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Taking liberties

| May 1, 2014

Anti-smoking activists’ careless use of the facts could have serious consequences for tobacco harm reduction.

By George Gay

You can usually judge the veracity of a statement by the conviction with which a person states it and the vehemence with which he or she defends it when challenged. As a general rule of thumb, veracity is in inverse proportion to conviction and vehemence.

Two propositions that seem to get stated with conviction and defended vehemently have it that smoking is addictive to the point of being almost impossible to quit and that secondhand smoke causes fatal diseases in nonsmokers.

In June 2006, the then U.S. surgeon general, Richard Carmona, was quoted in a Washington Post story as saying the health effects of secondhand-smoke exposure were more pervasive than had been previously thought. “The scientific evidence is now indisputable: Secondhand smoke is not a mere annoyance,” he was quoted as saying. “It is a serious health hazard that can lead to disease and premature death in children and nonsmoking adults.”

The Post pointed out that the findings of the report he was launching were not based on new scientific data, but rather were the result of looking again at research that had been conducted during the previous two decades. Nevertheless, a spokesperson for the Campaign for Tobacco-Free Kids was quoted as saying: “This report once and for all ends any scientific debate about whether exposure to secondhand smoke is a cause of serious diseases like lung cancer and heart disease.”

At this point, alarm bells go off in my head and a big neon sign starts blinking out: Whoa, dude! Surely if somebody says that scientific evidence is indisputable or that a scientific debate is over, you know there is something wrong because science doesn’t work that way—not at least in respect of an issue as complex as that surrounding the risk created by secondhand smoke. And there has been something seriously wrong with the debate on secondhand smoke for a long time. In 1998, the World Health Organization (WHO) was presumably rather embarrassed when it became known that a study it had commissioned had found no statistically significant increase in risk of lung cancer among the nonsmoking spouses of smokers. Workplace risk was similarly not statistically significant.

But, according to one report, there was a statistically significant result within the WHO study: that children raised by smokers were 22 percent less likely to get lung cancer than were those raised by nonsmokers.

The WHO study was by no means unusual in seemingly getting secondhand smoke off of the hook. As recently as December 2013, Daniel Fisher reported for Forbes that a large-scale study had found no clear link between secondhand tobacco-smoke exposure and lung cancer. Fisher cited an article in the Journal of the National Cancer Institute that provided the results of a study—commissioned by the institute—of 76,000 women over more than a decade. The study apparently found a link between smoking and cancer, with lung cancer 13 times more common among current smokers and four times more common in former smokers than in nonsmokers.

But the study found no statistically significant relationship between lung cancer and exposure to passive smoke.

And yet the fear of secondhand smoke has been used to introduce the most draconian restrictions on smokers, restrictions that are starting to reach into people’s homes and that, if one campaigner has his way, will include any public place used by children and nonsmokers, which, I guess, covers everywhere.

But I wonder whether some of this is the last throw of the dice. I say this simply because I see that the emphasis seems to be shifting to so called “third-hand smoke,” which, of course, is not smoke at all but the residues left by smoke on surfaces. One report I saw had it that research out of the U.S.’s Lawrence Berkeley National Laboratory had found that the residue from smoking indoors had the potential to cause cancer. The researchers were said to have found that when nicotine in secondhand smoke reacted with nitrous acid in the air, it created nitrosamines.


But let’s take a look now at addiction, which, as is mentioned above, is, like secondhand smoke, liable to raise strong feelings. In January this year, a report in Canada’s Globe and Mail told how the Non-Smokers’ Rights Association in that country had filed a complaint with the Collège des médecins du Québec against a key expert witness who had testified at the long-running class-action suit against tobacco manufacturers at the Quebec Superior Court in Montreal. The complaint accused Dr. Dominique Bourget, a forensic psychiatrist at the Royal Ottawa Mental Health Centre, of breaching the college’s ethics code by “minimizing the gravity of, if not denying the existence of, tobacco dependence.” According to François Damphousse, the Quebec director of the association, Bourget just “brushe[d] aside all the science on nicotine addiction and the neurophysiological effects of nicotine on the brain.” Damphousse apparently said that Bourget had played down tobacco’s addictive potential and rejected current scientific knowledge about addiction; and he added, “She is not allowed to do that as a member of the Collège.”

Again, I would suggest that this is not how science is supposed to work. The search for scientific truths doesn’t have a cut-off point, at which time you stick your fingers in your ears and go “la la la.” And luckily for us laypeople, there are scientists who are willing to peer beyond the cut-off point. The piece in the Globe and Mail was contributed by Sally Satel, who is a practicing addiction psychiatrist and a resident scholar at the American Enterprise Institute in Washington. “I can understand why the plaintiffs (and their supporters) reject Dr. Bourget’s view of addiction,” she said. “It is inconsistent with the narrative of enslavement: that once people become addicted to nicotine, they are helpless to quit.

