Health: The Four Commandments of the Anti-Smoking Movement

By Jonathan On Jul 5, 2017

A Tribute to the Memory and Legacy of Gian Turci

GIAN TURCI – A CHAMPION AND A HERO
March 11, 2009
Gian’s specific involvement in smoker’s rights began when he was living in Canada and his children came home complaining that at school, all of the students had been made to line up while a health official proceeded to smell each of them in search of the tell-tale odour of tobacco. Students guilty of having the smell of cigarettes on their clothes were taken aside and interrogated, and notices were eventually sent to the parents. Where most modern parents would have bowed their heads in shame and accepted the dogma that they should feel guilty for smoking around their children, or for having failed to prevent their children from becoming smokers, Gian reacted in righteous outrage over this grossly insulting treatment, and he decided to react rather than allow himself and his family to be walked upon.
Read more at C.A.G.E.

Gian Turci Has Passed Away
13th March 2009
Libertarian icon and longtime FORCES officer Gian Turci unexpectedly passed away of a brain haemorrhage on Tuesday.
Gian was, as ever, thick in the midst of plans and correspondence with FORCES colleagues when overcome. Some more of his own writings will appear along with a formal obituary and other articles of appreciation now being prepared for upcoming editions of this news page.
Gian is a force of nature and an undying inspiration. Those who have read him or listened to him through media over the years surely know of his profound dedication, humanity, humor, and warmth. Those of us who worked with him know better still. We loved him. There is sadness here beyond telling.
Read Forces

The Four Commandments of the Anti-Smoking Movement: A Tribute to the Memory and Legacy of Gian Turci

March 11, 2009
By Michael Siegel

I was saddened by the news today that Gian Turci, the C.E.O. of FORCES International, has passed away. I had the great pleasure of getting to know Gian quite well during the past four years, and spent some wonderful time having long phone conversations with him around a range of issues, mostly related to tobacco control and public health. I found Gian to be a remarkable individual and I enjoyed the relationship that we developed. Gian was a great general in the fight to preserve individual liberty, but what may not be readily apparent is that he was also a kind and gentle person on an individual level. Gian also showed a great deal of respect for me, despite some major differences in how we viewed certain issues. But the beautiful thing was that these differences did not come in the way of our friendship and collegueship. In fact, we found many areas in which we agreed and we both believed that these aresas of common ground greatly overshadowed our differences. The respect Gian showed me at all times was a great sign of his character and integrity and it is something that I will never forget.

The particular writing of Gian Turci’s that I want to highlight today – my personal favorite – is his Four Commandments of the Anti-Smoking Movement. In this post, I highlight each of these “commandments,” and share examples of the truth of these precepts from my own experience in the tobacco control movement. Many of these examples come from my own commentaries, to which I link below.

Commandment #1: Smoking kills, always and at any rate (no redemption other than quitting).

Gian was insightful, because there is great truth to the idea that in the tobacco control movement there is an almost abstinence-only approach to public health. The idea of harm reduction has been almost entirely shunned, but without careful consideration of the actual science-base and evidence for what might be the most effective strategies for tobacco control.

An excellent example of this was the American Cancer Society’s response to a study showing that smokers who smoke just 1-4 cigarettes per day are still at significant risk of heart disease, lung disease, and cancer. The study was a longitudinal (cohort) study of more than 42,000 adults, ages 35-49, in Norway, who were followed for nearly 30 years. The adjusted relative risk among smokers of 1-4 cigarettes per day of dying from heart disease was about 2.8 and for dying from lung cancer was about 2.8 among men and 5.0 among women.

The authors concluded: “In both sexes, smoking 1-–4 cigarettes per day was significantly associated with higher risk of dying from ischaemic heart disease and from all causes, and from lung cancer in women. Accordingly, five cigarettes per day is not a threshold value for daily cigarette consumption that must be exceeded before serious health consequences occur.”

