English translation of the French original of this paper that was presented at a meeting of la Société d'Addictologie Francophone at the Sainte Anne Hospital in Paris on December 9, 2010, under the theme ‘’Truths, Lies and beliefs in regards to addiction’’ ("Vérités, mensonges et…croyances en addictologie’’). It will be published in the next issue of the journal ‘’Le Courrier des Addictions’’, organ of the SAF.
Translated by Iro Cyr with the assistance of Pr. Robert Molimard and Dan Romano
Disclaimer: In accordance with French law, Pr. Robert Molimard declares that he doesn’t have any competing interests with neither the pharmaceutical nor the tobacco industries.
Beliefs, manipulation and lies in the tobacco issue
When contaminated by pesticides such as Gaucho ® or Regent ®, a bee becomes disoriented and can no longer find its hive or its wild flowers of choice. We cannot solve a problem if the messages are muddled. Undeniably, disturbing one’s sense of orientation and muddling communication hinders rational thought and behavior. Lies and manipulations are the weapons of choice for political and economic gains without regard for the well-being of people or the survival of the planet.
Tobacco manufacturers and merchants, the state, self-righteous non-profit organizations, the pharmaceutical industry - all powerful entities involved in tobacco issues - are ready to do anything to promote their own agendas. In a curious collusion, they all seem to be quite content with a general state of public confusion in which scientific truth has no place, and where the smoker, convinced of his own guilt, has become the apathetic victim.
The Tobacco Industry
As soon as the very first findings of the risks of smoking were publicized, the tobacco industry was quick to rebut these with misleading advertising.
Although some ads promoted the relaxing effects and social advantages of smoking, and even the glamorous aspect supposedly so seductive to women, other ads, however, specifically contested the negative health effects. During the period between the two world wars, in the United States where trade was not controlled by a Board of State as in France, many tobacco advertising posters were associated with doctors. For example:
‘’More doctors smoke Camels than any other cigarette’’; in a classic “argument from authority”, the ad encouraged people to follow the example of doctors, who must certainly know best.
Or in another ad where we find the caption "Not one single case of throat irritation due to smoking Camels!" accompanied by the photo of an ENT with his stereotypical head mirror. They can’t possibly be dangerous when it is an Ear, Nose and Throat specialist who says they are not.
And your doctor will go as far as prescribing L & M filter cigarettes: ‘’Just What the Doctor ordered’’. Instead of quitting smoking, they would even suggest that you switch to Philip Morris and in 3 out of 4 cases your cough will disappear! [1]
But the greatest success story in misleading tobacco advertising is the “light cigarettes” scam. On June 8, 1985, during the 3rd day of tobacco dependence I organized in Paris at la Faculté des Saints Pères, I had invited LT Kozlowski to give us a demonstration of the work he had done in Toronto with a smoking machine [2]. He explained that the amounts of nicotine and tar displayed on cigarette packs had nothing to do with the content in the tobacco itself. Moreover, tobacco contains no tar. It is formed during the combustion process. In other words, what the outcomes actually represented was the amount collected in the smoke when the cigarette was smoked by a machine under standard conditions. As for tobacco, it was virtually the same whether the cigarette was labeled heavy or light, based on the readings obtained from the machine. The big difference was made by the micro-perforations in the filter through which ambient air from the room can enter. Consequently, when the machine sucks the standard 35ml puff, if 30 ml enters through the perforations, the dosage relates to only 5 ml of smoke! All Kozlowski had to do is block the ventilation and change the setting on the machine to see the content multiplied by 22 for the reading obtained for 0.1 mg of nicotine and by 29 for that of tar. The smoker is perfectly capable of doing exactly that. Moreover, from determination of salivary cotinine in 2031 smokers of their usual cigarette, yielding from 0.1 to 1.mg of nicotine, Martin Jarvis calculated their real nicotine intake. He did not find any difference. Nicotine intake was about the same, irrespective of the machine-yield of the cigarette they smoke. (3)
The conclusion is clear and unequivocal: The smoker is not a machine. Yields reported are of no use in predicting the absorption of toxins. And yet, 20 years later, a European directive specified that as of January 1, 2004, contents (sic) for cigarettes should not exceed 10mg per cigarette for tar, 1mg for nicotine and 10mg for carbon monoxide. This 2003 directive is still in effect! It therefore becomes compelling to conclude that the EU endorses the light cigarettes deceit. I see only two possible explanations. Either the ‘’experts’’ who advise the EU are guilty of total incompetence and gross ignorance, or else they are moles of the tobacco industry. In any case, I personally have not been consulted and therefore plead not guilty.
