Supreme Court Lights Up

Unlikely to let states sue over low tar cigarettes.

Can states sue tobacco companies for marketing one of the most addictive products known to man? Not if the claim hinges on deceptive claims about “light” cigarettes, the U.S. Supreme Court seemed to say last Monday.

The Court began its new term by taking up the tobacco case, in which three residents of Maine filed suit against Altria Group Inc. and its subsidiary, Philip Morris USA, under a state law barring unfair marketing practices. According to an Associated Press report, the plaintiffs argued that Philip Morris had long known that smokers of low tar cigarettes compensate by taking longer puffs and smoking more cigarettes.

After being thrown out by a federal district court, a U.S. Circuit Court of Appeals allowed the suit to proceed. Several similar cases are in progress around the country, pending a decision. If the Supreme Court finds against Philip Morris and its parent company Altria, states could initiate a new round of lawsuits as tobacco manufacturers once again face the prospect of huge class-action settlements.

Industry Week reported that Altria’s defense is that “cigarette packaging falls under the domain of the U.S. Federal Trade Commission (FTC), which failed to act despite being aware that light cigarettes were no less a health hazard than regular cigarettes.”

In other words, Altria knew that its advertising was deceptive—but so did the FTC, which approved it. Judge Samuel Alito summed up this thinking when he told an FTC attorney that by allowing cigarette ads to display tar and nicotine levels, “You have misled everyone who has bought these cigarettes for a long time.”

Chief Justice Roberts, according to the AP report, questioned why the case was focused on deception rather than the relationship between cigarettes and health: “How do you tell it’s deceptive or not unless you look at smoking and health?”

At the heart of the argument is the question of whether the 1966 federal legislation governing cigarette labeling and advertising takes precedence over more recent state legislation. Representing Altria, conservative attorney Theodore Olson found himself in the odd position of arguing that federal law should take precedence over state law.

Clifford E. Douglas of the University of Michigan’s Tobacco Research Network, told the New York Times in May that the difficulties of pushing forward with cases against light cigarettes “underscores the need to combat the light cigarette scam in the public policy arena.” Douglas said he supported legislation that would give the U.S. Food and Drug Administration (FDA) authority to regulate tobacco.

The New York Times reported that a bill under consideration in Congress “would ban the use of terms like light and low-tar in marketing such cigarettes, which contain the same tobacco as other cigarettes but have filters that allow more air to mix with the smoke, diluting it.”

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Gates, Bloomberg Target Cigarettes

Billionaires pledge $500 million, but will it do any good?

If money were all it took, tobacco smoking would be on the run after Bill Gates and Michael Bloomberg jointly pledged last month to fight tobacco use worldwide, especially in low- and middle-income countries, through the Bill and Melinda Gates Foundation and Johns Hopkins University.

Mayor Bloomberg, who has been involved in anti-smoking campaigns for years, admitted at a joint news conference that "all the money in the world will never eradicate tobacco. But this partnership underscores how much the tide is turning against this deadly epidemic."

The program, put together by Bloomberg and Dr. Margaret Chan of the World Health Organization (WHO), is an ambitious, multi-faceted effort to be coordinated by the Bloomberg Initiative to Reduce Tobacco Use, the WHO, the World Lung Foundation, the Johns Hopkins Bloomberg School of Public Health, and the Centers for Disease Control and Prevention (CDC).

As Donald G. McNeil described the $500 million program, dubbed Mpower, in the July 24 New York Times: "It will urge governments to sharply raise tobacco taxes, prohibit smoking in publics places, outlaw advertising to children and cigarette giveaways, start antismoking advertising campaigns and offer people nicotine patches or other help quitting." The program also intends to bring "health officials, consumer advocates, journalists, tax officers and others from third world countries" to the U.S. for workshops and training.

It will not be the first such effort--far from it. Troubled by the rising tide of nicotine dependence among the common folk, Bavaria, Saxony, Zurich, and other European states outlawed tobacco at various times during the 17th Century. The Sultan Murad IV decreed the death penalty for smoking tobacco in Constantinople, and the first of the Romanoff czars decreed that the punishment for smoking was the slitting of the offender’s nostrils.

In America, the Prohibition years from 1920 to 1933 coincided with a short-lived effort to prohibit cigarettes. Leaving no stone unturned in the battle to eliminate drugs and alcohol from American life, Henry Ford and Thomas Edison joined forces to wage a public campaign against the “little white slavers.” Edison and Ford wanted to stamp out cigarette smoking in the office and the factory. Although that effort would have to wait another 75 years or so, New York City did manage to pass an ordinance prohibiting women from smoking in public. (See Siegel, Ronald K. Intoxication: Life in Pursuit of Artificial Paradise). Fourteen states eventually enacted various laws prohibiting or restricting cigarettes. By 1927, all such laws had been repealed.