In response to the study, the American Cancer Society (ACS) issued a statement, which read in part: “The finding that smoking just 1 to 4 cigarettes a day can significantly boost heart disease and cancer rates is important because many smokers, due to expanding restrictions on smoking in public places and at work, are cutting back on the number of cigarettes they smoke each day. By doing so, they often feel that they are sharply reducing or eliminating the health dangers from smoking. But this study shows that this is not the case and reiterates the important message that there is no such thing as a safe level of smoking.”

I find that statement to be misleading, or possibly inaccurate. The statement suggests, I think, that cutting back on cigarette consumption does not “sharply reduce” the health dangers from smoking. But for smokers of 1 pack per day who cut down to 1-4 cigarettes per day, the reduction in the relative risk for death from all causes drops from about 3.3 to about 1.5. For death from lung cancer, it drops from about 30 to about 4. And for all cancers, it drops from about 3 to 1.1 (basically, no increased risk). I do find these reductions in risk to be “sharp” reductions, and it is both misleading and damaging to suggest to smokers that there is no point in their trying to cut down on the amount they smoke because it is not going to improve their health.

While I obviously agree with the suggestion that quitting smoking completely is far better than continuing to smoke at lower levels, I just don’t think it’s accurate to imply that reducing cigarette consumption will not sharply reduce the health dangers from smoking.

The real danger here, however, is not in the possible misrepresentation of the scientific evidence. It is, rather, the possibility that in making this statement, the ACS might actually play some part in convincing smokers who would otherwise continue to cut down on the amount they smoke that it is simply not worth it because they aren’t going to see any health improvement anyway. Given the addictive power of nicotine and cigarette smoking, it is far more likely that these discouraged smokers will simply continue smoking at their current amounts then that they will quit smoking entirely. And they may even increase their cigarette consumption, since it may appear from the ACS statement that the amount smoked does not relate directly to disease risk.

This is, in fact, one of the downfalls of public health messages to the public in general – the fact that in trying to emphasize the health dangers of a particular behavior, we often fail to acknowledge that there is a dose-response relationship, and that there is such a thing as risk reduction (reduction in risk associated with decreased levels of the behavior).

To deny that fact may be to deprive many individuals of a golden opportunity to change their behavior and improve their health, if not to save their lives.

Commandment #2: Passive smoking kills, always and at any rate (no redemption other than bans).

I think Gian was insightful in this premise as well, because the anti-smoking movement has recently adopted the “there is no safe level of secondhand smoke” approach which basically argues that there is no point in reducing your exposure to secondhand smoke because any level of exposure is dangerous. In fact, more recently, anti-smoking advocates have argued that even “thirdhand” smoke is dangerous. This may lead smokers with children, for example, to continue to smoke in their homes rather than smoking outside because they figure that as long as the child is going to be exposed to toxic thirdhand smoke there is no point in protecting them from the secondhand smoke.

In a June 2006 column, I discussed how the Surgeon General’s pronouncement that there is “no safe level of exposure to secondhand smoke” and his efforts to make this the cornerstone of communications to the public about the issue may have the unfortunate effect of undermining the public’s appreciation of the relationship between dose and health risk.

There are a number of reasons why I’m not so sure that the publicity focus on the absence of any safe level of exposure to secondhand smoke is entirely appropriate and effective as a public health message.

First, the message is not particularly meaningful. One can say that there is no safe level of exposure to any carcinogen. There is no safe level of exposure to car exhaust. There is no safe level of exposure to the sun’s rays. There is no safe level of exposure to X-rays. There is no safe level of exposure to the benzene that is found in some sodas. There is no safe level of exposure to radon in homes. There is no safe level of exposure to arsenic that is found in many people’s drinking water.

Second, this emphasis on the hazards of minute levels of, and brief exposures to, secondhand smoke seems to belie the importance that the public must place on assessing the dose of secondhand smoke in making decisions about their potential health risk. Dose consists both of the concentration of the smoke and the duration of exposure, and both of these are important considerations that we want the public to be aware of. Don’t we?

