ZERO U.S. & Canada Cancer Deaths from Smokeless Tobacco, British Researchers Report

A study published in BMC Medicine (here) estimates that the number of cancer deaths due to smokeless tobacco (ST) use in the U.S. and Canada is ZERO. 

The researchers, mainly from the UK, had bad news for ST users in Southeast Asia, where products have high levels of contaminants and are mixed with other toxic ingredients like betel.   Deaths in that region contributed the lion’s share of the worldwide toll of 267,000 annual deaths from cancer and heart disease among ST users. 

The researchers developed risk estimates based on epidemiologic studies from each region.  As I have discussed many times, the risk of cancer among Swedish and U.S. ST users is so small that it is not statistically significant.  Attributing no U.S. cancer deaths to smokeless tobacco use, the UK researchers confirmed this.

They also estimated deaths from ischemic heart disease among ST users.  I have noted that several studies document the risk of heart attack among smokeless users in the U.S. and Sweden as “next to nil” (here, here, here and here).  Ignoring these published risk estimates, the UK researchers declared that “no good country-specific risk estimates were available.”  They assigned a risk value of 1.6 based on an international heart attack study that included ST use data from countries like Bangladesh, India, Pakistan, Sri Lanka, Nigeria and Cameroon, but not the U.S. or Canada.  Due to this, the UK claim of 11,000 heart attack deaths in the U.S. and Canada from ST use is a gross overestimate.

The U.S. and Canadian public should ignore scaremongering about ST deaths, as the real threat lies with adulterated products from Southeast Asia.  For Western ST users, there is much to celebrate in this report.

Pipe Smoking and Health

Health risks associated with cigar smoking are lower than those for cigarette smoking, reflecting a lower exposure to smoke toxicants (see my earlier post here).  The same holds true for pipe smoking, as a 2004 American Cancer Society study documented (abstract here).

Dr. S. Jane Henley and colleagues examined data from the Cancer Society’s Second Cancer Prevention Survey, which enrolled participants in 1982.  They compared deaths among exclusive men pipe smokers with those among never tobacco users over the next 18 years.  They also considered the number of pipes smoked each day, duration of smoking, and how much smokers inhaled.  The results are expressed as hazard ratios (HRs, similar to relative risks); a confidence interval spanning 1.0 means the risk elevation was not statistically significant.

The table shows that pipe smokers had small to moderate elevations for several smoking-related diseases, with the risk for laryngeal cancer remarkably high.

The Health Risks of Pipe Smoking
Disease	Hazard Ratio (95% Confidence Interval)
Cancer
Oral cavity and pharynx	3.9 (2.2 – 7.1)
Esophagus	2.4 (1.5 – 4.0)
Stomach	1.2 (0.7 – 1.9)
Colon Rectum	1.4 (1.2 – 1.7)
Pancreas	1.6 (1.2 – 2.1)
Larynx	13.1 (5.2 – 33)
Lung	5.0 (4.2 – 6.0)
Bladder	1.5 (0.9 – 2.4)
Kidney	0.9 (0.8 – 1.6)
Heart Disease	1.3 (1.2 – 1.4)
Stroke	1.3 (1.1 – 1.5)
Emphysema	3.0 (2.2 – 4.1)

The Cancer Society’s analysis of pipe smoking was thorough (in stark contrast to its consideration of smokeless tobacco, discussed here), producing a wealth of insights.  For example, the overall HR for lung cancer among pipe smokers was 5.0, but there was a distinct gradient related to the number of pipes smoked per day.  The HR was 2.0 with one to three pipes, but it increased to 7.7 for 11+ pipes per day.  There was a similar trend with longer duration of smoking, and inhalation played a major role.  The lung cancer HR was 2.9 for pipe smokers who didn’t inhale, but 11.1 for those reporting moderate or deep inhalation. 

Other diseases showed similar trends with dose, duration and inhalation, although some  results weren’t statistically significant.

Dr. Henley also illustrated that alcohol is a powerful risk factor for cancers of the oral cavity, pharynx, larynx and esophagus.  Pipe smokers who consumed less than one alcoholic drink per day had no increased risk for these cancers.  Those consuming 1-3 drinks had an HR of 4.7 (CI = 1.8 – 11.9), while those consuming 4+ drinks had much higher risk (HR = 15, CI = 5.9 – 39).  Never smokers consuming 4+ drinks also had elevated risk for these cancers (HR = 2.3, CI = 1.2 – 4.3). 

