Smoking Cessation Vs. Harm Reduction ------04 Former Director (1997-2003), Lars M

THE AMERICAN COUNCIL ON SCIENCE AND HEALTH PRESENTS

Dr. Elizabeth Whelan, President ACSH, 1995 Broadway 2nd Floor, New York, NY 10023 ACSH PRESENTS Helping Smokers Quit: A Role for Smokeless Tobacco?

by Kathleen Meister, M.A. for the American Council on Science and Health

Based on a paper by Dr. Brad Rodu and William T. Godshall, M.P.H.

Art Director: Jennifer Lee

October 2006

AMERICAN COUNCIL ON SCIENCE AND HEALTH 1995 Broadway, 2nd Floor, New York, NY 10023-5860 Phone: (212) 362-7044 • Fax: (212) 362-4919 URLs: http://acsh.org • http://HealthFactsAndFears.com E-mail: [email protected] This manuscript is a position statement of the American Council on Science and Health. The author gratefully acknowledges the assis- tance of the following ACSH staff who provided critical reviews of content and perspective, especially with regard to the policy sec- TABLE OF CONTENTS tions of the report.

Elizabeth M. Whelan, ScD, MPH Gilbert Ross, MD President and Founder Medical/Executive Director Foreword by Sally Satel, MD ------01

