New Cigar Research Fails To Understand That Behavior Matters
Tobacco control researchers frequently demonstrate astonishing ignorance about the subject of their life’s work. A recent example is a study comparing the health outcomes of cigar and pipe smokers to those of cigarette smokers. The results are useful, but they do not reflect differences in the products as the authors and other tobacco controllers seem to think. Rather they reflect differences in behavior.
Thinking that objects matter more than behavior is a common problem in tobacco control. Examples include breathless claims like, “this (e-cigarette cartridge or can of snus) has more nicotine than a pack of cigarettes!” Even setting aside that nicotine quantity is of little concern, this reflects a bizarre lack of understanding about product use. Someone will consume the quantity of nicotine he wants, whatever the product, by choosing the quantity of puffs or pouches over time and by controlling how efficiently the nicotine is extracted from them. The number of molecules in the container simply does not matter.
Part of the problem is that tobacco controllers try very hard to not admit that tobacco use is a matter of volition. Doing so would force them to face the fact that their business consists of punishing people for their personal choices. So they fixate on objects and corporations, trying to put the primary stakeholders out of their minds. This is compounded by the fact that products are easy to study, while behavior can require hard work. However, for the recent cigar research, a single simple behavioral question could have solved the problem.
The new paper, by Carol H. Christensen of the FDA and other U.S. government employees, looks at mortality rates in smokers of cigarettes, pipes and cigars in a large nationally-representative cohort. It found that all-cause mortality was elevated for all three groups of smokers when compared to nonsmokers. As expected, this was driven by larger elevations for the particular diseases often caused by smoking. Cigarette smokers died at twice the rate as nonsmokers (twice as many deaths from all causes, over a particular number of person-years). Smokers who used only cigars or pipes also had elevated risks, but these were much lower.
The results have been strangely misinterpreted as showing that risk from any smoking is the same. In reality the reported risks for people who exclusively smoked a non-cigarette product were on the order of one-fifth of those from cigarette smoking for most measures. Quite a few of the results for pipe smokers actually show a protective association (lower risk for mortality outcomes, by some measure, as compared to nonsmokers).
Those misinterpreting the results as evidence that all the products are the same, however, are correct in a sense that they probably do not understand. There is no reason to believe that smoke from these various products differs substantially in terms of its health effects. Undoubtedly there is some difference, just as there is among different varieties of cigarettes (despite the obviously false insistence by tobacco controllers that all cigarettes pose exactly the same risk). But the variation in risk is probably in the range of ten or twenty percent, not the five- or ten-fold difference found in the recent results.
The smoke does not vary substantially. The mortality outcomes vary so much because what people do with the smoke varies.
Smokers of pipes and premium cigars typically mouth-puff rather than inhaling most of the smoke into their lungs. Cigarette smokers typically inhale, as do smokers of little cigars. (Little cigars are basically cigarettes, but are technically cigars because they are wrapped in tobacco leaf rather than paper. This makes the standard tobacco control categorization fairly useless for understanding the products, which is a separate problem with these studies methods.) Intentionally inhaling creates enormously greater exposure for the lungs and more efficiently transfers harmful particles and gases into the rest of the body. In addition, on average pipe and premium cigar smokers do not smoke as often as cigarette smokers.
The authors of the paper appear oblivious to the important behavioral differences. They do not even mention inhalation versus mouth-puffing. Much of the discussion about the contrasting outcomes in this study has focused on some theoretical effect of the higher socioeconomic status of cigar and pipe smokers, with little or no recognition of the behavior difference. Tobacco controllers simply do not understand tobacco use.
This is a rare case in which studying the behavior would have been easy, had the survey designers understood smoking. They needed only to have asked a simple question about whether the smoker inhaled or mouth-puffed. This measurement would have been imperfect, of course, just like most other survey responses. But it would probably have been adequate to demonstrate that the behavior, not the products, is what caused the difference in outcomes.
The government authors, naturally, tried to spin the study results as reasons why they should further restrict people’s choice to smoke any product. But the relatively modest results clearly do not support aggressive anti-cigar or anti-pipe efforts. Indeed, if we pretend to be as oblivious as the authors were, these results actually suggest a risk reduction option: A naive interpretation of the results is that a cigarette smoker could reduce his risks substantially by changing what he smokes — by perhaps 80 percent with cigars and 90 percent with a pipe. These are similar to the level of risk reduction usually claimed for vaping (claims which underestimate the actual apparent risk reduction from switching to vaping).
In reality, a cigarette smoker who switched to one of the other products would presumably experience far less reduction in risk than the results imply. He would probably maintain his habit of inhaling, and would probably continue to smoke intensively, and there would be little or no change in risk. Though you would never learn it from what FDA and others will say about this research, changing behavior matters a lot (a cigarette smoker can reduce his risk by mouth-puffing instead of inhaling…), while changing products does not (…even if he continues to use cigarettes).
If you want to inhale something, smoke is a harmful choice, no matter what is burning.