The Medication Enterprises (Les entreprises du médicament)
Let us first of all acknowledge the change of name. It is neither innocent nor without reason. Formerly, it was known as the Pharmaceutical Industry, which is not a very reassuring name. Industry evoked factory chimneys belching black smoke. Pharmaceutical, springs to mind images of jars labeled “Poison’’ with a skull crossed in red. Enterprises on the other hand sounds dynamic, and evokes progress. As for Medication, it serves to heal, how can that not be beneficial? Is it a matter of a simple naive case for an enhanced image or a manifestation of the art of manipulation?
The big fraud in the tobacco issue was none other than the publication of the 1988 Surgeon General Report entitled “Nicotine Addiction’’. This fraud is incomprehensible unless one sees the link with the launch of the nicotine gum. The major premise of the Report seems to be a syllogism that states: “Tobacco products cause a powerful addiction’’ The minor premise is: “Tobacco contains a neurotropic poison - nicotine’’. Hence follows the conclusion: “Therefore nicotine is responsible for the addictiveness of tobacco’’. But there is no evidence that allows us to draw such a conclusion. A host of other assumptions are possible, and there are even major arguments to oppose it, such as the fact that no cases of nicotine dependence have ever been documented when this substance was used in isolation, as was already established long before the “Medication Enterprises” began marketing nicotine as a form of medication. This duplicity is more than amazing when you consider how common it is for addicts to experiment with the purified extracts of their plants of choice. Since no formal evidence of dependence to pure nicotine has yet to be produced, the conclusion that nicotine alone is addictive is not a syllogism, but rather, pure sophistry.
And yet, against all scientific rigor, this fallacy was implanted through repetition, hammered in as an unassailable truth, all with the support of health authorities and politicians. Thus the famous Fagerström test in the AFSSAPS good practice recommendations, continues to be called ‘’test for nicotine dependence’’. Yet not one of its 6 items even refers to it. This is simply a test for cigarette dependence and we would have no objection if it were referred to as such. Is this a minor detail? No, it is clearly an intentional mistake, extremely serious in its consequences both intellectually and scientifically. Because having arbitrarily decided that nicotine alone explains tobacco dependence and having it engrained in the minds of doctors, the authorities and the public, any research on the other possible factors of this dependency is now excluded in advance and a vast new market is made available for commercial exploitation by the pharmaceutical industry.
But a second manipulation, easy to debunk at least in theory, is also currently wreaking havoc: the big lie used as the basis of all repressive policies against smokers on the basis of passive smoking. As one would expect, they found popular support from non-smokers, forceful because they are now the majority, as well as among a number of smokers who considered that it would give them the incentive they required to rid them of their cigarette dependence. It is undeniable that the omnipresence of smoke was becoming increasingly intolerable and that regulation was necessary for the sake of non-smokers who had enough of the constant annoyance. But they had to find an argument that carried greater weight than simple inconvenience to non-smokers – the danger of other people's smoke to the health of nonsmokers. In 1990, Catherine Hill, estimated the annual deaths from passive smoking for France to be 1000, of which around one hundred were lung cancers. She noted that the margin of uncertainty becomes quite wide when dealing with estimates of such low impacts. In front of the Academy of Medicine, Pr. Tubiana in 1997 applied the considerable increase in cardiovascular risk of the U.S. assessment to France and estimated the death toll from passive smoking to be 2500, including 105 lung cancers. In 2005, without producing any specific study for France, Norman and Dubois reported 3000 deaths from passive smoking.
