  Someone just had to know enough to reason, “let’s see: about half of the deaths from smoking are from lung diseases, and no one claims that smokeless tobacco causes any measurable risk for those; the only claim anyone ever makes about smokeless tobacco causing more risk than smoking is for oral cancer, and that would be in the order of 1% of the total risk worst case”.  A bit of grade school arithmetic will then get you to “I can conclude the use of smokeless tobacco is safer than smoking.”

As it turns out, there was already ample evidence and expert assessment that the risk was in the low-single-digit percent range compared to smoking.  There was already clear evidence that the hypothetical oral cancer risk did not exist to a measurable degree.  Indeed, there was (and is) no disease for which any measurable risk had been demonstrated for popular Western forms of smokeless tobacco.  Someone who knew the science would not have to resort to the rough-cut reasoning I proposed.  Still, even someone with only rudimentary knowledge of maths and the subject matter could use that reasoning to figure out that the risk was lower than for smoking.

This statement is not actually the stupidest thing in the testimony, though it is the only claim that is ever quoted (sometimes in a different form since the same basic claim was repeated multiple times — e.g., “Smokeless tobacco is not a safer substitute for cigarette smoking.”).  There is actually even clearer evidence that this guy — or whoever was putting words in his mouth — was a really poor thinker.

Let me start with a few statements that were once accepted throughout society that have now been relegated to the status of myth.

  • Men do not suffer from depression.
  • Domestic violence is a ‘family’ or ‘private’ matter.
  • The HIV-AIDS epidemic is of no concern to most Americans.

All of us here know that these three statements are very dangerous public health myths.  My remarks today will focus on a fourth public health myth which could have severe consequences in our nation, especially among our youth: smokeless tobacco is a good alternative to smoking. It is a myth. It is not true.

Think about the message here.  You can even set aside the really stupid list of historical “myths”, and the fact that one was a moral claim rather than a factual one, and thus cannot be called a myth, one of them was basically correct, and one of them was never really believed by experts.  (I will leave which is which as a simple exercise for the reader.)  Just consider his implicit logic:  “Some people have been wrong about things before, and that is a reason to believe that (a different group of) people are wrong about this.”

Of course, he was right about one thing:  The popular myth about the risks from smokeless tobacco did constitute a threat to public health.  But the popular belief was the very myth that he was espousing — that it is just as harmful as smoking, and therefore you might as well smoke.

The talk had a few other gems:

Each year, 440,000 people die of diseases caused by smoking or other form [sic] of tobacco use

This is another great example of the conjunction lie I noted previously — he could have said “…by smoking or other forms of tobacco use or gazing upon my face and turning to stone”, and it would still be accurate.  He was using word games to imply that some nontrivial part of that figure cited was the toll from smokeless tobacco.  Indeed, that figure was the official estimated toll from smoking alone, so he was actually saying that neither smokeless tobacco nor his gorgon-like powers were killing anyone.  That is a bit of accidental truth that is conveniently overlooked by the anti-THR liars who still quote this national embarrassment to this day.

It is difficult to not be reminded of another bit of testimony from the same year from another cabinet-level official, Colin Powell insisting that Iraq had weapons of mass destruction.  In later years, Powell has expressed serious regret and apology for making that claim, and it basically cost him his legacy as a respected statesman, though he deserves a lot of credit for the apology.  But whatever one thinks of Powell and the war, the key observation is this:  Who would be stupid enough, years later, to quote Powell’s testimony and say, “this testimony is evidence that there were WMDs in Iraq”?  And yet that is equivalent to what the anti-THR liars are doing when they quote Carmona’s embarrassing and false testimony a decade later.

ERS position statement – lies, but D-minus work even apart from that

posted by Carl V Phillips

I mentioned that the “European Respiratory Society statement on E-cigarettes and emerging products“, probably written or at least overseen by demonstrated anti-THR liar Christina Gratziou,  might be the stupidest anti-THR statement I have ever seen from a theoretically-respectable organization.  Apparently they are not actually respectable, as demonstrated by the statement looking like something you would expect from some sock-puppet group of high school kids.

It starts out,

The European Respiratory Society, ERS is opposed to the use of all tobacco and unapproved nicotine delivery products such as cigarettes, chewable tobacco, and emerging products that include electronic cigarettes (e-cigs), snus, dissolvable tobacco and waterpipes.