“These risks,” according to the researchers, “were generally smaller than those associated with cigarette smoking and similar to or larger than those associated with cigar smoking.”  This confirms one of the tenets of tobacco harm reduction: it’s the smoke that kills, and the risk is proportionate to how much, how long and how deeply smoke is inhaled.  

Why Doesn't the Karolinska Institute Want To Disclose How They Conducted Their Research On Snus?

On February 7, Dagens Industri, Sweden’s prestigious business newspaper, published my commentary on snus misinformation emanating from the Karolinska Institute, Sweden’s premier research institution. The commentary is available in Swedish (here); the English version of my submission follows. I will post a detailed description of the Karolinska Institute misinformation in a few days.

Published in Dagens Industri, February 7, 2011

Many research studies from Sweden have not found any health risks from snus use, but researchers at the Karolinska Institute have produced a series of reports, based on a large cohort of Swedish construction workers, that emphasize very small risks for esophagus and pancreas cancer and fatal heart attack and stroke.

The KI reports do not change these indisputable scientific facts: the health risks from the use of Swedish snus are so low that they are difficult to measure with modern epidemiologic methods. Snus use by Swedish men has resulted in the lowest rates of smoking-related diseases and deaths in Europe for the past sixty years.

However, the KI studies have obvious technical problems and contradictions, and I have documented these concerns in medical journals. For example, in 1994 Dr. Gunilla Bolinder studied 135,000 Swedish construction workers who had enrolled in a health program from 1971 to 1974. She found that snus users had elevated risks for cardiovascular diseases.

But in 2007 another KI study excluded the 1971-74 workers because of “ambiguities” in tobacco use. Then another KI-study in 2008 included them.

These problems are unacceptable from a scientific perspective, and I gave the KI researchers several opportunities to resolve them. There was no response.

Over two years ago I asked KI researchers for access to the construction worker data so that their findings could be validated. In the past the KI has given data to American researchers while fully protecting the identity of the participants. But the KI refused my request.

I was at an impasse with the KI from a scientific perspective, so I pursued the matter in the administrative court as a last resort. The court ruled that the data is a matter of public record, and it encouraged KI to make a thorough and comprehensive assessment of which data can be disclosed. But the institute has twice failed to comply with the court’s instructions, and it has provided no reasonable explanation for its intransigence.

KI – which in this respect is a Swedish authority – recently decided that I should be granted partial access to the data. But not digitally – which is customary – but only via pieces of paper. In addition KI will remove information about health conditions, i.e. the very information that I want to validate! This means that I would get hundreds of thousands of pages of worthless paper, for which KI has the right to invoice me.

This cannot be seen as anything but pure obstruction, and KI’s position is that its research is exempt from validation.

Researchers at KI have more than implied that I am running the errands of the tobacco industry. That is of course not the case. For years my university has accepted unrestricted funding from tobacco manufacturers including Swedish Match. This is very common in the U.S., as well as in Europe. We would never – nor would KI – let our funding direct the focus or results of our research.

Personally I have conducted tobacco research for two decades, and I developed a deep understanding of Swedish snus as a visiting scientist at the University of Umeå in 2002.

At first glance this matter appears to be just a minor dispute between a sole American professor and a prestigious and powerful Swedish research institute. I would argue the issue is bigger than that.

The health risks identified in the KI studies are the raison d’être for the ban on snus in the E.U. (except Sweden), but it has also had a profound impact on tobacco regulation in the U.S. and other countries.

It would be a tragedy if snus restrictions and prohibitions were improperly based on exaggerated or fictitious health risks. As a result, millions of inveterate smokers outside Sweden might never know that snus is a much safer substitute for cigarettes.

KI’s position is counter to the scientific and ethical principles of data sharing among medical institutions. These principles require that scientific results are open to challenge by other scientists to determine their accuracy and integrity.

The best solutions for scientific debates are not found in the courts. I therefore hope that KI decides to follow the practices of the world of medical research. If the KI does not release the data, it risks damaging its outstanding international reputation.

Professor Brad Rodu
University of Louisville, U.S.A.

New Study Documents the Health Effects from Snus Use: Almost Zero

A detailed review of epidemiologic studies regarding snus use has just been published online by Regulatory Toxicology and Pharmacology (abstract here). Author Peter Lee, a UK epidemiologist, concludes: “Using snus is clearly much safer than smoking. While smoking substantially increases the risk of cancer and cardiovascular diseases, any increase from snus use is undemonstrated, and if it exists is probably about 1% of that from smoking.”