Finally, Adolf Hitler himself took on the battle against cigarettes--and lost. In 1942, after letting loose a torrent of misbegotten screed about "the wrath of the Red Man against the White Man," Hitler, in one of the most aggressive anti-smoking campaigns in history, banned smoking in public places and slapped heavy taxes on tobacco. But by the mid-1950s, smoking in Germany exceeded prewar levels.

There is no evidence to suggest that any culture that has ever taken up the smoking of tobacco has ever wholly relinquished the practice voluntarily.

Photo Credit: National Health Service

The Genetics of Cigarettes

Mutations on chromosome 15 linked to lung cancer.

A variation among the genes that code for nicotine receptors in the brain has been linked with increased cigarette smoking and a heightened risk for lung cancer, according to three new studies released this week.

Two studies in Nature, and one in Nature Genetics, demonstrated that people who inherited the genetic variation, or allele, from one parent—roughly 50 percent of the population--had a 30 percent higher risk of developing lung cancer. “What’s more,” according to Michael Hopkin at Nature News, “another 10 percent of the population is likely to carry two copies of this set of mutations, raising cancer risk by as much as 80 percent relative to people with equivalent lifestyles without the cancer-linked gene variant.”

More than 35,000 Caucasian smokers in Europe and North America took part in the government-funded research. It was the strongest evidence to date of a firm link between genetics and lung cancer. It was also added evidence for the existence of biological proclivities in addicted cigarette smokers.

Earlier studies had demonstrated that having a parent or sibling with lung cancer could triple the odds of developing the disease. But teasing out the precise genes responsible has been, as always, a frustrating hunt.

Christopher Amos of the University of Texas, author of one of the studies, characterized the variant as “kind of a double whammy gene” in an Associated Press article by Seth Borenstein. Amos said of the nicotinic acetylcholine receptor gene alleles on chromosome 15: “It also makes you more likely to be dependent on smoking and less likely to quit smoking.” In the same article, psychiatry professor Dr. Laura Bierut of Washington University in St. Louis said that the three studies are “really telling us that the vulnerability to smoking and how much you smoke is clearly biologically based.”

Study author Kari Stefansson of Iceland’s deCode Genetics believes strongly that the genetic variation in question makes people more susceptible to nicotine addiction, and increases the difficulties of quitting: “In our study, we found if you have one allele you smoke about one more cigarette per day; if you have 2 alleles you average two more cigarettes per day.”

However, according to Denise Gellene of the Los Angeles Times: “The studies were divided on whether the genetic variant directly increased the risk of lung cancer or did so indirectly by predisposing people to smoking.” In a third study, Paul Brennan of the International Agency for Research on Cancer in Lyon, France noted no evidence of a link between the rogue gene and nicotine addiction itself.

It is not clear whether non-smokers with the mutation suffer an increased risk of lung cancer as well. (However, even smokers who lack the gene variant are still ten times as likely to develop lung cancer than nonsmokers).

About one million people die annually from lung cancer. According to the World Health Organization, smoking is the leading cause of preventable death worldwide.

Graphics Credit: Technology Review

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100 Million Killed By Tobacco

WHO estimates 1 billion more deaths in 21st century.

The World Health Organization (WHO) estimates that 100 million smokers died of tobacco-related causes in the 20th century, making cigarettes the leading preventable cause of death worldwide.

The agency estimates that as many as a billion people will die from tobacco in the 21st century, if present trends continue.

According to the WHO report, “Global Tobacco Epidemic 2008,” almost two-thirds of all smokers live in only ten countries, with China accounting for as much as 30 per cent of the total. Nearly 60 per cent of Chinese men smoke cigarettes, the report claims. The other leading countries, in order of consumption, are India, Indonesia, Russia, the U.S., Japan, Brazil, Bangladesh, Germany, and Turkey.

“The shift of the tobacco epidemic to the developing world will lead to unprecedented levels of disease and early death in countries where population growth and the potential for increased tobacco use are highest and where health care services are least available,” the report concluded. Or, as the Economist puts it, “the tobacco industry is getting the world’s poor hooked before governments can respond.”

