Some trusted health institutions seem unable to cope with the reality of a huge variation in risk between different tobacco products – notably combustible versus non-combustible. If you were paying attention, you may have noticed a subtle change in the Mayo Clinic’s approach to smokeless tobacco last week.
On 1st April 2016, its advice on smokeless tobacco looked like this. See Wayback Machine archive – and in Google’s cache at the time. “Chewing tobacco: Not safer than cigarettes”
By 2nd April 2016, it had changed to this. “Chewing tobacco: Not a safe product“.
What could have prompted such an important change in advice from the Mayo Clinic? Those headlines are really quite different.
Perhaps it was this?
1st April 2016. Lynn Kozlowski and David Sweanor paper on the ethics of placing information on the relative risks of different nicotine products “in quarantine” – i.e. hiding the truth from people in order to affect their choices and behaviours, in which they round on Mayo Clinic for its continuing deceptive headline.
Kozlowski LT, Sweanor DS. Withholding differential risk information on legal consumer nicotine/tobacco products: The public health ethics of health information quarantines. Int J Drug Policy 2016 [link]
Progress of a grudging and dishonest nature
It is disappointing that we have to count as ‘progress’ the Mayo Clinic’s movement from an outright falsehood to being merely deeply misleading. Of course, it is hard to prove anything is ‘safe’ in absolute terms. Even if the tobacco and nicotine are completely benign, it is probably a choking hazard of some sort. So no-one ought to claim smokeless tobacco is perfectly safe and no-one really does. But it is universally understood in the tobacco and health field that smokeless tobacco products are much less risky than smoking.
However, saying something is not a safe product tells the consumer next to nothing of value and has the obvious potential to mislead – which is possibly its purpose, given what this wording has just replaced. “Not a safe product” for example, can mean any of the following things in relative terms:
- 3% safer than cigarettes
- 25% safer than cigarettes
- 54% safer than cigarettes
- 77% safer than cigarettes
- 98% safer than cigarettes
No-one does know or can know the exact answer and there will be differences between products, but only one of these is even approximately right – the last one. Smokeless tobaccos, even in the riskiest forms available in the United States, simply do not and cannot create the same range of the big killers – lung cancer, respiratory disease or cardiovascular disease – as cigarettes.
And the Mayo Clinic has form…. back in 2013, it was guilty of similar dissembling over e-cigarettes. See Mike Siegel: Even the Mayo Clinic is Spreading Lies About Electronic Cigarettes; What is the Anti-Smoking Movement Coming To? “The manufacturers claim that e-cigarettes are a safe alternative to tobacco cigarettes.” They didn’t then and they don’t now.
What the Mayo Clinic should do now
1. Own up properly and apologise
It should acknowledge that it has made this change on its website and apologise for misleading people who trust it to provide high-quality health advice. It is good practice to acknowledge significant changes and errors (see BBC policy, Correcting mistakes, for example), especially when they have life-threatening consequences My suggested text:
Earlier versions of the page were headlined: “Chewing tobacco: not safer that cigarettes”. The Mayo Clinic accepts this is and always has been inaccurate – chewing tobacco is much safer than cigarette smoking – and apologises to anyone who has been confused or mislead by this advice.
2. Conduct a
purge review of governance and quality control
In the light of such a severe error that persisted for so long, despite concerns have been on the record and accepted by the U.S. government since 2003, the Mayo Clinic should review the governance and quality control of its advice on tobacco and health to ensure that it is making truthful and meaningful statements of the ‘whole truth’ to consumers.
3. Assess legal risks and liability arising from misinformation on tobacco and health
Given the litigation in this field and the potential that this advice has to mislead smokers into maintaining more harmful behaviours, the Mayo Clinic should assess any legal liability it may have for misleading smokers from its position of trust. It should consider its liability in all advice it offers that may have adverse behavioural consequences if wrong or misleading.
4. Provide better advice on tobacco and health to people who trust the Mayo Clinic
The formulation, Chewing tobacco: not a safe product, is in the category technically-correct-but-misleading and, therefore, is not truthful. Remember the imperative to tell “the truth, the whole truth and nothing but the truth”? The Mayo Clinic should progress to the next level of reduced deceitfulness and attempt to communicate something factually useful about smokeless tobacco. For example, it could use the following formulation.
No tobacco product is safe, but smokeless tobacco products present substantially lower risks to health than cigarettes
This is based on the suggested wording of tobacco companies trying get the FDA stop imposing warnings on cigarette packs that mislead consumers – see my posting: Misleading the public for their own good? Changing the warnings on snus.
It could even move closer to truthfulness. It should ask its experts to undertake a literature review and provide reasonable and defendable quantified estimate so that the visitors to its site in search of meaningful information would, in fact, find meaningful and actionable information. Perhaps ending up with something like following, which is the advice I would give about smokeless tobacco:
You should not assume that any tobacco product is completely safe, but smokeless tobacco products are likely to have at least 95% lower risks to health than cigarettes and there will be some variation in risks between between different types and brands
5. Try to uphold its own mission and values statement
The Mayo Clinic should uphold its Mayo Clinic Mission and Values and stop trying to fool the public, by accident or design, about the risks of smokeless tobacco.
Mission: To inspire hope and contribute to health and well-being by providing the best care to every patient through integrated clinical practice, education and research.
Primary value. The needs of the patient come first.
Integrity. Adhere to the highest standards of professionalism, ethics and personal responsibility, worthy of the trust our patients place in us.
Others are guilty too
See Brad Rodu’s excellent post on the misleading smokeless tobacco campaign of the U.S. FDA – FDA Smokeless Tobacco Campaign is Incompatible with Science-Based Regulation.
Naturally, the U.S. Centers for Disease Control continues its leadership in misleading by omission. It says nothing about the most relevant health comparator – cigarettes – on its smokeless tobacco pages.