Dr. Lee confirms what I have been asserting since 1994: Smokeless tobacco use is 99% less hazardous than smoking, and the magnitude of risk, if it exists, is difficult to measure using modern epidemiologic methods.

Lee reviewed the evidence from over 150 studies covering many diseases. Previously, he published separate meta analyses involving smokeless tobacco use and all cancers (abstract here), dental problems (abstract here), pancreas cancer (here), oral cancer (here), and circulatory diseases (here).

The hallmark of Lee’s analytic approach is to use all of the published evidence in a systematic and unbiased manner. This is in direct contrast to anti-tobacco advocates like Dr. Paolo Boffetta, who cherry pick the data and use only numbers that confirm their pre-existing belief that smokeless tobacco causes disease. Pancreas cancer is an excellent example.

In 2008, Boffetta published a meta analysis (abstract here) in which he claimed that snus use is a risk factor for pancreas cancer. He cited two studies, one from Norway (here) and another from Sweden (here). The Norway study reported a risk increase among all snus users (Relative Risk = 1.7, Confidence Interval = 1.1 – 2.5) but not for a subset of snus users who were never smokers (RR = 0.9, CI = 0.2 – 3.1). The Swedish study reported exactly the opposite: There was virtually no risk among all snus users (RR = 0.9, CI = 0.7 – 1.2), but the subset of snus users who never smoked had an increased risk (RR = 2.0, CI = 1.2 – 3.3).

Dr. Boffetta chose only to use the elevated risks, even though they were from different groups. As Lee points out, “For pancreatic cancer, Boffetta cited only the increases for never smokers from the [Swedish] study and for the whole population from the [Norwegian] study, not mentioning the lack of increase for the whole population for the construction workers and for never smokers for the Norway cohorts.”

It is important to note Dr. Boffetta was an author of both studies; that makes his selective use of data from them even more objectionable.

Another issue raised by Lee about another Boffetta meta analysis (here) claiming that snus use is a risk factor for fatal – as opposed to non-fatal – heart attack and stroke. In a 2009 blog post, I noted that Boffetta’s claim was questionable (here): “Boffetta found that smokeless users had no significant risk for all heart attacks and strokes but had elevated risks for fatal cases. It logically follows that smokeless users probably had LOWER risks for NON-FATAL heart attacks and strokes.” Lee echoes my concern: “Anyway, an association for fatal cases but not for all cases seems unlikely unless implausibly snus protects against non-fatal cases.”

Finally, Lee reviewed epidemiologic studies to answer this question: Does snus encourage initiation of smoking or discourage quitting? His conclusion: “There is no good evidence that introducing snus in a population would encourage smoking initiation or discourage cessation.”

This is an especially important point, because RJ Reynolds has just launched a campaign encouraging smokers to switch completely to Camel Snus (article here). While apparently in full compliance with FDA tobacco regulations, the ads have enraged prohibitionists like Matt Myers, who said that Reynolds should “stop its insidious marketing of tobacco products in ways that seek to discourage smokers from quitting and keep them hooked on nicotine...The ads are trying to take advantage of people trying to end all uses of tobacco.”

Myers is wrong about many things. Most smokers are not trying to achieve abstinence, but they are interested in enjoying tobacco in a safer manner. As Dr. Lee documents, snus is a vastly safer cigarette substitute.

Good News You Never Knew About Life Expectancy in the U.S.

The National Center for Health Statistics in May released final data on life expectancy and deaths in the U.S. for the year 2007 (read it here). It is an extraordinary report, because it further documents that Americans continue to live longer and healthier lives, year after year.

Compared with 2006, the age-adjusted death rate from all causes declined 2.1% in 2007. This is an extraordinary single-year decline, and it was driven by impressive reductions in five of the top 10 causes of death, as noted in the table.







Top Ten Causes of Death, and Percentage Change from 2006 to 2007

Cause of Death	Percent Change From 2006
1. Heart Diseases	- 4.6
2. Cancer	- 1.3
3. Stroke	- 3.2
4. Respiratory Diseases	+ 0.7
5. Accidents	+ 0.5
6. Alzheimer’s Disease	+ 0.4
7. Diabetes	- 3.4
8. Influenza/pneumonia	- 9.0
9. Kidney Diseases	None
10. Blood Infection	None

Heart disease, accounting for about one-quarter of all American deaths, declined almost 5% in 2007, and stroke deaths dropped by over 3%. Deaths from cancer were down over 1%, and there were impressive declines for diabetes (-3.4%) and influenza/pneumonia (-9%). These aren’t just one-year wonders; declines have been occurring for 20 to 30 years.

