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After the American Heart Association came out with a strong statement against the use of smokeless tobacco as a smoking cessation aid, Dr. Gilbert Ross sent them this letter on Sept. 23:
Re: Piano et al, “Smokeless Tobacco Products and CVD”
To the American Heart Association: Physician leaders such as yourselves who consider themselves experts in cardiovascular disease and public health should be deeply ashamed of the recent AHA policy statement downplaying—indeed, denying—even the possibility of using smokeless tobacco to help addicted smokers quit.
Your statement was supposedly the distillation of an extensive review of the effects of smokeless tobacco on various health outcomes, as outlined by Piano, Benowitz et al in the most recent issue of Circulation: Journal of the American Heart Association. Whatever one’s feelings are towards the tobacco industry—and those of us involved in public health or clinical medicine harbor deep, negative, and well-justified antipathy towards those who market lethal addictive products to the unwary public—the problem now is how to help the 45 million addicted American smokers to get off deadly cigarettes and reduce the toll of 440,000 premature cigarette-related deaths each year. The AHA review and policy statement clearly shows that you are more concerned about an unscientific agenda than reducing smoking’s toll.
Assertions based on minimal or non-existent evidence are presented as documented fact. An attitude of “absolute proof” of efficacy holds sway—despite the fact that currently approved cessation methods, alone or in combination, result in an unacceptably low number of long-term successful quitters. Observations from large populations of smokeless users over decades—Scandinavian data—are downplayed or ignored to justify an anti-smokeless bias completely inappropriate in a scientific organization devoted to public health.
The evidence is clear, disturbingly so, that you abandoned science in sounding this baseless, destructive alarm: the studies your own authors cite show minimal if any harm from using smokeless tobacco—and even those few studies supporting your thesis are based on a mélange of various types of smokeless tobacco bearing little resemblance to modern snus-type smokeless products. The studies cited typically failed to discriminate between the various types of smokeless used. Your repeated references to “spit” tobacco are another clear sign of bias: the term itself is bound to cause readers to feel disgust, and snus products are not spit. You profess concern that the tobacco industry might manipulate the smokeless market to weaken the efficacy of tobacco control—thus presenting a hypothetical situation as a justification for denigrating a possible method for reducing the toll of cigarettes. As one piece of “evidence,” you note that several major cigarette makers have purchased smokeless companies—without giving any credence to the likelihood that cigarette makers also want to jump on the bandwagon of reduced-risk nicotine products to help their bottom lines.
You refer to an increased risk of oral cancers due to “carcinogens” in smokeless tobacco—although extensive studies over the past decade have clearly disproven any such link. You take pains to point out the unimpressive nicotine blood levels among smokeless users—without expressing any concern that such levels might suffice anyway to reduce cigarette craving. While acknowledging that smokeless is much less harmful than smoking, you disingenuously say that you have no evidence that smokers who switch to smokeless actually reduce their disease risk. Does that make any sense to you? Only by a bizarre refusal to open your eyes to the facts can that type of cognitive dissonance be accepted into a supposedly scientific discourse. Finally, you conclude that the AHA does not recommend the use of ST as a cessation aid, nor even as an alternative to smoking, because of several clearly irrelevant rationalizations: first, that ST products are not “without harm;” second, ST use is associated with an increased risk of some diseases, and it is addictive; third, there is “inadequate evidence of smoking cessation efficacy and safety.”
All of your concerns must be framed thusly: compared to what? ST is “not safe,” but it is proven to be about 99% safer than smoking cigarettes. The evidence of its safety and efficacy is clearly available from the Scandinavian data of the past five decades or more: lower smoking rates concomitant with increased snus use, and the lowest smoking-related disease rates in Europe. The unacceptable quit rates we currently experience with all the approved methods combined with the evidence (albeit evidence you fail to acknowledge) of ST’s safety and efficacy cry out for increased consumer awareness of this product and truthful communication of its properties—not moralistic, prohibitionist denials of the possible benefits out of fear of hobgoblins and the quest for “safety.” We all agree that no one should take up smoking, and smokers should quit. Adhering to that message in the face of millions of addicted smokers who want to quit but can’t tell our addicted smokers: Just keep right on smoking. Is that the message you wish to convey? Shame on you.
Gilbert Ross M.D.
The American Council on Science and Health