But these increases were still not sufficient to reach the critical level that would have made second hand smoke a serious public health problem warranting drastic measures. That’s when an international report made its appearance. Produced by four institutions, Cancer Research UK, European Respiratory Society, Institut National du Cancer and the European Health Network, announced, with great precision, 5863 deaths for France, quickly rounded to 6000 deaths for the press [4]. They had finally reached the level that was required to justify the measures that were quickly adopted in most countries. (Figure 1)
(Figure1) Reproduction of the table in the report ‘’Lifting the SmokeScreen’’ assessing mortality for France by passive smoking. It is broken down by age and exposure at home or at the place of employment, indicating separately the employment in the ‘’hospitality industry’’, including hotels, restaurants, bars and nightclubs. Moreover, deaths are calculated separately for the various causes - lung cancer, cardiovascular disease, stroke and chronic respiratory diseases. None of these estimates takes into account statistical spreads.
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But anyone who would had carefully read this report would have discovered that, with the utmost simplicity and dare I say nonchalance, the authors also showed separately the estimates for non-smokers thus revealing that smokers themselves were included in their total death estimates. In doing so, they changed the definition of passive smoking itself! And suddenly, with only 1,114 deaths in non-smokers including 152 lung cancers, we almost went back to Catherine Hill’s estimate of 20 years earlier.'' When breaking down these 1114 deaths, it becomes unclear how a law banning smoking in public spaces can have any effect on 1007 of these 1114 deaths that relate to exposure at home, providing of course that the police are not permitted to break down your door with a ram to fine your smoking spouse. 107 deaths were attributed to exposure at work, and 6 of them to the special conditions for the hotels restaurants, bars and discos where the application of the ban was delayed by one year. (Figure 2)
Figure 2 .- Reproduction of the table in the report ‘’Lifting the SmokeScreen’’ assessing mortality for France by passive smoking among non-smokers. This is the only assessment that matches the traditional definition of passive smoking, ie ‘’non-smoking victims due to other people's smoke’’. The overall assessment comes from old data. The importance of exposure to the spouse’s second hand some at home is surprising, as is the weakness of death by exposure in the workplace, especially in the hospitality industry, where the consequences of the ban have had the biggest social impact.
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But in terms of marketing, the operation is a failure. Indeed, not only have smokers, despite being stigmatized and persecuted, did not rush off to the pharmacies in response to the bans, but sales of all drugs known as ‘’nicotine replacement therapy’’ are plummeting. And this notwithstanding the intense indirect television advertising that should in fact be banned since in France it is not permitted to advertize for medication that is reimbursed by social security. One has to be blind not to see through their hardly veiled scheme that these ads make smokers aware of the drugs that are eligible for reimbursement so they can insist that their doctor prescribes those particular drugs to them.
But the major concern for anyone who really cares about the health of smokers, is that such drastic measures are counterproductive to smoking cessation. The official sales of tobacco increased while the smuggling figures do not show any reduction. The prevalence of smoking among youth is increasing. Smoking cessation consultations are increasingly abandoned by their clients. The Diplomas of Tobacology no longer attract any students. In defense of their proper identity, smokers now sink into themselves and shut themselves off in a way that public health messages [6] can no longer reach them.
The Anti-Tobacco Crusaders
These activists have abandoned logical reasoning and replaced it with faith and passion. Anything goes when it comes to pursuing the triumph of their such “good cause’’, and “white lies’ are a perfectly acceptable tool. Any open debate and any valid scientific research is therefore precluded. We do find of course some pure idealists, survivors of former “virtuous movements’’ among them. Be that as it may, there are unfortunately a great number of self-interested do-gooder apostles fueling and exploiting to their advantage this blind militant force in an effort to assert their own power and fame, not to mention more tangible benefits.
For these knights of purity, tobacco is the absolute evil, the devil. It must be eliminated, eradicated. At the very least, it must be hidden or sold “under the counter’’, much like porn magazines (sic). The tobacco industry is diabolical. It must be destroyed, made to disappear, bankrupted through litigation.