In response to the successful increase in tobacco-free policies, the tobacco industry has developed these new products, allowing consumers to obtain nicotine without the use of a cigarette.[1] In many cases, these new products are claimed and/or perceived to be ‘harm reducing’ or safe alternatives to conventional cigarettes; however, there is no reliable science to substantiate this claim.[2] Rather, available research suggests that these products pose a significant health risk to citizens, placing them at continued high risk for disease and negative health outcomes. [3,4]

I could just write about the simple falsehoods — the claim that the tobacco industry developed the products and there is no reliable science — but this blog is going to get awfully boring if we just keep finding people making such false statements and repeating that they are false, over and over.  We will respond to claims like that when writing formal challenges like our formal complaint about Ellen Hahn, and will inevitably mention them periodically.  But we will try to minimize writing post after post about simple falsehoods in non-scientific statements.

In this case, beyond the blatant false statements there are three interesting and somewhat subtle lies in this position statement that I will cover in three posts.

The first can be found in the “and” toward the end of the last sentence.  There is almost nothing that can be said about this list as a collective entity (as in “these products” in the next sentence) that would be true.  Even setting aside the inclusion of cigarettes in that list, which I will be charitable and assume was a typo, what appears on this list of “new” alternatives to cigarettes with “significant health risks”, brought to you by “the tobacco industry”?

  • “Chewable tobacco” (normally called chewing tobacco), which is probably the original tobacco product, far older than cigarettes, and poses no health risks that are large enough to measure for the forms popular in North America and to a lesser extent, Europe.
  • E-cigarettes, a clearly low-risk alternative to smoking that is quite different from using whole tobacco in many ways, and was entirely an indy development until very recently.
  • Snus, the Swedish word for oral snuff, a product that like chewing tobacco is prehistoric, has been quite popular throughout the modern era (more now than before), and has also not been found to cause measurable levels of risk; alternatively, this word is commonly used in casual conversation to refer specifically to Swedish style snuff, in which case is it not prehistoric, but merely centuries old, with all of the other descriptions remaining the same.
  • “Dissolvable tobacco” (presumably referring to tobacco in a dissolvable substrate — the tobacco does not dissolve) which is a new innovation and is generally believed to pose close to the same very low risk as similar smokeless tobacco products, though there are some possible differences.
  • Waterpipes, another centuries-old traditional product, though one that is a form of smoking, and thus may pose risks that are similar to those from cigarettes (many estimates put the risk a bit lower, but the anti-tobacco industry has taken to saying it is 50 0r 200 times worse than cigarettes).

I trust it is fairly obvious that no statement that tries to generalize about that list, beyond simple statements like “these are all ways of using nicotine and tobacco that many people like”, is bound to be a fail.

But this is not an accidental fail.  It is a new version of the conjunction lie that my colleagues and I documented in what I believe is the first study of anti-THR lies.   The simplest version of this anti-THR lie is to refer to “tobacco” as if that plant name refers to an exposure — a single exposure, no less — and then start quoting statistics about the risks from smoking as if they are relevant to other forms of tobacco use.

The particular version of it that was popular c.2004 was the claim, “smoking and smokeless tobacco cause 75% of oral cancer.”    This was actually a bastardization of the more defensible “smoking, drinking alcohol, and smokeless tobacco cause 75% of oral cancer.”  This was based on a single study or one dataset that concluded that smoking and drinking (alone) were responsible for 75% of oral cancer.  So, add something else to that list that does not seem to cause oral cancer, and the estimate is still 75%.  As in “smoking, drinking, and listening to Mozart cause 75% of oral cancer.”

So, for any list that includes a form of smoking alongside a several smokeless alternatives with no proven risks, it is possible to say that “these” apparently cause various risks and have not been shown to be less harmful than smoking.  (This is even more obviously so if we leave cigarettes on the list rather than assuming it was a typo.)  Obviously any such claim is a lie, meant to trick the reader into believing that the claim is true for everything on the list, when it is actually true of only a small subset of the items on the list.

Those anti-THR liars think that they are just soooo clever.

As a final note, it is now generally accepted that papilloma virus causes a large fraction of oral cancers.  It was actually fairly clear that sexual transmission accounted for a lot of oral cancers back when the 75% claim was originally made, and that 75% was not even close to accurate.  That is now the conventional wisdom.  (I never got around to publish a paper that pointed this out — my bad.)  If anyone is aware of any case where the anti-THR or anti-smoking or anti-alcohol activists explicitly admitted they were wrong about their adamant declarations that “their” product caused most oral cancer, I would love to see it.  I have never seen any such admission of error in spite of this clear disproof of what was once one of their favorite claims.

…to be continued…