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 publichealth 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 harmreduction 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 lesshazardous 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 publicawareness 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.
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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
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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
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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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By Brian Newsome
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