If you want to say something absolutely jaw-dropping in its idiocy, then you need to cloak it in lots of fake sophistication. And this is what ASH Scotland has done with its new position paper on smokeless tobacco.
No less than 266 references are used to support the truly stupid idea that smokeless tobacco, which can substitute for cigarettes and is far less hazardous, should be banned. Smokeless tobacco is far less dangerous because there is no, er, smoke to draw into the lungs. The red hot particles, volatile gases and thousands or organic products of combustion ingested deep into the body do the harm.
If you put that idea to any normal person they look at you as if you’ve lost your mind. Only in the insular world of ‘tobacco control’ do these ideas survive for longer than it takes to express them. In fact, there is a wealth of evidence that it is, as you would expect, a truly stupid thing to do – not least because the place where it is most widely used (Sweden – see chart) has much lower rates of smoking related deaths….
The chart shows male lung cancer mortality rates in some major countries [Source: IARC / WHO Cancer Mortality Database CANCERMondial]. One country stands out: Sweden. And Sweden also has lower rates of oral cancer and other smoking-related diseases. The difference between Sweden and the others is that a high proportion of its tobacco use in Sweden is in smokeless form [view]. One of Europe’s especially ludicrous policies is to ban most forms of ‘oral tobacco’ [Directive 2001/37/EC Art 8], though not in Sweden.
So the main ASH Scotland policy idea is that other countries should be prevented by law from reaching a position where more of the tobacco use is through far less harmful forms of tobacco consumption and that addicted individuals should be prevented by law from having access to lower risk products. What next? A ban on anti-lock brakes? Cycle helmets? Ropes while rock climbing? Any risk reduction measures at all while engaging in inherently risky behaviour? There’s the warped logic of the overweening health planner behind all this… if you make a risky activity much safer, then people might not stop doing it altogether.
Confused about burden of proof
Apart from the unsettling coerciveness of such positions, there are simplistic errors in the analysis – concerned with the handling of scientific uncertainty when making policy. Science can (and should) reserve judgement indefinitely or use ‘beyond reasonable doubt’ tests of evidence. But policy making requires decisions whatever the available evidence – and a decision includes “maintaining the status quo”. This requires the policy-maker not to demand perfect knowledge but a ‘balance of probabilities’ assessment of available evidence. Throughout the document, the authors draw conclusions of the form: “there is not enough evidence [for doing something sensible]” and so decide to stick with doing something stupid, as if there is conclusive evidence to support the stupid ban. Which there isn’t and they don’t pretend there is, or even seem to recognise that there ought to be. All they’ve done is set a high or impossible evidential hurdle for the thing they don’t like and not applied any evidential challenge whatsoever to maintaining the ban, which they do like. But what if the ban, by denying people less hazardous alternatives, is actually killing more people? It’s at least plausible. And given the position in Sweden, where it isn’t banned and many fewer people die, you might think that was a good starting point and expect some evidence to show that bans aren’t just making everything worse. For me, the burden of proof is on those supporting the utterly insane idea of banning much less hazardous substitutes for very deadly products. Look through the ASH Scotland paper and you’ll find no evidence to support a ban or give any confidence that it isn’t doing more harm than good.
Confused about individual rights
But I think the thing I find most troubling about this sort of posturing is what it means at an individual level. In effect, these remote health planners are saying to a person who smokes cigarettes that they should not have access to a much less risky alternative. Where did the acquire the authority and the bare-faced arrogance to do that? How did they become so sure of themselves that they feel qualified to restrict the harm reduction options available to someone struggling with addiction? So on those estates in Glasgow, where smoking prevalence can be as high as 70%, ASH Scotland says ‘no’ to lower risk alternatives. You must quit. And if you don’t quit – well, you might as well die.
Wrong questions
ASH Scotland solemnly poses questions like should smokeless tobacco be given a “legal designation as a harm reduction product in the UK? Eh? There’s no such thing. It’s a tobacco product – just much less dangerous than the norm. Or they state a preference for use of NRT for harm reduction or stopping smoking – but what if others find smokeless tobacco more effective or don’t want or wont use a medicalised approach? What is the case for reducing the available options for quitting or reducing smoking? They prefer other interventions such as smoke-free places legislation and bans on advertising. All good ideas, but they don’t explain explain why these are mutually exclusive with policies that reduce the harmfulness of the tobacco that is sold or why removing smoke would have a beneficial supportive ‘denormalising’ effect. Or why there wouldn’t be additional benefits from reducing passive smoking exposure, role modelling and fire risk.
With top epidemiologists predicting 1 billion premature deaths from tobacco in the 21st Century, one might think that all options would be in play- especially as the smokeless products have done so much to keep the carnage down in the one place where they are widely used.
So for the next edition of this position statement:
1. please provide evidence that the ban you favour maintaining isn’t doing more harm than good at population level by denying smokers access to much less hazardous products and opportunities to manage nicotine addiction, in the way it appears to work in Sweden. We know that even if a few extra people used it that were never going to be tobacco users or would have quit anyway, the extra harm would be small.
2. please outline your ethical basis for denying a person access to an alternative product that is much less dangerous than the one they may be addicted to. You might think it will save the lives of others (I don’t, and you can’t show it will), but what about that person’s individual rights? Do they count for nothing in the face of your bossy prescription?
3. please explain why it would be good policy to provide legal protection to the cigarette makers in the market for tobacco and a barrier to entry to potential competitors offering much lower risk products. This is an especially stupid idea now being aggressively pioneered by health campaigners in the United States through their seedy and desperate deal with tobacco giant Philip Morris to support a Bill to pass regulation of tobacco to the FDA. Expect many dead.