Executive Summary ------02 The author also gratefully acknowledges the following individuals, who provided peer reviews, critical analysis, commentary, and sug- gestions during the development of this review, and whose names Introduction ------02 have been listed with their permission: Cigarette Smoking: Scott D. Ballin, JD Carl V. Phillips, PhD It's Even Deadlier Than You Think ------03 Tobacco and Health Policy Associate Professor, University Consultant of Alberta School of Public Washington, DC Health Nicotine: Addictive But Not Deadly ------03 Edmonton, AB, Canada Clive Bates Smoking Cessation vs. Harm Reduction ------04 Former Director (1997-2003), Lars M. Ramstrom, PhD Action on Smoking and Health, Director, Institute for Tobacco UK Studies Smokeless Tobacco Products ------04 London, United Kingdom Stockholm, Sweden Health Effects of Smokeless Tobacco ------05 Ronald W. Brecher, PhD, DABT, William O. Robertson, MD C Chem Medical Director, Washington Principal, Globaltox: Toxicology Poison Center Does Switching to Smokeless Tobacco Work? ------06 Focused Solutions Seattle, WA Guelph, ON, Canada Health Policy Questions ------06 David Schottenfeld, MD Emil William Chynn, MD, FACS, Professor Emeritus, School of MBA Public Health, University of Conclusions and Recommendations ------08 Medical Director, Michigan IWANT2020.com, Inc. Ann Arbor, MI Appendix: New York, NY Peter G. Shields, MD Examples of Smokeless Tobacco Products ------09 Michael Dubick, PhD Prof. Medicine/Oncology, Dir. Senior Research Cancer Genetics/Epidemiology, Pharmacologist, US Army Georgetown Washington, DC Institute of Surgical Research San Antonio, TX Robert B. Sklaroff, MD Elkins Park, PA ACSH accepts unrestricted grants on the condition that it is solely Dwight B. Heath, PhD Department of Anthropology, Jacob Sullum responsible for the conduct of its research and the dissemination of Brown University Senior Editor, Reason its work to the public. The organization does not perform propri- Providence, RI Dallas, TX etary research, nor does it accept support from individual corpora- tions for specific research projects. All contributions to ACSH—a Rudolph J. Jaeger, PhD, DABT, David T. Sweanor, BA (Hon), publicly funded organization under Section 501(c)(3) of the REA (California) LLB Internal Revenue Code—are tax deductible. Consulting Toxicologist, Adjunct Professor of Law and Environmental Medicine Inc. Medicine, University of Ottawa Individual copies of this report are available at a cost of $5.00. Westwood, NJ Ottawa, ON, Canada Reduced prices for 10 or more copies are available upon request. Michael Kunze, DrMed John W. Waterbor, MD, DrPH Professor, Institute of Social Associate Professor of Copyright © 2006 by American Council on Science and Health, Medicine, Medical University Epidemiology, University of Inc. This book may not be reproduced in whole or in part, by Vienna Alabama at Birmingham mimeograph or any other means, without permission. Vienna, Austria Birmingham, AL FOREWORDBy Sally Satel, M.D. smokeless tobacco is far safer than cigarettes. Even mouth cancer is only about one-third to one-half as For decades, public health advocates have champi- likely with traditional chewing tobacco and moist snuff oned harm reduction for people who either can't or products as with smoking. don't want to stop taking health risks. Needle exchange is a classic example. If intravenous drug It is rare to find such a powerful cause-and-effect rela- users get clean needles, the reasoning goes, their tionship in health epidemiology as the one between risk of contracting HIV and spreading it will be snus and reduction in lung cancer incidence and mor- reduced. tality. The other best example, it turns out, is the danger of cancer posed by smoking itself. Repeat: from Smoking is another dangerous addiction. While there smoking, not from nicotine per se. is no denying that public education has done some good, more than 40 million Americans continue to Public health experts have for years endorsed harm smoke. We must face the fact that a smoke-free coun- reduction as a pragmatic last resort for hard-core sub- try is a pipe-dream. stance users. For heroin they advocate needle exchange and even supervised distribution of heroin So what about harm-reduction for committed smok- itself. For problem drinkers they have suggested ers? Unfortunately, the smoking-cessation lobby drinking in moderation. In Seattle, new public housing wants nothing to do with it. Its “experts” insist on programs for homeless alcoholics allow drinking in pushing a quit-or-die philosophy even in the face of the privacy and safety of their own apartments – a overwhelming evidence that there already exists a controversial move that is based on the tenet of harm life-saving alternative to cigarettes: smokeless tobac- reduction: that relative safety can accrue to the user co. and society even if he or she does not relinquish an addiction. The safest types are modern products like snus, or Swedish moist snuff, and a host of similar products It is ironic that much of the public health community available in the U.S. Crucially, they satisfy smokers' accepts such radical accommodations for people nicotine addiction and cause negligible health risks of addicted to intoxicants but resists the use of smoke- their own. All of these products are held discreetly less tobacco to treat an addiction that afflicts a far between lip and gum, releasing nicotine, and because greater percentage – and causes far more suffering they do not stimulate saliva production there is no from disease and death. spitting. Significantly, the blood levels of nicotine obtained with smokeless are higher than those asso- In documenting the evidence on the relative benefits ciated with gum or a patch; this is why smokeless has of smokeless tobacco as compared to smoking, this such a powerful anti-craving effect. report serves another invaluable function: It makes the powerful case that most of what people believe Even better, there is no smoke. they know about the product is outdated, wrong or both. Lamentably, the public has been subject to a And this is key. Tobacco smoke, with its thousands of vast miasma of misinformation, generated, some- toxic agents, can lead to cancer, heart disease and times deliberately, by anti-tobacco zealots and, per- emphysema. Eliminate the smoke, and you signifi- haps unwittingly, by the U.S. Department of Health cantly reduce the risk. To put it bluntly: it's the smoke, and Human Services. stupid. Reducing the harm from cigarettes depends on This comprehensive and indispensable monograph responsible science. One can ponder the political from The American Council on Science and Health agendas driving the anti-smokeless lobby, but what- presents the latest epidemiological findings on ever their motives, distorting the truth about smoke- smokeless tobacco and offers wise policy recommen- less tobacco is a grave disservice to millions of dations. The authors draw on an impressive archive American smokers. This clearly written and exhaus- of Swedish data, which is both long-ranging and tively researched monograph is a potent antidote to much-replicated. bad science and a life-saving prescription in itself.