The problem is that if the tobacco industry exists it is because it responds to a demand. If tobacco has spread around the world since Christopher Columbus, during an era when there was no other means of advertising than word of mouth and when tobacco was cultivated by primitive means, it is because there is something attractive about the product that causes people to crave for it. The industry responded to the demand, it did not create it. If the industry were to disappear, the demand would remain and would require to be fulfilled. And it would be fulfilled. Multinationals would be investing their money in tax havens, where they would fund an offshore production in some underdeveloped nation. Cigarettes would be distributed through organized criminal networks, fueling underground commerce and auxiliary crimes in the process. No quality control could ever be achieved. Control could only be dealt with through the police and corruption would inevitably creep in. For these reasons, the fundamentalist anti-tobacco crusaders are a true danger to social balance and public health.
As for the smoker, he is seen as someone possessed by the devil. He must be pursued, hunted down to his last hide-out, even in his own home. The smoker loses the ordinary rights of ownership and freedoms within his own home. Already in the U.S. smokers are increasingly denied rental housing. Moreover, in the spirit of good Judeo-Christian morality, he must be punished by where he has sinned. Let his vice cost him and ruin him. Let us therefore increase the price of cigarettes and rolling tobacco. For decades, we have been served a lie, with no tolerance for any criticism or challenge, namely: that the only effective method to reduce smoking prevalence is to increase the price of cigarettes. But since it does not work, they allege that it is because the increases are neither high enough nor frequent enough! But just as with their tactic of stigmatization of smokers, the high-price policy does not work.
That is where the real failure lies. One could always be tempted to defend such a policy if its success outweighed its serious adverse effects. Effects that destroy the individual, the HUMAN-slave to cigarettes. It sinks him into poverty and social exclusion, pushing him into more dangerous smoking behaviors. But it does not exorcise the demon of addiction.
They attempt to justify these dehumanizing policies by referring to large statistics with abstruse mathematical models [7]. However, if any of these policies were truly effective one would think that after 30 years of applying them worldwide we should be noticing their effects. Smoking prevalence should be lower in places where the prices are high. Comparing the 27 countries of the European Union for smoking prevalence according to price, and after adjusting for purchasing power, we should be able to calculate a significant regression line with a nice negative slope. I drafted this graph based on 2009 [8,9] data. The result is not debatable. We observe a cloud of dots, there is no significant correlation, and to add mockery to injury, the calculated regression line shows a positive slope! (Figure 3)
Figure 3 – Distribution of smoking prevalence in the EU in 2009 according to the price of the most popular brand of cigarettes (Marlboro ® ) adjusted for purchasing power.
Science can only progress if we learn from its mistakes. What is truly diabolical is keeping our eyes tightly shut and manufacturing the results to best serve our own interests and obsessions!
References
1.- The University of Stanford website contains an important collection of cigarette advertizing images that can be downloaded from http://lane.stanford.edu/tobacco/index.html
2.- Kozlowski LT, Rickert WS, Popo MA, Robinson JC. Estimating the yields to smokers of tar, nicotine and carbon monoxide from the "lowest-yield" ventilated-filter cigarettes. Br. J. Addict. 1982b, 77 : 159-65
3.- Jarvis MJ, Boreham R, Primatesta P, Feyerabend C, Bryant A. Nicotine yield from machine-smoked cigarettes and nicotine intakes in smokers: evidence from a representative population survey .J Natl Cancer Inst. 2001 Jan 17;93(2):134-8.
