The Plain Truth About Tobacco Contents Page Introduction: Interrupting the Mantras ............................................. 1 1. Population Statistics .......................................................................... 8 2. Statistics Madness .............................................................................. 73 3. Blood Libel .......................................................................................... 108 Epilogue: The Provenance of Lifestyle Epidemiology ................... 154 Revision date: 29 June 2012 1 Introduction: Interrupting the Mantras The effects of habitual tobacco use over decades on general health, and with regard to specific illnesses, vary greatly between individuals, and related statistical findings from around the world vary greatly as well. The single clearest statistical link between smoking and disease is the link with lung cancer. Cigarette smoking particularly, far more than cigar or pipe smoking, clearly influences the risk of lung cancer statistically. The particular influence of cigarettes stands to reason, since cigarettes are designed using mild tobaccos which produce a mild smoke that smokers typically find pleasant to inhale into the lungs, while directly or deliberately inhaling the smoke of strong nicotine-rich cigar and pipe tobaccos is quite aversive to most smokers. The link between cigarette smoking and lung cancer is often cited as the strongest case in the vast research on factors influencing cancer risk amongst the population at large and this is a fair assessment. However, what has typically been made of that link by medical and public health practitioners and institutions, is absolutely and terribly flawed. The purpose of this paper is to point out clearly, with reference to statements and research of the medical and public health communities, what sense can be made of the smoking and lung cancer link, in contrast to the plain nonsense that most often has been made of it. A kind of groupthink exists amongst health professionals on the subject of tobacco, based on statistical over-interpretations amounting to perfect misinterpretations, and leading to a long chain of fallacious reasoning, producing ever more fallacious conclusions. This mindless groupthinking is positively rampant in the professions. Critics – there have always been critics within and without the professions – are long and well acquainted with this sorry state of affairs. It has been called, and is, truly scandalous. However, most among the public at large probably take fallacious statements from generally obtuse health workers on the subject of tobacco at face value. As these commonly expressed but certainly false statements are analyzed here the average reader will likely be surprised and appalled at the patent illogic displayed by health professional groupthinkers. Though this paper will delve considerably into the medical/statistical literature, it takes a perspective of common sense (something rarely evident in the literature itself), and is written for a general readership. Any intelligent person can understand the basics that will be here discussed. The perplexing tragedy is that most health “experts” manage so awfully to misunderstand them. 2 Particular notice will be given in this essay to so-called environmental tobacco smoke (ETS) or passive smoking, but an understanding of common myths about active smoking is necessary in advance of ETS discussion, so we may begin with a typical message conveyed to the public about active smoking, and crucial analysis of that subject, before proceeding at length to the topic of ETS. Messages given on the cable network CNN on 7 March 2006, following on the lung cancer death of never-smoker Dana Reeve, wife of actor Christopher Reeve, are typical. The hosts were correspondents Heidi Collins and John Roberts. The well-known CNN medical spokesman Doctor Sanjay Gupta was among the guests. Portions of transcript follow. ROBERTS: OK, tonight, Dr. Gupta is going to help us sort through fact and fiction when it comes to cancer. Even though lung cancer is the leading cancer killer, there are clearly huge gaps in our understanding of it. So, let's do a little true and false with Dr. Gupta. And let's start with this one: If you smoke now, you might as well continue, because you're destined to get lung cancer. Dr. Gupta, true or false? GUPTA: That is absolutely false, John, a really important point that it's always a good time to quit smoking. Let me give you a couple of quick facts. If you're – if you're 50 years old and you have been smoking your entire life, quitting today will cut your risk in half in a few years. If you're 30 years old, and you quit smoking today, you can reduce your risk back down to zero within a few years. So, it's always a good day to quit. ROBERTS: All right. Question number two: Smoking is by far the number-one cause of lung cancer, but radon gas is the leading