Although 40% of Swedish men use tobacco products, the same rate for men in the other 14 countries in the Dr. Satel, a psychiatrist, is a resident scholar at the European Union, Sweden has the lowest rate of lung American Enterprise Institute. She is a widely-pub- cancer by far. Why? Largely because of snus. What’s lished expert in addiction and harm reduction. more, over 20 epidemiological studies show that 1 EXECUTIVE SUMMARY According to the Centers for Disease Control and modern smokeless tobacco products. It reviews Prevention, about 45 million Americans continue to the epidemiologic evidence for low health risks smoke, even after one of the most intense public associated with smokeless use, both in absolute health campaigns in history, now over 40 years old. terms and in comparison to the much higher risks Each year some 438,000 smokers die from smok- of smoking. The report also describes evidence ing-related diseases, including lung and other can- that smokeless tobacco has served as an effective cers, cardiovascular disorders, and pulmonary dis- substitute for cigarettes among Swedish men, who eases. consequently have among the lowest smoking- related mortality rates in the developed world. The Many smokers are unable – or at least unwilling – report documents the fact that extensive misinfor- to achieve cessation through complete nicotine mation about smokeless tobacco products is wide- and tobacco abstinence; they continue smoking ly available from ostensibly reputable sources, despite the very real and obvious adverse health including governmental health agencies and major consequences. Conventional smoking cessation health organizations. policies and programs generally present smokers with two unpleasant alternatives: quit or die. The American Council on Science and Health believes that strong support of tobacco harm A third alternative, tobacco harm reduction, reduction is fully consistent with its mission to pro- involves the use of alternative sources of nicotine, mote sound science in regulation and in public pol- including modern smokeless tobacco products. A icy, and to assist consumers in distinguishing real substantial body of research, much of it produced health threats from spurious health claims. As this over the past decade, establishes the scientific and report documents, there is a strong scientific and medical foundation for tobacco harm reduction medical foundation for tobacco harm reduction, using smokeless tobacco products. which shows great potential as a public health strategy to help millions of smokers. This report provides a description of traditional and

ing has recently been suggested: encouraging INTRODUCTION smokers to switch from cigarettes to less harm- Even though people have known for more than ful smokeless tobacco products so that they can 40 years that cigarettes are deadly, cigarette reduce their risk of tobacco-related illness and smoking remains the number one preventable death without having to break their addiction to cause of death in the United States, accounting nicotine. Some health experts and antismoking for more than 400,000 deaths per year. advocates have welcomed this idea, but others have strongly criticized it. Efforts to reduce the number of people who smoke have had mixed results. On the plus side, In this report, the American Council on Science it is less common for people to start smoking and Health (ACSH) evaluates the prospect for now than it was in the past. On the minus side, the use of smokeless tobacco as a harm reduc- smokers’ efforts to kick the cigarette habit usu- tion alternative for smokers, discusses the rea- ally fail. Statistics show that 70% of smokers sons why this approach is controversial, and rec- want to quit and that 40% make a serious ommends some policy changes that may reduce attempt to quit each year; however, each year the risk of tobacco-related illness and death fewer than 5% succeed in quitting permanently. among cigarette smokers. This report is based Because nicotine is addictive, most people who on a peer-reviewed ACSH report entitled want to quit smoking find themselves unable or "Tobacco Harm Reduction: An Alternate unwilling to quit when they try. Cessation Strategy for Inveterate Smokers," by Dr. Brad Rodu and William T. Godshall, M.P.H., A new approach to reducing the number of from the Dec. 21, 2006 issue (Vol. 3, issue 1) of deaths and illnesses caused by cigarette smok- Harm Reduction Journal.