4.- Lifting the smokescreen, 10 reasons for a smokefree Europe .www.ersnet.org
5.- Molimard R. Le rapport européen "Lifting the smokescreen: Etude épidémiologique, ou manipulation? Revue d'Epidémiologie et de Santé Publique, (2008) 56 ;(n°4): 286-90
6.- Falomir, J. M., Mugny, G. (2004) Société contre fumeur, Une analyse psychologique de l’influence des experts. Grenoble : Presses Universitaires de Grenoble
7.- Ross H, Blecher E, Yan L, Hyland A. Do cigarette prices motivate smokers to quit? New evidence from the ITC survey. Addiction. 2010 Nov 9. doi: 10.1111/j.1360-0443.2010.03192.x. [Epub ahead of print]
8.- Prevalences Europe 2009 selon http://ec.europa.eu/health/tobacco/docs/ebs332_en.pdf
9.- The 2009 prices of a pack of 20 Marlboro cigarettes in 27 countries of the EU adjusted for purchasing power, according to http://www.cancer.be/images/journaliste/Communique-de-presse-taxation-tabac-100929.pdf
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11 comments:
Just below Figure 1 there seems to be a mistake:
But anyone who would had carefully read this report would have discovered a stunning revelation: there was a change in the definition of passive smoking. Indeed, with the utmost simplicity and dare I say nonchalance, the authors also included non-smokers in their estimates!
Shouldn't it be "smokers" instead of non-smokers?
Molimard's first paper was noticed here in Danmark and were no doubt one of the reasons to why the Danish smoking ban not tightened in 2009:
French expert: Passive smoking is harmless
(google translated)
Klaus: It lacked clarity in the translation. Reread it now that I got it fixed and you will understand what he meant. Compare figure 1 with figure 2. While figure 1 shows the total, figure 2 shows non-smokers separately, the difference between the two being smokers. Let me know if you still think it's not clear. Thanks.
Iro
It is still confusing and needs to be clarified.
In my opinion the "change in the definition of passive smoking" is, that the report included smokers (in order to kick up the death toll).
This is also clear in Molimard's earlier paper:
They changed this definition, by including active smokers’ deaths, because, as it is of course difficult to smoke far from oneself, smokers inhale the environmental smoke their own cigarettes produce.
http://cagecanada.blogspot.com/2009/01/discours-du-pr-molimard-speech.html
The best and most honest way to do studies like this is to show the effect in never-smokers. Some lower quality studies though, show the effect in non-smokers (i.e. with former smokers also).
But the EU report is highly unusual, because it shows the effect in smokers also and cites those figures in the death toll from passive smoking in the abstract. This is pure dishonesty, and I am quite sure this is what Molimard is referring to.
Had they only counted never-smokers (the right way to do it), they would probably not have been able to show one single death in all of EU.
Klaus,
This is exactly what Pr. Molimard is referring to, there is no doubt. The problem is that I am trying to stay as faithful as possible to his original French text and obviously it's not coming across clearly in English without going into lengthy explanations.
How clear does the following sound if I were to change it to that?
''But anyone who would had carefully read this report would have discovered that, with the utmost simplicity and dare I say nonchalance, the authors also showed separately the estimates for non-smokers thus revealing that they included smokers in the total death estimates. Stunningly, they changed the definition of passive smoking itself! And suddenly, with 1,114 deaths in non-smokers including 152 lung cancers, we almost went back to Catherine Hill’s estimate of 20 years earlier.''
Iro
Interestingly enough when the talk is about addiction the "demon" thing comes up and it all goes medieval. I don't know if Molimard knows of Bruce Alexander, but here's an interesting except from a speech he did:
"I learned the falsity of demon drug mythology. The demon drugs mythology is the story that there are certain drugs, heroin being the best known, that magically transform normal, well-integrated people into addicts. It is said that if you take these drugs once or a few times, you’re somehow converted into an addict, which you remain forever after, unless either medical or divine intervention undoes the pharmacological hooks that are holding you in that position.
[...]
If you think about it, the image of a drug that will convert a person, just like that, into an addicted, subhuman reprobate, is exactly the medieval idea of demon possession, although stated in modernized, pharmacological jargon. It’s not the devil taking possession of the soul, it’s the drug molecule taking possession of the dopamine D2 receptors (or whatever the physiological substrate is said to be is in the theory of the day) and making this person into a reprobate.
[...]