Maybe I’m wrong, but isn’t it more useful and informative to provide the public with a sense of the relative levels of exposure to secondhand smoke in different environments and situations then to scare the public into simply thinking that any exposure is terrible and that (perhaps) all exposures are equally bad? I think that it is important for the public to have some appreciation of the strong and important relationship between dose and risk. And I’m afraid that the overwhelming emphasis on there being no risk-free level of smoke exposure may obscure the importance of the dose-risk relationship.

Failing to emphasize the dose-risk relationship could have negative public health consequences, both from an individual and a policy perspective. From an individual perspective, is it not possible that some people will conclude that since any secondhand smoke exposure is putting them at risk, it doesn’t make sense to reduce their exposure if they cannot eliminate it. In other words, for people who cannot avoid some exposure to secondhand smoke, is there any incentive for them to reduce their exposure if they are repeatedly hammered over the head with the idea that their limited smoke exposure is going to kill them anyway?

And for smokers, what incentive is there for them to cut down on their smoking if it is true that even brief exposure to secondhand smoke may cause them to have a heart attack anyway? If you’re going to have a heart attack one way or another, why not continue to smoke and at least enjoy yourself before you keel over?

The point is that by making secondhand smoke exposure sound so bad, such that even a tiny and brief exposure is hazardous and such that if you are exposed you are doomed to disease, aren’t we taking away an incentive for people who cannot eliminate their exposure entirely to reduce it? Are we not taking away an incentive for smokers to quit smoking if they know that they will still hang out in the same smoky bars and be exposed to secondhand smoke. What’s the point of their quitting smoking if the secondhand smoke in these bars is going to kill them anyway and there is no perceived benefit of reducing the level of their exposure?

Third, by emphasizing that any brief exposure to secondhand smoke can cause lung cancer, I believe this publicity may well harm efforts to search for the other causes of lung cancer among nonsmokers. Since I’ve devoted my career to the role of secondhand smoke in causing lung cancer among nonsmokers, I obviously think this is a critical issue, but by giving people the impression that any nonsmoker who gets lung cancer may well have gotten it from secondhand smoke, even if their exposure was minimal, are we not doing a potential disservice to the search for other causes of non-smoking-related lung cancer?

Fourth, when you give a message like this one – everyone is at risk – do you not undermine efforts to try to reach people who really are at the most risk? By scaring everyone in the population into thinking that they are at risk of disease from secondhand smoke, are we not taking attention away, perhaps, from the groups that are at the highest risk because of the highest levels of exposure? And might not these groups be less likely to take action to protect themselves than if the message was that certain groups are at particularly high risk and need to be protected urgently?

Rather than being a call for specific and prioritized actions to prevent disease in the most effective and efficient manner possible, it seems that the publicity put out by the Surgeon General’s office is more of just a general public scare, devoid of any priorities, focus, or policy or intervention directives.

In some ways, I believe that the basic message here – everyone is at risk and the dose doesn’t matter; no matter how small the dose, you are still at risk – may be a counter-productive one. Or at least it may undermine some of the very important findings of the Surgeon General’s report. The report reviewed, for example, the levels of secondhand smoke exposure among different population groups and came to some conclusions that should guide policy makers. But those conclusions are completely obscured by the all-out emphasis on the absence of any safe level of exposure.

Commandment #3: Public health is the paramount value of society. All other values – such as liberty, constitutionality, truth, economics, free enterprise, personal responsibility, and moral integrity – are absolutely irrelevant and/or have to submit unconditionally.

This premise rings so true and the examples are so numerous that one only need read a random selection of posts on this blog to see illustrations of this principle. Let me highlight just a few of the most pertinent examples.

First, in the desire to save health care costs for employers, anti-smoking advocates are completely ignoring the rights of smokers to fair treatment in employment. They are willing to embrace employment discrimination in order to promote the saving of health care costs. But there are only willing to promote this type of discrimination against smokers. They do not promote efforts to ban obese or overweight people from employment or to throw away the job applications of people who eat a poor diet or do not get enough physical activity. Clearly, public health is the paramount value in the promotion of these discriminatory policies. Individual rights, employer privacy, and social justice are ignored or if they are considered, they are deemed irrelevant.