Read this instead…
For a decent review of the evidence, don’t spend too long watching ASH Scotland struggle with basic epistemology. See Brad Rodu and Bill Godshall in Harm Reduction Journal 2006, 3:37; and the collection of 50 best papers on the International Harm Reduction Association tobacco section. Even tobacco companies provide better and more balanced analysis than this effort by ASH Scotland: see this account of Experience from Sweden by Swedish Match – or this literature review by United States Smokeless Tobacco.
I am particularly amused by the ASH Scotland statement “There are three main arguments for banning snus and other forms of snuff: that it is hazardous; that it may introduce young people to smoking; and that it is a product developed by the tobacco industry.” Though I take issue with each, the last is the most risible. According to this,if the industry developed a flotation device, or a cola drink, either could easily be banned on the basis of origin.
Secondly, the continual dismissal of any research even tangentially related to industry is not mirrored by a similar concern with research having ties with the pharmaceutical industry.
On the whole, ASH seems much more concerned with where the research comes from than the results thereof.
Absolutely fascinating. I wonder if you live in Cambridge, btw, it’s where I am based.
I really like the topics you write about and your intelligent approach, I found you via Bishop’s Hill.
Dear Cap’n Flint
Yes I have always assumed there there is relatively small harm from smokeless tobacco, and this varies with product and so could be controlled with regulation, but these harms are very small compared with smoking. Perhaps in the range 1-50 where smoking is 1000.
The test of whether something is a harm reduction product isn’t whether you can prove no-one who wouldn’t otherwise have used tobacco will ever use it, but whether overall harm is reduced. This means you need to consider the harm done and change in use patterns. Kozlowsky refers to this as a ‘risk/use equilibrium’. In crude terms: if smokeless tobacco use is 1/100th the harm of smoking, you’d need 100 non-users to take it up to wipe out the health impact on one smoker that switched. Implausible.
But a deeper point than that, is the individual rights and responsibilities argument… should you stop someone who wishes to use a lower risk product because others might use it too? I feel very uncomfortable about trading individual choices for aggregate effects on principle.
On the burden of proof point – my whole argument is that the banners need to prove their case. It is they that advocate the most extreme and unusual idea of banning a less hazardous product than the market leader.
People like the fools at ASH Scotland and much of the tobacco control Taliban talk as if there is no evidence that smokeless tobacco is a harm reduction effect. Rubbish. Not only are there many studies on this now, but they somehow ignore dramatic proof of concept in Sweden where the smoking rate is the world’s lowest and tobacco related disease is the world’s lowest. I say the burden of proof is with those that want to prevent by law any country having the possibility of getting to where Sweden is. We should just note that if Sweden was doing something that tobacco control people liked and it was giving these results it would be lauded as the ultimate clinching argument…
One of the most silly arguments I hear is of the form “well you can’t prove it will work outside Sweden” (so we should continue to ban it). Of course not. This is a market intervention and will take years to develop and a gradual culture change to embed. It cannot be judged using a randomised controlled trial as you might do for a medicine. So the right thing to do is to lift the ban and allow it on to the market with a set of regulatory measures that ensure as far as possible that it works for health (sensible warnings messages, favourable excise tax treatment relative to cigs, toxicity standards etc). Then conduct post-market surveillance and in the unlikely event it all seems to be going wrong, reign it in or ban it again.
What you can’t do is ignore all the Swedish evidence and then say, ‘now prove it will work in Spain’. As I’ve said throughout, you have to proceed with a balance of probabilities approach and some common sense. The Sweden case is very compelling and common sense says that allowing lower risk products to compete with higher risk, is obvious. Banning is the opposite.
Clive
You comments on Smokeless (S/T) is spot on and we experience similar problems here in Australian. It is not legal to sell S/T in Australia but strangely, users can order their own supplies from overseas and have it posted to them at great expense. You can still buy smoking tobacco at every corner store though.
It has been estimated by the Federal government that there are up to 20,000 smokeless tobacco users in Australian and recently the government has seen fit to categorise S/T in the same customs tax bracket as smoking tobacco. We have been informed that their reasoning is that the World Health Organisation is against all tobacco and S/T is seen to be just as bad for your health as smoking tobacco.
As a consequence, the import tax has gone from $2.90 per kilo to over $300 per kilo making S/T financially unobtainable to most users. S/T is 50% water and has freight and numerous charges added making it far more expensive than cigarettes.
This government intervention has been going on many years and in 1998 a group of S/T users came together under the banner of S.T.A.G. (Smokeless Tobacco Action Group) which has been actively lobbying governments over their unfair and discriminatory laws.
Regards
Dave
So, you admit that the ASH has a well-cited and supported position, and in response you post one graph with one country that has a lower rate of one type of cancer. Huh…that’s…interesting. Sweden could have a million things that explain the lower lung cancer rate. They also have higher rates of other types of cancers, and the mechanism, nicotine disabling the P53 apoptosis path, is systemic. No comments on the bazillion papers about that? What difference does it make whether you get lung cancer from smoking, or instead you get prostate cancer from e-cigs?
I might be wrong, but I am pretty sure this op-ed piece clearly puts “rights” above science by a healthy margin.
If you can find any credible citation linking nicotine use to cancer I would be grateful for a reference. I don’t think there are any. Sweden does not have higher rates of other smoking/tobacco related cancers.
There are not a million reason why Sweden has low rates of the cancers most closely associated with smoking/tobacco – but there is one very obvious one: the low rate of smoking that arises from nicotine consumption through snus.