Wednesday, 18 April 2012

Snus: they knew all along (part 2)

While doing some research recently, I came across a letter in a library archive written by Dr Richard Peto to Dr. B. MacGibbon. Peto was, and is, a highly respected epidemiologist who worked closely with Richard Doll on smoking and health.

The letter is dated 28th June 1984. Two months earlier, the Daily Mail had run a story about Skoal Bandits, an American form of snus made by US Tobacco Inc. who were due to build a factory in Scotland. Shortly thereafter, ASH's director David Simpson started a moral panic about this smokeless tobacco product which ultimately resulted in the EU ban on oral tobacco (1992). See Chapter 4 of The Art of Suppression for the full story.

I do not know who Dr. B. MacGibbon was or why Peto was writing to him, but Peto begins by recommending that some research into the saliva concentrations of snus users be conducted "fairly urgently". He continues...

I have given some further thought to the question of how many cancer deaths would be likely to be caused each year if one-third of the British population were to become habitual tobacco suckers.

Then, basing his figures on data from the US and UK...

This suggests that if about a quarter of the British population took to dipping 100 gms of tobacco a week, then in the long run “only” some 500-1000 excess deaths/year would result (see Appendix [which is a couple of studies, including the influential study by Deborah Winn looking at women in North Carolina - CJS]).

Maybe Skoal Bandits would be worse than SE US snuff, or maybe (especially if you take the advice in the first part of this letter! [ie. to carry out research "fairly urgently" - CJS]) they would be less hazardous. In any case, no matter what epidemiological studies you mount, you probably won’t get even a preliminary answer this century, so as a practical basis for action I suggest you assume that the adoption of Skoal Bandit-like products by a quarter or a half of the British population will cause about 1000 cancer deaths a year. In contrast, tobacco smoking currently causes about 100,000 British deaths a year!

This may be wrong – they could be carcinogenic, and the Asian experience with oral cancer suggests that they could be a lot more carcinogenic than I’ve estimated, but in any case you have most of what you need for political action, viz:

  • The risks are not zero
  • The risks can probably be reduced by immediately commissionable laboratory research;
  • The risks are much, much less than those of cigarette use.

The final thing you need is to know whether they will help avoid tobacco. No proof is possible, but it is noteworthy that among women in North Carolina, where both products have been widely available for decades,

  • The proportion of smokers among snuff-dippers is only one-third as great as that among non-dippers, and
  • Even among those dippers who smoke, mean cigarette consumption Is significantly lower than among non-dippers who smoke.

I suspect that, no matter what the risks might be, Skoal Bandits and allied products would be allowed to be sold [alas, this prediction was wrong - CJS]. Fortunately, however, the above arithmetic suggests that this may well do more good than harm. In any case, one should try to avoid producing a situation where the warnings or statements about Skoal Bandits etc. are so strong as to divert attention from the much more serious hazards of tobacco smoking.

He concludes by saying:
"The real message is that there is a hazard, but that it’s much less than that of smoking, and that a widespread shift to such products could probably save a lot of lives."

As I mentioned recently, Peto was not alone in seeing the harm reduction potential of snus. In 1985, the addiction expert M.A.H. Russell published a letter in the Lancet, estimating that 49,000 premature deaths would be prevented by a switch from cigarettes to Skoal Bandits. Unfortunately, and not for the last time, the voices of scientists were drowned out by those of activists who were itching for prohibition.


dearieme said...

Could they be sued for manslaughter? If not, why not?

Ivan D said...

I believe that they cannot be tried for manslaughter for a number of reasons, the most important being that it is impossible to identify with any certainty any individuals who have died as a result of their actions. I am willing to stand corrected if there are any lawyers reading.

I am however certain that ASH is a dishonest and irresponsible organization. It is quite clear that it is fighting a private war with “big” tobacco and does not have any interest in harm reduction or health. It is highly probable that its opposition to safer forms of tobacco use together with that of the DH has cost lives whilst achieving nothing of any great note.

That the DH continues to support ASH financially shames the UK government. As for CRUK and The BHF, we at least have a choice over whether to donate to them. Sadly, most donors are unaware what their money is actually funding thanks to the lax UK laws that govern such charities

I am beginning to wonder if any epidemiologist can be "highly respected" based on their collective output over the last 40 years.

Jonathan Bagley said...

There have been several articles in favour of snus over the years. See this for example
and this by Clive Bates, who was head of ASH UK when it was concerned about reducing the harm caused by tobacco.
To give Peto credit, although he has not spoken out about the fraudulent statistics behind the smoking ban, he never gave it a ringing endorsement. See his evidence to the Houses of Parliament - harm is likely to be small and is impossible to measure. All the BBC could get from him on the day the ban came in was a hope that people might be encouraged to give up.

Ivan D said...

Had Peto really wanted to establish epidemiology as a credible science then he should have spoken out long ago about the poor quality, misleading rubbish associated not just with passive smoking but with many other public health “causes”. The fact that he has remained silent does him no credit and adds to the impression that epidemiology is a pseudo-scientific fad of little use except as a political tool for the unscrupulous. There is no quality control in epidemiology or public health.

Clive Bates said...

Dear Chris - I write as former director of ASH (the one based in London: I was director from 1997-2003. I am now no longer involved in public health and these are my personal views.

The public health community does know about smokeless tobacco and harm reduction, or it should know as it is their responsibility to understand what they are doing. There is plenty of evidence and sources available to those prepared to approach the issue with an open mind. In fact a debate has raged on this subject for some time and continues to this day - with many protagonists on both sides. The denial of evidence, warped logic, weird ethics and rejection of common sense has been extraordinary to behold. My concern now is that the EU is considering a new tobacco directive to replace the one that bans oral tobacco in the EU outside Sweden. Despite the reality that illiberal, self-defeating measure is deeply harming to health and civil liberties, as far as I can see no-one is lifting a finger to do anything about it. There is now the opportunity of the new directive to replace the ban with a regulated market in reduced-risk smokeless tobacco.

Just so you can see that the public health community has never been united in its view on this, here are a few posts from me on smokeless tobacco and harm reduction:

Killing by the million: and that's just the health campaigners "If there is a reason to be a Euro-sceptic, then this is one of the strongest – deliberate denial of access to products that are much lower risk to people that are addicted to nicotine."

Saying stupid things with fake sophistication - a critique of ASH Scotland's position statement on smokeless tobacco: "jaw-dropping in its idiocy".

Mass killing machine making lots of money "One danger is that fussy, insular and instinctively authoritarian public health people will continue down the evidence-free path of blocking these developments and insist that for smokers it has to be ‘quit or die’. On the other hand, and more positively, tobacco companies may see smokeless products as a way of doing business with less death and disease and persuade regulators that they needs some regulatory tweaks to make it work – for example it is still impossible to tell smokers the truth about relative risks, and much public effort go in to obscuring it."

Useless scientific advice from the EU including a submission to the committee evaluating smokeless tobacco, and a more complete critique of what they were doing and how they were going about their work.

The European Commission continues to rely on the work of this committee to justify its stance in favour of banning lower risk products, yet the terms of reference, the assessment and its interpretation were all thoroughly flawed and easily discredited.

Anonymous said...

Is this Dr. MacGibbon?

"Dr B. MacGibbon, Principal Medical Officer, Division of Toxicology, Environmental Pollution and Prevention, Department of Health and Social Security, London, England;"

Dave Atherton