Second, in the desire to promote smoking bans, anti-smoking advocates are disseminating untruthful information about the acute cardiovascular effects of secondhand smoke. The value of the protection of health is so paramount that it is deemed acceptable to use false information to promote this cause.

Third, in the desire to extract money from tobacco companies, public health organizations ignored the precepts of the law and basically asked the judge to ignore the law in order to award money for anti-smoking organizations to conduct their programs. They were in fact admonished by a federal judge for asking for money without any legal basis.

Fourth, in the desire to promote the FDA tobacco legislation, anti-smoking groups have engaged in a massive campaign of deception. The American Cancer Society, for example, claimed that Big Tobacco is lying about the ingredients in its cigarettes, but failed to provide any documentation that this claim is true. The legislation is apparently deemed as being so important that it is acceptable to deceive the public in order to promote it. The truth is secondary to the paramount value of health.

Commandment #4: The antitobacco movement is inherently right, just and true – thus, it is heresy to disagree with its goals and methods.

This commandment is basically the story of my last few years and the underlying story behind this entire blog. I have experienced the unfortunate truth of this commandment in a very personal way. My disagreement with some of the research, policies, and tactics of the tobacco control movement has largely been greeted with personal attacks, censorship, and attempts to silence me. Essentially, I have been called and treated as a heretic solely because I have disagreed with certain aspects of the tobacco control movement’s tactics and agenda. It is indeed a religious-like movement and if you question any aspect of the dogma, you are a heretic. I have learned that lesson the hard way.

When You Don’t Like What You Hear, Attack the Messenger – But Don’t Discuss the Issues

November 30, 2005

By Michael Siegel

In response to my post yesterday which provided a detailed analysis questioning the claim that smoking bans lead to immediate and drastic reductions in heart attacks, a prominent anti-smoking advocate publicly attacked me as follows:

“My general approach has been to ignore Michael Siegel, but his latest “analysis” is just too strange. He is publicising a “study” on the “Smokers’ Club” web site. This “study” does not even account for population growth and there are no controls … but only Mike can tell real quality.”

The Rest of the Story

First of all, had the advocate taken the time to actually read and think about what I wrote instead of simply publicly attacking me, he or she would have noted that I was not relying upon the Smokers’ Club web site study, but that I analyzed the data myself. It is my analysis (and not just what Michael McFadden and David Kuneman did) that suggests that there has been no observable (or at least no substantial) decline in heart attack admissions due to state-wide smoking bans. Even if I had relied upon the Kuneman-McFadden study without performing my own analysis, I would argue that it isn’t invalidated because of who the authors are, but that it needs to be examined based on the actual data it presents. But this analysis is not going to be shot down on the basis of its authors being affiliated with the Smoker’s Club, because I stand by the analysis, I think it is entirely an appropriate one (certainly with my extensions that extended the baseline period and used two comparison groups), and I think it demonstrates that there simply was not a dramatic decline in hospital admissions following the implementation of state-wide smoking bans.

Second of all, there is simply no way that population growth can account for the failure to observe a 27% to 40% decline in heart attack admissions (or even half of that) if one existed. Plus, if population growth were explaining the failure to detect such an effect, then there would have had to be basically at least a 13% difference in population growth between the smoking ban and comparison states and that difference would have had to be systematically different between the two groups.

Third of all, had the advocate read and thought about my comments before attacking me, he or she would have noted that I did employ 2 comparison groups – first, all of the states in the HCUP database in which a smoking ban was not implemented during the study period; and second, the entire country. If the entire country does not qualify as a comparison group, then I don’t know what does.

Look – I am not claiming that this analysis is perfect or even that it suggests that smoking bans do not have a significant effect on heart attacks. My only point is that I think it is simply premature to be publicly claiming that smoking bans will produce a 27%-40% reduction in heart attack admissions. That’s it.

Most importantly, I think I am bringing to light an important issue that deserves careful attention and further scientific analysis. I think that it deserves consideration. But attacking and insulting the person who makes such a suggestion without even attempting to read the entire piece or to discuss the scientific issues intelligently is just not appropriate.

