Saturday, September 01, 2007

Saying stupid things with fake sophistication

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.


Paul said...

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.

Anonymous said...

Scottish ASH clearly goes to great effort to dress up an opinion that lacks logic, ignores science and dismisses human rights. The fact is that many hundreds of millions of human beings smoke cigarettes and half of them will eventually be killed – not by the nicotine they seek but from repeatedly sucking smoke deep into their lungs in order to get it. In the absence of the availability of less toxic consumer-acceptable delivery systems and non-misleading information about relative risks consumers will continue to die in mind-numbing numbers. Banning snus merely perpetuates the deadly status quo. If Scottish ASH were genuinely interested in advancing public health rather than promoting a moralistic abstinence-only agenda the organization should be embracing both snus and nicotine replacement therapies as evidence that consumers can indeed alter their method of obtaining nicotine. That would in turn give the basis for an intelligent discussion on appropriate regulatory policy aimed at having cigarettes join open sewers, smallpox and the plague as an issue of interest to historians rather than the biggest cause of preventable death in Europe.

Anonymous said...

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.

Anonymous said...

Clive Bates is absolutely right to say that snus is a less harmful way to consume tobacco. But I don't think that even he would claim it was harmless.

I guess you could argue that snus is a valid harm reduction product if you can demonstrate that the only people who take up the snus habit will do so instead of smoking, i.e. that there would be a shift away from smoking towards snus.

While there may be evidence that snus use among Swedish males has been effective in displacing smoking, the same cannot be said for Swedish women. And in India, the use of smokeless tobacco (particularly among women) is rocketing, while smoking rates remain stable. Harm reduction? I don't think so.

And I would argue that those who wish to see the current EU ban on smokeless tobacco should bear the burden of proving that it is an effective harm reduction method, and will consistently prevent people from smoking. If it merely adds to tobacco use, it's a waste of space.

Clive Bates said...

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.


Anonymous said...

The ASH Scotland position paper is full of stunning contradictions, confusion and general nonsensical statements. Claiming a lack of evidence that Snus is less harmful than smoking is at best naive, and at worst a deliberate ignoring of 50 years real world evidence from Sweden. ASH Scotland claims that there is a 'great deal of experience with NRT in the US and UK' - so they are happy this is safe, yet per head of population Snus has arguably saved far more lives than NRT in Sweden.

It may not be 100% harmless, but rejecting a lift on the the EU ban based on ASH Scotland's pretty non-existent arguments is ethically irresponsible.

stag said...

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.



Anonymous said...

Cap’n Flint warrants some remedial public health training. While Clive Bates has responded to some of the misunderstandings there are more.

The implied condition that smokeless tobacco would need to be ‘harmless’ is meaningless drivel. Everything in life has risks, and sensible strategies involve reducing those risks. It makes no more sense to say that smokeless should not be an alternative for smokers than to say that clean needles should not be an alternative to intravenous drug users. Or, indeed, that properly prepared hamburgers should not be an alternative to inadequately cooked ones made with tainted meat.

As to whether smokeless tobacco is making sufficient inroads among Swedish women (where in recent years it has done well, but still lags far behind use by men) or in India it is worth asking for examples of the public health campaigns that have been run to inform such people of the risk differential between alternative tobacco products. It appears that the only messages getting to smokers in these countries reinforce the misperception that all tobacco products are equally bad. One of the basic realities of public health efforts is that consumers need to be given adequate information and otherwise empowered to make better choices. If the public is systematically misinformed about relative risks it is hardly fair for those advocating quit-or-die strategies to then point to the poor decisions consumers are making as justification for continued denial of the conditions that could lead to better decisions.