Chances are that you knew nothing about these incredible statistics. That’s because the federal government and most health organizations cast every health issue as a crisis. They argue that Americans are in poor health and are being killed by obesity, as well as chemicals in our food and in our environment. They portray our health care system as ineffective. They don’t want you to know the truth: death rates for most major diseases continue to plummet.

The long-term decline in smoking is playing a role, especially in the impressive reductions in heart disease, cancer and stroke rates. But many Americans are also eating healthier foods, and using preventive medications like aspirin and statins (that lower cholesterol levels) to reduce risks. And the health care system is providing ever-improved treatments.

I offer the following example to illustrate that the decline in American death rates over the past couple decades is truly astounding: let’s compare 2007 with 1987. In 2007, the nation’s age-adjusted death rate for all causes was 760 deaths per 100,000, and a total of 2,423,712 Americans died. Just twenty years earlier, the age-adjusted death rate was 970, about 28% higher than 2007 but still far lower than in previous decades. If the 1987 rate had been effective in 2007, there would have been 669,000 more deaths!

The average life expectancy at birth for the U.S. population in 2007 was the highest in history at 77.9 years, an increase of 0.2 year over the 2006 number. In other words, every American gained almost 2½ months of life expectancy in just one year! This is irrefutable evidence that our health and social system, despite its limitations, has sustained remarkable advances in the prevention and treatment of most life-threatening diseases, extending and improving the lives of millions of Americans.

European Experts Continue to Ignore the Swedish Miracle

A new study by cancer epidemiologists clearly provides evidence that snus use among men in Sweden is responsible for the lowest cancer death rate on the European continent. Surprisingly, the authors avoid drawing this obvious conclusion in both their article and their press release.

The study examined cancer mortality trends in 34 European countries over the period 1975-2004. It found that cancer deaths among men throughout Europe declined, mainly due to a drop in “lung and other tobacco-related cancers,” according to co-author Cristina Bosetti. The study shows that men in Sweden have the lowest death rates for lung cancer (less than 50% of the European Union rate) and for all cancers, while rates for Swedish women are at or above EU averages.

These findings are fully consistent with my recently published study of European lung cancer, which I discussed in a recent blog post.

The authors of the new study recognize that differences in cancer death rates among European countries reflect differences in smoking; they conclude that “further reduction of tobacco smoking remains the key priority for cancer control in Europe.” That’s perfectly true. But why did the authors ignore the only legitimate explanation of low cancer rates for Swedish men: the miracle of tobacco harm reduction?

It is important to point out that the difference in cancer rates between Swedish men and the rest of Europe is not a new finding. The first author of the current study, Carlo La Vecchia, is a prolific epidemiologist who previously published a study of cancer in Europe during the period 1955-1989. That study clearly shows that Swedish men have always had the lowest lung cancer rates on the continent.

When that study was published in 1992, there was little appreciation, either in Sweden or elsewhere, of the effect of snus use on smoking. But now there is a wealth of scientific literature on the Swedish miracle. When epidemiologists, tobacco researchers, policy experts and government regulators purposefully avoid talking about tobacco harm reduction, they put their reputations in jeopardy, to speak nothing of the lives of millions of smokers.

Misinformation from the American Dental Association

On October 9, the American Dental Association submitted a letter to the Food and Drug Administration in response to a federal register notice requesting public input on the role of the FDA in tobacco regulation. In the letter, available on the regulations.gov website, the ADA uses pseudo-scientific language to advocate for prohibition of all tobacco products, including smokeless tobacco. Following are some of the letter’s most absurd statements.

1. “We also ask that you begin your work by regulating industry assertions that smokeless tobacco is a healthier (or less harmful) alternative to cigarette smoking.”

While the ADA refers to “industry assertions” about the relative safety of various tobacco products, it ignores the growing number of independent health assessments from academia, public health organizations and other non-industry sources. The British Royal College of Physicians, the American Council on Science and Health and the American Association of Public Health Physicians have concluded that smokeless tobacco use is associated with a tiny fraction of the health risks of smoking.