The Economist reports that the most powerful prescription for fighting the trend is higher taxes: “Studies show that raising tobacco taxes by a tenth may cause a 4 per cent drop in consumption in rich countries, and an 8 per cent drop in poor ones, with tax revenue rising despite lower sales. The agency wants a 70 per cent increase in the retail price of tobacco, which is says could prevent up to a quarter of all tobacco-related deaths worldwide.”

The eradication of tobacco use will be as difficult as fighting insect-born diseases, WHO officials say. The WHO analysis strongly asserts that “partial bans on tobacco advertising, promotion and sponsorship do not work.”

In a soon-to-be-published paper by researchers at MIT and the University of California, cited by the Economist, the authors claim that “the monetary value of the health damage from a pack of cigarettes is over $35 for the average smoker, implying both that optimal taxes should be very large and that cigarette taxes are likely progressive.”

In a forward to the report, noting that 5.4 million people a year die from lung cancer and tobacco-related heart diseases, WHO Director-General Margaret Chan wrote that the world has reached “a unique point in public health history as the forces of political will, policies and funding are aligned to create the momentum needed to dramatically reduce tobacco use and save millions of lives by the middle of the century.”

What are cigarette makers doing to combat these grim revelations? According to the Economist, “The tobacco industry is regrouping in order to focus on ‘promising’ markets and escape the pesky lawsuits it is likely to face in rich, litigious countries.”

photo credit: UCR/California Museum of Photography

Chantix and Suicide

Anti-smoking pill joins the list—but is the risk real?

The U.S. Food and Drug Administration fired both barrels last week, announcing that a variety of anti-seizure medications—as well as the anti-smoking pill, Chantix—may increase the risk of suicidal thoughts in patients who take them. The FDA will require new label warnings for a total of 11 drugs used for epilepsy.

New label warnings are also in the works for Chantix, the nicotine cessation aid being widely used by people attempting to quit smoking cigarettes. In a public health advisory issued last Friday, the FDA declared it “increasing likely” that Chantix may be associated with psychiatric problems. A month earlier, the FDA had advised that Chantix users should be monitored for the onset of suicidal urges, but backed off from making a strict cause-and-effect connection.

The FDA reviewed clinical data on anti-epileptic medications, including Pfizer’s Neurontin and Ortho-MacNeil’s Topamax, and concluded that “patients who are currently taking or starting on any anti-epileptic drug should be closely monitored for notable changes in behavior that could indicate the emergence or worsening of suicidal thoughts or behavior or depression.” Topamax has shown additional promise as an anti-craving medication for alcoholism.

This follows on the heels of earlier warnings about increased suicide risk in adolescents taking SSRI antidepressants.

In the case of Chantix, the FDA’s Bob Rappaport, in a conference call with reporters, said the agency had “no definitive evidence there is a causal relationship here, they are just strongly appearing to be related.” Rappaport, quoted at WSJ.com, also said that “Chantix has proven to be effective in smokers motivated to quit,” and that the new warnings would help doctors and patients “make an informed decision regarding whether or not to use this product.”

A spokesman for Pfizer, quoted at Bloomberg.com, said that “no causal relationship has been established. There are some post-marketing reports and you cannot exclude those. We go by our scientific data, and from our clinical trial data we have not seen this.”

Discussions about a possible link between Chantix and suicide were fueled by the death last year of New Bohemians lead singer Carter Albrecht, who was shot while attempting to break into a house in Dallas. His girlfriend told authorities that his behavior had been erratic since he began taking Chantix in an effort to stop smoking.

In no case are the numbers of suicides linked to any of the drugs alarmingly high. The FDA study of epilepsy medications appears to demonstrate, as summed up by the San Francisco Chronicle’s Bernadette Tansey, “2.1 more people for every 1,000 on the medications exhibited suicidal thoughts or behavior, compared with every 1,000 on placebo.”

Note that the FDA is not discussing an increased risk of suicide, but rather an increased risk of suicidal thoughts or feelings. This is called “suicidal ideation.” The FDA usually refers to it as “suicidality.” Unlike an actual suicide attempt, suicidal ideation is the act of contemplating the act—a sort of “what if.” It is the difference, as a mental patient once put it, between buying the rope, and contemplating buying the rope

Persistent suicidal ideation is obviously not a desirable state of mind. But it does not downplay this behavior to note that it is, by nature, often fleeting and difficult to quantify. Moreover, the act of going cold turkey itself can cause heavily addicted people to feel temporarily suicidal—to ideate about killing themselves without killing themselves. These and other factors make it difficult to reach firm statistical conclusions about such risks.