“As a psychiatrist specializing in addiction, I routinely hear that addiction leads to changes in the brain that ‘hijack’ the smoker’s capacity to change his behavior. Yet, insisting that the biological changes produced by addiction do not [my emphasis] prevent recovery is entirely consistent with what we know about addiction.

“Do brain changes make it hard to quit? Yes. But by no means do they make it impossible. Indeed, we can give our patients hope precisely because heroin (or cocaine, alcohol and so on) [does] not cripple their brains. With motivation and guidance, they can and do free themselves. So can smokers.”

There were a number of things I liked about the Satel piece, not least the message of hope it brings, which makes a pleasant change from the voices of doom that offer no hope of salvation to smokers, only the bitter medicine of victimhood. I also liked the fact that the message was in line with what the layperson observes every day. Smokers—lots of them—do give up, most of them in my experience without assistance and, I suspect, without planning.

Staying with the idea of the layperson as observer, and taking addiction and secondhand smoke together, there is something that has long puzzled me. Why have I never observed a nonsmoker stalking a smoker down a street trying to get a whiff of tobacco smoke to feed the addiction caused by her exposure to secondhand smoke? I have, after all, heard it said that one puff on a cigarette is enough to get a person hooked on smoking.

And so it should be the case also that, say, all of the women who were the partners of the smokers reported on in the study published in the Journal of the National Cancer Institute mentioned above should have become addicted smokers long before the end of the study.

It is certainly the case that tobacco addiction is not a simple matter. It seems that it is not only about nicotine, for instance. Researchers in New Zealand reported last year that non-nicotinic components had a role in tobacco dependence and that some tobacco products had higher abuse liability than did others, irrespective of nicotine levels.

Apparently, tobacco addiction can be stronger or weaker depending on the person addicted, or on whether the nicotine is “manipulated” in some way: something that tobacco manufacturers have been accused of in the past. Even the addition of menthol, in some people’s estimation, can make cigarettes more addictive than they otherwise would be.

One of the oddest aspects of tobacco addiction is that, again in some people’s eyes, no matter how powerful that addiction might be, it, like everything else, comes at a price. People in government, especially those connected with finance ministries, believe that the price of cigarettes can be raised to the point where addicted smokers simply give up their habit. In fact, the figures are quite explicit in South Korea, where the current average price of a pack of cigarettes is won2,500. A recent report had it that for smokers in the bottom 25 percent income bracket, won8,497 per pack would prompt them to give up, while those in the top 25 percent would hold out until the price went to won9,660 per pack.

Physical aspects

It has long been known that a smoking habit is about more than just taking in smoke. In describing last year a cigarette substitute they had developed, two Canadian doctors said they had wanted to make it look like a cigarette. There was something about hanging out with friends and holding something and putting it up to your mouth, they said. There was a physical addiction and a social addiction.

Later on, the doctors pointed out that, by itself, nicotine focused attention and improved alertness, with few negative side effects. It had some pretty good properties in relatively small doses. It was the dirty delivery system that made cigarettes incredibly harmful.

Indeed, I sometimes get the idea that addiction is a fairly normal human condition that has simply been given a name and a medical history so that a lot of people can make money out of providing remedies and cures. Last year I saw a promotional piece for a book offering to cure addiction in which it was said that almost everyone was touched by addiction. And I have seen over the years addiction applied to more and more products and activities: drugs, alcohol, prescription painkillers, smoking, gambling, sex, pornography and soap operas to name but a few. Now I would be the first to admit that some of these products and activities can prove destructive, but where they don’t prevent a person from functioning normally in public life, what’s the problem?

Having said all of this, I don’t think that the important point is whether secondhand smoke is deadly or not, or whether tobacco addiction is impossible or difficult to break. What is important in my view is that only the truth about such matters, in so far as it is known, is used to make decisions concerning “tobacco” consumption. We are entering a new phase of the tobacco industry, and there is a great danger that the debate about products such as e-cigarettes is being hijacked by people who, having learned bad habits in dealing with traditional cigarettes, don’t mind being careless with the truth if it suits their viewpoint—often the viewpoint that people shouldn’t be seen to be enjoying themselves. When the debate was focused on traditional cigarettes, the conclusions drawn from the distortions told about secondhand smoke caused inconvenience to those who enjoyed tobacco. Now that the debate is about a product that some find a useful substitute for tobacco and that is almost certainly a gazillion times less risky than tobacco cigarettes, the distortions, which are beginning to appear by the truckload, could be lethal.


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