Sunday, June 8, 2003

Dr. Richard Carmona, the Surgeon General and the Bush administration’s primary adviser on the nation’s public health, demonstrated that he is sadly ill-informed about the nation’s No. 1 health problem, cigarette smoking, during testimony at a House Energy and Commerce subcommittee hearing on June 3.

Dr. Carmona’s first blunder was his contention that “there is no significant scientific evidence that suggests smokeless tobacco is a safer alternative to cigarettes.” Dr. Carmona ignored decades of published research and the prestigious British Royal College of Physicians, who reported last year that smokeless tobacco products are “on the order of 10 to 1,000 times less hazardous than smoking.”

Surely Dr. Carmona knows that cigarette smoking is a major risk factor for lung and other cancers, heart diseases and emphysema, resulting in 440,000 deaths annually in the United States. But he doesn’t seem to appreciate that smokeless tobacco use carries no risk for lung cancer, heart diseases or emphysema.The only consequential risk for long-term smokeless use is mouth cancer. Fifty years of research prove that even this risk is very low (less than half that associated with smoking). In fact, smokeless tobacco use is about as safe as automobile use.That’s 98 percent safer than smoking.

Saying that smokeless tobacco is as dangerous as cigarettes sends a callous, medically misleading message to smokers from America’s No. 1 doctor: Quit or die. With stable smoking rates, this is an approach cigarette manufacturers can live with. For more than half of inveterate smokers (those who simply cannot quit), it’s a prescription they will die with.

Dr. Carmona wants smokers only to use “FDA-approved methods such as nicotine gum, nicotine patches, or counseling.”But reliance on these methods is exactly why the 40-year-old American anti-smoking campaign has failed to help inveterate smokers to quit. First, counseling is all about getting smokers merely to change their behavior. For example, a government smoking cessation manual tells doctors to recommend ineffective coping tips such as “Keep your hands busy — doodle, knit, type a letter,” “Cut a drinking straw into cigarette-sized pieces and inhale air;” “Keep a daydream ready to go.” Such advice has little effect on adult inveterate smokers, because they need nicotine.

Second, smokers are told that they must achieve nicotine abstinence in order to quit. They are advised to use nicotine medications temporarily. These medicines are expensive, unsatisfying and frequently ineffective.A recent review reported a 7 percent success rate for over-the-counter nicotine medications. The authors called this result “modest,” and even “efficacious,” and Dr. Carmona probably agrees. Objective scientists and physicians call programs with 7 percent success rates abject failures.

Dr. Carmona’s other blunder was his support for banning tobacco products. Asked if he “would support banning or abolishing all tobacco products,” Dr. Carmona responded “I would at this point, yes.”This marked the first time a Surgeon General has called for outright prohibition, and he sent would-be supporters running from the Hill.Even the Campaign for Tobacco-Free Kids, which has shown little interest in helping inveterate adult smokers, couldn’t support Dr. Carmona.Its spokesman commented that “We would all like to see a tobacco-free world…we can’t just take away their tobacco.”Dr. Carmona’s boss can’t be happy; Bush administration officials responded quickly. “That is not the policy of the administration,” commented White House spokesman Scott McClellan, saying that Dr. Carmona’s comments represented only his views as a doctor.

But Dr. Carmona’s views as a doctor are just the point.He occupies one of the most trusted positions in American medicine and in American government.The Bush administration should do more than distance itself from these dangerous and irresponsible positions. It should direct Dr. Carmona to read the dozens of scientific research papers on tobacco harm reduction.It should direct him to review the evidence from Sweden that smokers can quit by substituting smokeless tobacco.

Finally, it should require that he tell American smokers the truth about all available options for quitting. After all, the 10 million smokers who will die over the next two decades are, in a very tangible way, his responsibility and his legacy.

Dr. Brad Rodu, a professor, is the senior scientist at the University of Alabama’s Comprehensive Cancer Center in Birmingham.

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