And what it suggests to me, honestly, is that there is something missing. And what I think is missing is a sincere interest in discussing the science and in considering the different possibilities for what might explain the observed findings in the existing literature. This is precisely why it suggests to me that for some in the anti-smoking movement, the agenda seems to be driving the interpretation of the science rather than the science driving the agenda.

This has been a true learning experience for me. Never did I dream that some day, after 21 years of experience in tobacco policy research, as a statistical editor of perhaps the top tobacco control journal, and with over 50 peer-reviewed publications in top public health and medical journals, I would present a reasonably detailed scientific analysis of a tobacco control policy issue and then be publicly attacked and insulted for having the courage to present my opinions.

But because they apparently go against the anti-smoking agenda, I have now been publicly attacked and insulted. That’s a shame.

But what’s even more of a shame is that this issue really has nothing to do with the anti-smoking agenda. The issue of smoking bans should be decided based on the evidence regarding the health effects of secondhand smoke on bar and restaurant workers. It really doesn’t matter, in my mind, whether smoking bans reduce heart attacks or not. The justification for such bans does not rest on such a determination. What does seem to depend on it, however, is the political ammunition that some anti-smoking groups and advocates seem to desire.

Finally, there are a lot of people who have expressed their scientific opinions on issues in tobacco control who I disagree with. But I would never attack and insult any of them, privately or publicly, for expressing their views. I think there has got to be a better way to practice public health and tobacco control.

Anti-Smoking Advocates Have No Interest in Even Discussing the Science; The Agenda Cannot Be Challenged

December 1, 2005

By Michael Siegel

In response to my post yesterday which provided a detailed analysis questioning the claim that smoking bans lead to immediate and drastic reductions in heart attacks, another anti-smoking advocate (different from the one whose attack and insult I discussed in my previous post) publicly attacked me as follows:

He called me a “contrarian gadfly,” stating that “every group needs one–it’s rather like a corpse at an Irish wake, and nobody pays much attention.”

In response to my suggestion that it was inappropriate to insult me personally, rather than to actually attempt to discuss the scientific issues involved in the determination of the effects of smoking bans, yet another anti-smoking advocate stated:

“Michael McFadden is a personal insult, to me and (at least) several other people who read this list. Take it somewhere else.”

The Rest of the Story

First of all, I am a good sport and don’t mind being called a “contrarian gadfly.” It actually has kind of a nice ring to it, and the advocate who attacked me as such has every right to opine that I am such. However, what is disturbing to me is the suggestion that we don’t need to pay attention to opinions that differ from the dogma of the anti-smoking movement.

In other words, that in the anti-smoking movement, we have selective attention. We pay attention to, and consider the studies that support our agenda. However, if a study or analysis doesn’t support our agenda, then we don’t need to pay attention. We can just ignore it.

I view my role in public health as being a public servant. That’s always how I have viewed my career as a physician and now as a public health professional. And I think we owe it to the public, who are essentially our clients, to be willing to examine all of the evidence before we make public claims.

Now this doesn’t mean that we have to accept the evidence. It just means that we have to be willing to at least examine it. It may well be that an analysis is invalid or scientifically flawed. That’s fine, and the study can then be trashed, but I think it needs to be trashed based on the lack of scientific merit, not based on the fact that it tends not to support the anti-smoking agenda.

Even studies that are produced by the tobacco industry or industry-paid consultants require our attention. Again, it may be that there are heavily biased and therefore laden with serious flaws, but it is our responsibility, I think, to examine the evidence and point out those flaws rather than simply to trash the study and ignore it because the author has a tobacco industry affiliation.

The danger here is that we are starting to do exactly what some have accused the anti-smoking movement of doing for a long time – cherry-picking the information that supports our cause. That’s precisely what I think is going on here.

The truth of the matter is that while many tobacco control groups or advocates may not care enough about the science to pay attention, many individuals outside of the tobacco control movement are paying attention. Certainly, the thousands of readers who read my blog are paying attention. Certainly, those who read Reason Online’s Hit&Run; blog are paying attention. The readers at the Smokers’ Club web site are paying attention. And the readers at FORCES are paying attention. And you can bet that my readers from the three leading tobacco companies are eagerly paying attention.