For a Chantix user's point of view on the debate, visit www.stopsmokingcigs.com

Photo Credit: eNews 2.0
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Where Can I Smoke?

An international survey of the cigarette scene.

It was a tough year for smokers. 2007 marked the onset of new restrictions on public smoking in dozens of nations around the world.

Contrary to popular belief, smoking bans are nothing new under the sun. Troubled by the rising tide of nicotine dependence among the common folk, Bavaria, Saxony, Zurich, and other European states outlawed tobacco at various times during the 17th Century. The Sultan Murad IV decreed the death penalty for smoking tobacco in Constantinople, and the first of the Romanoff czars decreed that the punishment for smoking was the slitting of the offender’s nostrils. Still, there is no evidence to suggest that any culture that has ever taken up the smoking of tobacco has ever wholly relinquished the practice voluntarily.

In order to sort things out, the BBC News Website, among others, recently compiled a chart of global changes in the climate for smokers. Herewith, a representative sampling:

In FRANCE, January 1, 2008, marked the day when cafes, bars and assorted French eateries were slated to go smoke-free, joining the existing ban on smoking in public buildings. However, in a gesture of Gallic tolerance, the government instituted a last-minute grace period, postponing the deadline 24 hours. French authorities are not expecting widespread civil disobedience among smokers and café owners--an optimism bolstered by a stiff fine of 450 euros ($660) for violations. (Most European restrictions allow for closed-off smoking sections with ventilation, something most bar and café owners say they cannot afford to build.)

GERMANY followed a similar path, when eight states, including Berlin, went smoke-free in pubs and restaurants on the 1st of January. Having passed legislation guaranteeing workers the right to a smoke-free workplace, German officials are less sanguine about the enforcement picture, according to the BBC report. German pubs bitterly fought the ban, reminding the citizenry that Hitler had wanted to ban cigarettes, too. The hard test will come in good weather, when the beer tents go up and the festivals begin.

THE UNITED KINGDOM has banned smoking in all “enclosed public spaces,” with on-the-spot fines of 50P, after a long and contentious debate on the subject of second-hand smoke.

Cafes and restaurants in FINLAND went smoke-free, along with many other European nations, on June 1, 2007. NORWAY has had a national ban on smoking in bars and restaurants in place since 2004, and SWEDEN followed in 2005. IRELAND has had strong anti-smoking laws since 2004, and the same is true of ITALY since 2005.

ESTONIA, LITHUANIA AND MONTENEGRO have smoking bans in place for bars and cafes. SPAIN made shops and offices smoke-free in 2006, but there have been boycotts, and enforcement is said to be lax. PORTUGAL observed the January 1 ban, but will let small bars continue to allow smoking if they choose.

THE NETHERLANDS—a country, like Germany, Spain and Greece, with a serious population of smokers—went all the way on January 1st, banning indoor smoking, but certain details remain unclear. How will cannabis coffee shops be required to deal with the restrictions?

INDIA has tightened smoking restrictions on public places in recent years, and has banned the sale of cigarettes to children. However, the BBC reports that a lack of money and resources mean that the smoking restrictions are only sporadically enforced. The same is true in IRAN, where restrictions on smoking in public buildings are widely ignored.

The UNITED STATES represents a confusing amalgam of state and local ordinances that vary widely and is the subject of bitter debate. New York banned smoking in bars, clubs and restaurants five years ago. California, with some of the most rigid anti-smoking legislation in the world, prohibits smoking in bars, restaurants, enclosed workplaces, within six meters of any public building, and even on public beaches. Countless local, regional, city and state regulatory agencies continue to grapple with the issue.

VENEZUELA, another nation of heavy smokers, initiated a partial ban on public smoking in 2007. Restaurants and bars in ARGENTINA must now include no-smoking areas.

AUSTRALIA, which already had rigid no-smoking rules in place, from airports to restaurants, is considering a smoking ban at Bondi Beach, the country’s most famous stretch of sand.

In CANADA, British Columbia and Alberta joined with other provinces and banned indoor smoking in public places on January 1st, 2008.

In CHINA, the nation with more smokers than any other, the government undertook small-scale test bans last year in the cities of Guangzhou (Canton) and Jiangmen. Otherwise, smoke ‘em if you got ‘em.

RUSSIA remains a smoker’s paradise as well, with a comprehensive anti-smoking package passed by the Duma, but still awaiting implementation.

MEXICO has required separate smoking and non-smoking areas since 2004. Mexico City, with some of the highest air pollution readings in the world, began battling over a smoking ban in bars and restaurants last year, and the outcome remains clouded.

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