cause among non-smokers; true or false? GUPTA: That is true. And this is actually surprising to a lot of people. Smoking is far and away the number-one cause. You know, eight – eight or 3 nine times out of 10, it's going to be smoking. But radon, which is this naturally occurring uranium byproduct found in the soil, can actually infiltrate into your basement, and has been associated with lung cancer as well. So, it's actually the second most common cause of lung cancer. ROBERTS: And I think I know the answer to this question, number three: Asbestos causes lung cancer; true or false? GUPTA: That is true as well – a lot made of asbestos over the years. You won't find much asbestos anymore, because of all the regulations with regards to building, John. But asbestos specifically causes a type of cancer known as mesothelioma. And that is a type of lung cancer that is – is somewhat treatable, but can also be very deadly, if not caught early. ... ROBERTS: We're also answering your e-mails tonight. Allison from Missouri sent in an e-mail, and she asked, "Do lungs ever fully recover after quitting smoking?" And Sanjay Gupta, why don't you handle that one. Is it dependent on how long a person has smoked or is it not dependent? GUPTA: Yes, it is dependent, to some degree, on how long the person's been smoking. Let me say a couple of things. One is that it's always a good time to quit smoking. So regardless of whether your lungs can fully recover or not, it's always good to quit smoking. A couple of quick stats, though. If you're 50 years old and you quit smoking today, you can cut your risk in half. That's really important. If you're 30 years old and you quit smoking today, you can actually bring your risk back down to zero. And if you consider that your lungs are fully recovering, taking your cancer risk back down to zero, then it certainly does. In these excerpts, Sanjay Gupta mouths more than one of the dogmatic nonsensicalities which we shall here call the “mantras” of the tobacco control movement. We will discuss several of these in this paper. One that may have stood out to you is Gupta’s repeated citation of the “zero risk” of lung cancer which can be attained by those who quit smoking before middle age. Note particularly that the doctor chanted this belief on a program 4 prompted by the then-recent death of Dana Reeve, who never smoked. Note also, that despite the patent absurdity of anybody’s (smoker, former smoker, or never smoker) having a “zero risk” of lung cancer, both of the program’s hosts accepted the doctor’s statement, over and again, without ever once blinking an eye. This is very typical. The statements made by doctors and health officials about tobacco are very often dogmatic, plain foolish, and infinitely repeated, yet rarely questioned. The mantras get chanted with considerable uniformity by one doctor or official, or another, in the media, and in supposedly scholarly papers. Now, of course, nobody can be said to have a zero risk of lung cancer. Anybody could get it. Review of research does suggest that a person who quits a typical cigarette habit before middle age (i.e. within about twenty years of establishing about a pack-a-day habit: since smoking inception is typically on either side of age twenty, this usually would equate to quitting in one’s thirties or forties) will eliminate all excess risk of lung cancer, but that’s an altogether different thing from establishing a zero risk, which never existed for anybody. We here call the common tobacco control dogmas “mantras” because of the monotonous uniformity of their widely repeated chantings. A further similar example lies in a PBS Newshour program of 10 August 2005. In reaction to the then-recent lung cancer death of television news man Peter Jennings, host Jeffrey Brown invited Doctor Mark Clanton, Deputy Director of Cancer Care at the US National Cancer Institute, and Doctor Joan Schiller, a practicing oncologist from Wisconsin, to comment. The obdurately obtuse interchange which followed requires a bit of introduction in order to be fully appreciated. In transcript excerpt which follows below, note the near-identity of Clanton’s comments to Gupta’s shown above, particularly regarding “zero risk”. In this case, Jeffrey Brown is astute enough (very rare in the media) to try to correct the doctor, by suggesting Doctor Clanton might really mean that quitting smoking would result in a smoker’s reducing risk to the more moderate level a never-smoker enjoys (which is the truth of the matter), rather than establishing a “zero” risk. Note the reaction: the doctor acknowledges the comment but returns immediately to the “zero” mantra, revealing his apparent belief that ex-smokers with less than twenty years’ habitual smoking, and never-smokers, cannot get lung cancer, despite all perfectly contrary evidence, and certainly despite any pesky interruption from a logical news reporter. 