The task of regulating “industry assertions” was intensively covered in the bill granting FDA regulatory control over tobacco. In fact, the agency was empowered to restrict any action that could “be reasonably expected” to result in “consumers believing” that an alternative tobacco product may have some health benefit vis a vis cigarettes. That’s not just regular commercial speech (e.g., advertisements), but ANY speech, and it’s one reason that several tobacco companies are suing in federal court to block this part of the law.

2. “Smokeless tobacco is not a healthy alternative to cigarette smoking; both products pose health risks. Compared with cigarettes, smokeless tobacco products are less likely to cause lung cancer but they are associated with oral (mouth) and pharyngeal (throat) cancers, as well as cancers of the stomach and pancreas (5,6,7,8).”

No one is suggesting that smokeless tobacco is a “healthy” alternative. The ADA is inappropriately manipulating the legitimate message of tobacco harm reduction.

At least the ADA admits that smokeless tobacco is “less likely” to cause lung cancer. In fact, the most comprehensive study of smokeless tobacco and cancer (previously discussed in this blog) revealed NO risk for lung cancer. Apparently, the ADA doesn’t consider the elimination of 125,500 deaths from lung cancer to be a sufficient public health gain to offset what it believes are risks from other cancers. That meta-analysis also proves that the ADA is wrong on the other cancers as well.

Note that three of the four numbered references supporting the ADA’s statements about other cancers were from the 1990s, when many experts mistakenly believed that smokeless products weren’t much safer than cigarettes. Either the ADA only reviewed selective scientific literature prior to 2000, or the organization chose to ignore irrefutable evidence supporting tobacco harm reduction. The fact is: If all U.S. smokers had instead used smokeless tobacco, cancers now attributable to smoking would plummet to around 1% of their current numbers.

3. “Researchers have found that adolescent boys who use smokeless tobacco products are highly likely to become cigarette smokers within four years (14).”

This is the ADA’s major rationale for its allegation that smokeless tobacco is a “gateway” to cigarette smoking. The reference is to a study by Scott Tomar, a staunch opponent of tobacco harm reduction at the University of Florida. Tomar’s theory has been disproven by Kozlowski and colleagues in published articles available here, here and here. These studies carefully examine datasets in order to determine whether ST or cigarettes were used first. They concluded that ST use plays no significant role in smoking initiation. The vast majority of smokers never used ST, and two-thirds of ST users either never smoked, or they smoked prior to using ST. That makes two-thirds of ST users ineligible to even be considered as gateway users.

It is not surprising that boys who use ST are more likely to become smokers, since experimentation with one tobacco product is closely linked to other similar behaviors. But opponents of harm reduction are deliberately confusing association with causation. Smoking among teenagers is also associated with alcohol use, drug use, risky driving, risky sex, bad grades and behavior problems, but it doesn’t cause them.

4. “That is one among many reasons former U.S. Surgeon General Richard H. Carmona classified the smokeless tobacco alternative as a ‘public health myth.’”

I am astounded that the ADA is still quoting the 2003 Congressional testimony of former Surgeon General Richard Carmona; he has virtually no credibility on this topic. I also testified at that hearing, and I was stunned by Carmona’s uneducated and completely inaccurate statements.

In his testimony, Carmona stated: “There is no significant scientific evidence that suggests smokeless tobacco is a safer alternative to cigarettes.” Carmona ignored decades of published research and the prestigious British Royal College of Physicians, who had reported a year earlier that smokeless tobacco products are “on the order of 10 to 1,000 times less hazardous than smoking”.

Carmona also testified that he wanted to ban tobacco products. Asked if he “would support banning or abolishing all tobacco products,” Carmona responded, “I would at this point, yes.” This marked the first time a Surgeon General had called for outright prohibition, and he sent would-be supporters running from the Hill. Even the Campaign for Tobacco-Free Kids, which has shown no interest in helping inveterate adult smokers, couldn’t support Carmona. Its spokesman commented that “We would all like to see a tobacco-free world…we can’t just take away their tobacco.” Bush administration officials responded quickly. “That is not the policy of the administration,” commented White House spokesman Scott McClellan, saying that Carmona’s comments represented only his views as a doctor.

The American Dental Association’s prohibitionist policy towards tobacco use is a disservice to dentists and their smoking patients; it denies them life-saving information about effective and vastly safer smokeless alternatives.