We are public servants. I think it’s about time that we start paying attention.

Second, the fact that one individual advocate happens to be insulted by the mention of the name of one of the authors of a study does not in any way justify an attack and insult against me. What is happening here is classic guilt-by-association.

Frankly, this is really scary to me. I have heard certain smokers’ rights groups talk about McCarthyism in the anti-smoking movement, and I honestly thought that was a bunch of crap, but now I am beginning to question whether or not there might be some truth to it after all. My experience during the past 24 hours certainly hasn’t helped to dispel that notion.

The rest of the story is that it is becoming quite clear to me that many tobacco control advocates really are not interested in discussing the science behind their public claims. If the science doesn’t support the agenda, then the messenger of that bad news needs to be attacked. This is a truly sad state of affairs.

This is the Anti-Smoking Movement???

December 1, 2005

By Michael Siegel

Is this what the anti-smoking movement is all about?

In response to my post yesterday which provided a detailed analysis questioning the claim that smoking bans lead to immediate and drastic reductions in heart attacks, yet another anti-smoking advocate publicly attacked me as follows:

“I find your comments intrusive and divisive… please look at the impacts of your comments and consider in a larger way what you are up to. It is a disservice to the larger community if what you are saying is about your ego, and an even larger disservice if it is intentionally dishonest.”

The Rest of the Story

I can’t help but start my commentary with the obviously inappropriate and possibly defamatory accusation that I am intentionally lying. I didn’t include the advocate’s entire comment, but I can certify that there was not a single specific fact mentioned in the response that I had purportedly lied about. If I am lying about something, I’d like to know what it is so I can correct it. But more importantly, I don’t think it is appropriate to accuse me publicly of lying in front of a broad audience of my colleagues, and without even the decency of pointing out the specific fact or claim in question so that I have an opportunity to provide documentation (or correct the claim, if need be).

Second, the attack based on my ego is completely unwarranted. I can certify that the personal attacks I have been receiving since having the gall to suggest that maybe, just maybe, the claim of a 40% immediate drop in heart attacks due to a smoking ban was an exaggeration are not doing wonders for my ego. But even if they were, this has nothing to do with the basic matter at hand, which is the scientific evidence behind the evaluation of the impact of smoking bans on acute cardiovascular events.

Third, the substantive message behind this advocate’s comments appears to be not that my arguments are scientifically invalid, but that I should muzzle myself because by challenging the dogma of the movement, I am being divisive.

And, more interestingly, that it is actually an intrusion upon anti-smoking advocates for them to have to listen to an opinion which doesn’t coincide with their own. Expressing my opinion is apparently intrusive because of what my opinion happens to be. If I had conducted exactly the same analysis, but found a significant decline in heart attack admissions associated with smoking bans, then my comments would not have represented a divisive intrusion.

The lesson I am learning, and it is being driven home repeatedly now (this is not just an isolated case of one or two inappropriate and misguided actions), is that for many anti-smoking groups and advocates, the science and the facts are really not of interest. Unless they support the pre-conceived agenda, in which case they are of great interest.

But if the science doesn’t support the agenda, then the messenger must be attacked, discredited, and silenced. Even defamed if that is necessary.

The sad thing is that many of these anti-smoking groups or practitioners do not seem to be willing to even look at the evidence. If they know it doesn’t support the agenda and the claims that are being made, then it must be discredited before even examining it.

I find it quite interesting that over the past two days since I published my analysis and commentary, there has been literally zero discussion of the scientific issues behind the evaluation of the impact of smoking bans on acute cardiovascular morbidity. Instead, the discussion has been entirely focused on attacking me as well as the authors of the original study.

I can’t help but make note of what FORCES’ Gian Turci termed the Fourth Amendment of the tobacco control movement:

“The antitobacco movement is inherently right, just and true – thus, it is heresy to disagree with its goals and methods.”

Honestly, when I first read that I thought it was a bunch of crap. But now I’m beginning to see that perhaps there is some serious truth to it. And it greatly saddens me.