5 Many readers may not understand Doctor Clanton’s reference, within the PBS interview, to a “twenty pack year history”. This is a technical phrasing used amongst biostatisticians which describes a patient’s history of smoking a pack of cigarettes a day for twenty years. The twenty pack-year history is often cited as the latest point at which a smoker can achieve a “zero” (foolishly over-interpreted, of course) lung cancer risk by quitting. The twenty pack-year point was also formerly an international standard for acceptability of donor lungs for transplantation; smokers with a higher pack-year history were considered unsuitable donors. The proscription against longer-term and heavier smokers as lung donors was dropped several years ago, as discussed in a 2003 publication by the American College of Chest Physicians, excerpt below. In a related study from the University of Texas Health Science Center, researchers evaluated the clinical outcomes of lung transplants in patients receiving either extended or standard donor lungs. Donors were considered "extended" if they met any of the following criteria: donor age of 55 or older, smoking history of more than 20 pack-years, having a history of pulmonary disease, chest radiographic changes, purulent sputum on bronchoscopy, or a decrease in oxygenation on 100 percent oxygen. Donors were matched with recipients, resulting in 20 patients receiving extended donor lungs and 11 patients receiving standard lungs. Recipients in both donor groups had similar outcomes in all posttransplant evaluation categories, including hospital and intensive care unit length of stay, length of intubation, readmission to the hospital, 6- and 12-month lung function tests, and 30-day mortality. "Most of the donors whose lungs we are now transplanting have met at least one of the criteria for extended donors, which would have made them an ineligible donor in the past. By using the physician-directed protocol, working closely with the Texas Organ Sharing Alliance, and extending the criteria for lung donation, we have been able to significantly decrease a recipient's waiting time on the transplant list, without compromising recipient outcome," said Dr. [Deborah] Levine. Discussion throughout the PBS interview of never-smoker Dana Reeve, who had not yet died but was known to have lung cancer at the time, likewise did not deter Clanton, the National Cancer Institute representative, any more than it did Sanjay Gupta in his CNN appearance, from stubbornly reflexive dogmatism. 6 In reaction to this, Jeffrey Brown, having in preface stated his aim of clarifying what seemed confusing, and then faced with the extra-confusingly incantatory responses of Clanton, gives up on him. He turns instead to Doctor Schiller. This finally elicits an admission of reality from her which, in the face of Brown’s direct question, is practically unavoidable. Yet, given the ubiquity of mindless dogmatism in the health professions, one doubts that reality and logic can ever really take root in the impossibly sullied minds of most health “professionals”. The specific double-thinking point illustrated here, is this, and it does apply to most health “authorities” generally: they know that ex-smokers and never-smokers get lung cancer yet they do not believe it, and as we shall see, with wide application, they base their analyses on their beliefs rather than on reality. Let us now look at Doctor Clanton’s confusion as he expresses it himself before analyzing further. JEFFREY BROWN: Dr. Clanton, I would like to clear up some things that are still confusing to people. For example, in the case of Peter Jennings, as for so many people, they smoked at one time, and then they quit. Now, when a person quits smoking, to what extent does his or her risk of developing lung cancer go down? DR. MARK CLANTON: It doesn't matter what stage you stop smoking. Your lung cancer or your risk of getting lung cancer does begin to go down. And the longer you spend in terms of time between the time you smoked and the time you stopped smoking, your risk continues to go down. The problem is in those people who have smoked a great deal – a 20-pack-year history, it's clear that the risk never returns to zero – JEFFREY BROWN: Never goes down to the case of someone who never smoked? DR. MARK CLANTON: That's exactly correct. So the more you smoked, the less likely it is it will go back to zero. The issue is your risk does go down and continues to go down for as long as you stop smoking. 7 JEFFREY BROWN: Dr. Schiller, another thing that I think a lot of people wondered about this week was, in the case of Dana Reeve, you mentioned earlier people who develop lung cancer who never smoked. Now, how unusual is that? DR. JOAN SCHILLER: Well, actually, about 10 to 15 percent of all lung cancers occur in people who have never smoked. Poor Jeffrey Brown. He tried to clear confusion. He tried at least better than the CNN crew did, or most news men ever do. He made but little headway. We shall look further and try here to do better still. 