2 CIGARETTE SMOKING: IT’S EVEN NICOTINE: ADDICTIVE BUT NOT DEADLIER THAN YOU THINK DEADLY Although most people know that smoking ciga- At this point, it’s necessary to make an important rettes is unhealthful, many do not realize just how distinction. Cigarettes kill; nicotine doesn’t. deadly cigarettes really are. One in every five deaths in the United States results from smoking- Nicotine is a highly addictive substance, but in all related diseases, and half of all smokers die from other respects, it is not especially dangerous. It smoking-related diseases. Each year, smoking does not cause cancer or emphysema, and there is steals more than five million years of potential no evidence that it plays a direct role in the devel- life from the over 400,000 Americans who die opment of heart disease or stroke, although it from illnesses linked to smoking. does have some effects on the circulatory system. If it weren’t for its addictive power, nicotine To put these statistics into perspective, it may be would be of little public health concern. helpful to consider the impact of cigarette smoking in comparison to that of six other major caus- Most people are not aware that nicotine is not es of death: alcohol abuse, drug abuse, AIDS, responsible for the health damage caused by motor vehicle crashes, homicide, and suicide. All smoking. A survey of American smokers showed six of these causes combined kill only half as that 53% incorrectly believed that nicotine caus- many people as cigarettes do. es cancer and 14% didn’t know. Even health professionals may be misinformed about the health Cigarette smokers can substantially reduce their effects of nicotine. A survey of physicians in the risk of smoking-related illness and death by quit- United Kingdom showed that 40% believed, ting smoking, but this is not as easy as it sounds. incorrectly, that nicotine may cause cardiovascu- Even with the help of currently approved smok- lar disease and stroke and one-quarter believed it ing cessation methods, most people who want to may cause lung cancer. do so fail to quit permanently. Their inability to give up smoking is due to the strong addictive power of nicotine. Research has shown that nicotine fits all the criteria of an addictive agent and that the intensity of desire for cigarettes among smokers is as intense as or greater than the desire for heroin, alcohol, or cocaine among those addicted to these substances. As British tobacco addiction research expert Michael A.H. Russell noted more than 30 years ago, “There is little doubt that if it were not for the nicotine…people would be little more inclined to smoke than they are to blow bubbles or light sparklers.”

3 longer periods of use would be considered SMOKING CESSATION VS. HARM acceptable. However, whether nicotine replace- REDUCTION ment therapy can be provided at a cost that would be attractive to smokers is uncertain. In the past, public health campaigns to reduce health hazards among smokers have focused Another alternative source of nicotine, however, exclusively on smoking cessation. Traditionally, is already on the market at competitive prices. experts have not suggested any alternatives to That alternative is smokeless tobacco. As will be quitting for smokers who are unable or unwilling discussed in the next section, cigarette smokers to break their addiction to nicotine. However, the who switch to smokeless tobacco can greatly fact that the addictive component of tobacco, reduce the risks to their health. nicotine, is not responsible for most of the health damage resulting from cigarette smoking sug- gests possibilities for harm reduction. SMOKELESS TOBACCO PRODUCTS The term harm reduction refers to a public health philosophy that seeks to decrease the potential The term smokeless tobacco refers to tobacco harm associated with a particular behavior with- products that are not burned. Instead, most are 1 out necessarily eliminating that behavior. Harm placed in the cheek or between the lip and gum. reduction approaches to public health problems Many different smokeless tobacco products are include the provision of clean needles and used in various parts of the world, but the follow- syringes to users of injected drugs to reduce the ing four types are best known in the U.S. and risk of infectious disease transmission and mak- other western countries: ing condoms readily available to reduce the risks of sexually transmitted diseases and unintended • Dry snuff. In the U.S., this powdered product pregnancy. Less controversially, the use of sun- has traditionally been used primarily by screen to reduce the risks of sunburn and skin women in southern states. Its popularity has cancer without requiring people to give up out- declined greatly in the past few decades. door activities can also be regarded as a harm reduction strategy. • Loose leaf chewing tobacco. This product is used primarily by men in the U.S., commonly In the case of tobacco, the risks of illness and in conjunction with outdoor activities. It is typ- death associated with cigarette smoking could be ically used in large amounts, resulting in the reduced if cigarette smokers could be persuaded production of large amounts of saliva. Sales of to switch to a different, safer source of nicotine. this type of smokeless tobacco have decreased Theoretically, this could be done using nicotine recently, probably because of the problem of replacement therapy products, such as nicotine saliva production and the resulting need to patches. However, the versions of these products spit. currently on the market were not designed for use as long-term cigarette alternatives. Instead, they • Moist snuff. Moist snuff is now the most popu- were intended for use as short-term aids to smok- lar form of smokeless tobacco in the U.S. ing cessation, with abstinence as the eventual Users compress a “pinch” between the thumb goal. They contain relatively low doses of nico- and finger and place it inside the lip. Moist tine — much less than the amount that smokers snuff is much less bulky than chewing tobacco are accustomed to receiving daily. In the United but still produces some saliva that needs to be States, federal regulations limit their use to 10 to expelled. Recently, user-friendly forms of 12 weeks. And they are much more expensive moist snuff sold in preportioned pouches that than cigarettes. It is technically possible to man- look like miniature teabags have become pop- ufacture a high-dose nicotine patch, and it is ular. These products stay in place in the mouth, legally possible to modify regulations so that unlike traditional pinches of snuff, which tend