The important and, I hope, feasible goal for tonight is to show why the demon drug mythology has turned out to be disastrous. There are several reasons. For example, if the myth were true, then the severest punishments would be suitable for anyone who would sell drugs because children might unwittingly try them and be converted into addicts for the rest of their lives. If that myth were true, we ought to be helping the US wage war on drugs in Columbia right now to prevent peasant farmers from growing drugs in quantities that could addict the entire world. In the case of Columbia, the main drug at issue is cocaine, but it’s the same demon drug mythology that has been applied to heroin and dozens of other drugs at various times in the 20th and 21st centuries.
Moreover, if the demon drug mythology were true, there would be really no point in drug addicts struggling to change their lives because ... How could they? Only God in his mercy or medical doctors with their miraculous technologies or psychologists like myself with supremely attuned knowledge of conditioned and unconditioned responses and neurotransmitter substances would be able to get drug addicts off the fatal hook that they had impaled themselves upon.
As well, the demon drug myth is a disastrous idea for policemen because it implies that a person who has been possessed by a demon drug, isn’t really a person anymore. They have lost their power of choice -- you could say their soul -- to a vile powder. They have become alien, and you can do what you want to with them because their lives don't matter much any more.
Most important of all, if the demon drug myth were true, society would never have to ask itself why some of our children decide to hang around at Main and Hastings rather than working their way into the future that we have so lovingly envisioned for them. Or why some other children decide that it’s more important to stay in their rooms and play video games all day than it is to take on the tasks that are so carefully sequenced for them to follow in school, for their improvement."
Just for the record I don't equate heroin and nicotine. Caffeine would likely be the better comparison.
And to appreciate the case with caffeine, so similar to nicotine, I highly recommend this funny and insightful clip with Ethan Nadelmann of the Drug Policy Alliance:
http://www.youtube.com/watch?v=aCPX1ZHLovs
Vad,
So sorry for not taking the time sooner to reply to your most thoughtful post.
I don't want to speak for Pr. Molimard, but I don't think that he's equating smoking addiction to any real ''medieval demons'' or possessions by the devil when he speaks of the ''demon of addiction''. It's just a matter of colourful speech in his case, albeit I do agree that repeated often enough (even innocently) it perpetuates stereotypes and prejudices against anyone who uses psychotropic substances.
Iro
@Iro: I think we're on the same page. I didn't mean to imply that Molimard was claiming real demons exist or some such. I realize it's "colorful speech". What I wanted to draw attention to was that it's the same essential model being used.
Such models are mental constructs that tend to provide a familiar framework within which to interpret phenomena. In sociology (I believe) it's something thought of as the fertile, cultural soil in which certain ideas/memes are able to flourish better than other ideas.
So what I'm saying is that the medieval model has provided something familiar and that the model is being used - mostly unknowingly - by modern people.
Clearly Molimard (and Alexander) are not subscribing to this outdated idea, rather they're fighting it :)
Didn't they say at the beginning of the article that nicotine is not addictive in order to make all their nicotine products acceptable, nicotine patches, gum, etc. etc. and, in that case, wouldn't e-cigarettes be a wonderful substitute? Why are they fighting it so bad??
They have never said that nicotine is not addictive. On the contrary they are saying that it's addictive but harmless and this is how they can market their NRT's. Yet it is becoming more and more apparent that nicotine in isolation is not what keeps people smoking (vaping).
Even Fagerström, the scientist who was instrumental in driving in the addiction theory now agrees that nicotine alone is not what causes the addiction. If you read this article http://cagecanada.homestead.com/fagerstromfindshiswaytodamascus.html you will get the clear answer as to why e-cigarettes are nixed. They cannot be patented by Big Pharma (too late sorry) and they come in direct competition with NRT and after the billions Big Pharma spent in marketing smoking bans to force smokers to try to quit using their virtually useless NRT, they won't have a third player (e-cigarettes) ruin it all for them. And while they once told us that you can't wear a patch and smoke because you can overdose on nicotine they are now saying that you can be a dual user. They want the monopoly of nicotine (a very cheap substance) that they can mark up to extortionist levels under the guise of ''medication''.
Iro
Loved reading this thank youu
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