8 1. Population Statistics There is presently an anti-tobacco fanaticism abroad across much of the world. If you smoke your abolitionist doctor may blame nearly any medical condition you suffer on the smoking, whether there is any basis for this, or not. Smoking can be more or less plausibly linked with a number of afflictions, but as we have said, the single clearest statistical link is with lung cancer. It is therefore of lung cancer, a large enough topic in itself, that we shall treat in this paper. We will look at the realities of the smoking / lung cancer link and contrast them with the fallacies that have taken root in the minds of far too many in the medical establishment. Similar fallacies exist regarding other supposed links between smoking and health problems. The situation with lung cancer provides the best example for illustrating widespread misunderstanding of smoking relative to health generally. Proper understanding of the topic requires proper grounding in the essential elements surrounding smoking in relation to lung cancer. So let us look at these, individually, and then collectively. This section will present a comprehensive and easily comprehensible overview of lung cancer prevalence and provenance, in the West as specifically illustrated via United States national statistics, as well as discussion of lung cancer in the East, particularly regarding the case of Asian women, with national statistics from Taiwan employed as illustration. In order to present this comprehensive view we shall, before presenting the US population overview via clear tables, first review at some length each crucial part of the lung cancer puzzle, and then combine those pieces, so as to complete the big picture. Let’s begin with the plain question: what, if you never smoked, is your risk of lung cancer? What, in other words, is the “base risk” of lung cancer, amongst the population at large, independent of any excess risk imposed by a smoking habit? Very little specific research on this question has been done but the figure can be ascertained for regional populations. Regarding region, it’s necessary to note that statistical research on lung cancer varies considerably between the West and the East. Studies in the West (mostly done in North America and in Western Europe), while suggesting some inter-regional or national distinctions, have a general conformity, while Eastern studies (mostly from the Orient), though they likewise can be said to have a general conformity with each other, present a picture different in some crucial respects to that suggested by the Western studies. 9 Both Eastern and Western studies suggest a statistical link between smoking and lung cancer but they tend to show a different configuration between “base risk” and “relative risk” (terms to be discussed further along in this section). This East/West divide is a result of an apparently greater degree of diagnostic bias amongst Western practitioners than amongst those in the East, as will be explored and explained in due course, but let us begin with the West, which shall be the primary focus of this essay overall. In necessary preface to the question of a never-smoker’s risk, let us ask: who is a smoker, and who is not? Lung cancer statistical research has burgeoned since the nineteen fifties. Biostatisticians in the West early learned that from amongst typical Western populations, from that period and even today, it was virtually impossible to collect substantial study groups of mature persons (lung cancer is a disease of old age as we shall illustrate) who had truly never sampled tobacco. Mere sampling or very small experience of tobacco had to be eliminated from any definition of a “smoker”as a purely practical matter. Thus, although individual studies vary enormously in their methods, including how populations are categorized, a fairly consistent definition of “never smokers” has emerged. A “never smoker” is a person who has never smoked more than 100 (or, in some studies, up to several hundred) cigarettes in a lifetime. An “ever smoker” is a person who has smoked more than 100 (or a few hundred) cigarettes in a lifetime. The most typical sub-categories of smokers are “former smokers / ex-smokers” (smokers who quit – usually at least a year or a few years before lung cancer diagnosis – this varies from study to study) and “current smokers” (who smoked until, or nearly until, the point of lung cancer diagnosis). Various other subdivisions, based on length or intensity of smoking habit, or other factors, appear variously from one study to another, but “never”, “former” and “current” are the fairly consistent “usuals”, and the “never” category specifically is fairly consistently used in terms of its definition. In our population computations here we shall use lung cancer death statistics. These are