4 to move around, and they generate very little cancer associated with cigarette smoking. saliva, allowing them to be used discreetly, Moist snuff, the type of smokeless tobacco without spitting. Moist snuff, called snus most popular today, as well as the less popular (rhymes with “moose”) is very popular in chewing tobacco, pose an oral cancer risk sub- Sweden; it will be discussed in detail later in stantially lower than that of dry snuff. This this report. In the United States, moist snuff is may be because the process of manufacturing currently the most popular form of smokeless modern moist snuff produces smaller amounts tobacco, with increased sales over the past 15 of cancer-causing nitrosamines than older years. methods did. Some moist snuff products may pose little or no oral cancer risk. • Miscellaneous modern products. In addition to the moist snuff pouches mentioned above, • Smokeless tobacco often does cause a charac- other types of small-sized smokeless tobacco teristic change in the tissues of the mouth products that can be used discreetly without (usually where the tobacco is held) called “oral spitting have appeared on the market in recent leukoplakia.” However, this condition usually years. They include dry, flavored pouches; represents irritation rather than anything more small pieces of leaf tobacco; and pellets of serious, and it rarely progresses to cancer. compressed tobacco that dissolve completely Smokeless tobacco use may cause local in the mouth. changes in gum tissues. But people don’t die of gum problems.

• The use of smokeless tobacco does not expose HEALTH EFFECTS OF SMOKELESS other people to tobacco smoke. Although the TOBACCO exact degree of health risk associated with exposure to environmental tobacco smoke is The health risks associated with smokeless tobac- disputed, decreased exposure to “secondhand” co are much less extensive than those associated smoke would certainly be welcome. with cigarette smoking. Consider the following: • Overall, the use of smokeless tobacco confers • Cigarette smoking causes chronic lung dis- only about 2% of the health risks of smoking. eases (chronic bronchitis and emphysema). For example, if the 400,000 people who died Smokeless tobacco doesn’t. of smoking-related diseases had instead been using smokeless, the death toll might have • Cigarette smoking increases a person’s risk of been only 8,000. Every one would still have heart disease two- to fourfold. Most studies of been tragic — but the public health impact smokeless tobacco indicate that it has no influ- would have been incredibly lessened. ence on heart disease risk. Most people are not aware of the large difference • Cigarette smoking causes cancer both at sites in risks between cigarettes and smokeless tobac- that come in direct contact with cigarette co. In 2005, a survey of adult U.S. smokers found smoke — including the mouth, nose, throat, that only about 11% correctly believed that and lungs — and at sites that don’t — includ- smokeless tobacco products are less hazardous ing the bladder, kidney, pancreas, uterus, than cigarettes. In another survey, 82% of U.S. cervix, and stomach. Smokeless tobacco, on smokers incorrectly believed that chewing tobac- the other hand, has been associated with only co is just as likely as cigarette smoking to cause one type of cancer — oral cancer — and the cancer. risk of oral cancer associated with the use of smokeless tobacco is less than the risk of oral

5 the much more dangerous habit of cigarette DOES SWITCHING TO SMOKELESS smoking, but the Swedish experience doesn’t TOBACCO WORK? support this idea. Studies of men in Sweden have indicated that the use of snus is more likely to There is evidence from a small number of scien- lead to quitting smoking than starting it. Snus tific studies and one real-life natural experiment users were less likely than nonusers to start that switching from cigarettes to smokeless smoking, and snus was the most commonly used tobacco can help people to quit smoking and smoking cessation aid. Among Swedish men, the thereby decrease the risks to their health. number of smokers has dropped during the past 20 years, while the number of exclusive snus A few surveys in the U.S., mostly in the 1980s users has increased. Among Swedish boys aged and 1990s, indicated that people who switched 15 and 16, the percentage that use snus has from cigarettes to smokeless tobacco were more increased in recent years (to about 13%), but the likely to quit smoking successfully than those percentage that smoke has declined. Among who did not use smokeless tobacco. There has Swedish girls, very few of whom use snus, smok- also been one clinical trial in which people who ing rates are about double those of boys. wanted to quit smoking were informed about the health effects of all forms of tobacco use and provided with information about and samples of a smokeless tobacco product. In this study, 16 of 63 HEALTH POLICY QUESTIONS participants (25%) successfully quit smoking for at least one year, and 12 (19%) were still smoke- Based on the Swedish experience and the limited free after seven years. This is better than the quit scientific research that is available, it appears that rates typically produced by conventional smok- switching to smokeless tobacco can help cigarette ing cessation methods. These successes were smokers reduce the risks to their health if they achieved among smokers who had previously cannot or will not abstain from the use of tobac- failed with nicotine gum or patch. co completely. However, the idea that health authorities might advocate that cigarette smokers The most interesting information on smokeless switch to smokeless tobacco — or even that they tobacco use as a smoking cessation aid comes might inform people that the health risks of using from Sweden, where the moist snuff product snus smokeless tobacco are less extensive than those is very popular among men but not women. of cigarette smoking, without necessarily advo- Smoking rates among Swedish men have been cating any particular course of action — is high- lower than those of men in other European coun- ly controversial. tries for decades, and Swedish men have the lowest rates of smoking-related cancers such as lung Official publications from U.S. government cancer and the lowest percentage of male deaths agencies emphasize that the use of smokeless related to smoking in Europe. In contrast, women tobacco is not risk-free (which is undeniably in Sweden smoke and die at rates similar to those true), but they never say that it is far less risky to of women in other European countries. It has use smokeless tobacco than to smoke cigarettes. been calculated that per capita nicotine consump- In fact, the U.S. government seems to go out of tion in Sweden is similar to that in other countries its way to avoid telling people the truth about such as Denmark, but the tobacco-related death smokeless tobacco. rates for Danish men are higher than those for Swedish men. The difference is that Swedish men For example: mostly get their nicotine from snus rather than from cigarettes as the Danish men do. • A Centers for Disease Control and Prevention summary of the harm caused by tobacco use2 Concerns have been expressed that the use of states, “Smokeless tobacco, cigars, and pipes smokeless tobacco might serve as a gateway to also have deadly consequences, including

6 lung, larynx, esophageal, and oral cancers. • Until early 2006, a document entitled “Tips for Low-tar cigarettes and other tobacco products Teens: The Truth About Tobacco,”6 published are not safe alternatives.” The huge difference by the Substance Abuse and Mental Health between the risks of cigarettes and smokeless Administration, answered the question “Isn’t tobacco is not mentioned, and the wording of smokeless tobacco safer to use than ciga- the sentence on smokeless tobacco, cigars, and rettes?” as follows: “No. There is no safe form pipes may incorrectly suggest to readers that of tobacco.” Although the statement “There is smokeless tobacco has been convincingly no safe form of tobacco” is consistent with linked to lung, larynx, and esophageal cancers, current scientific evidence, the “No” that pre- when in fact it has not. cedes it is a misrepresentation of the facts. In this instance, the government agency respond- • A Q & A–style fact sheet on smokeless tobac- ed to a NLPC request for correction by with- co from the National Cancer Institute3 fails to drawing the document from its Web site rather mention the relative risks of smokeless tobac- than by providing accurate scientific informa- co vs. cigarettes in answers to the questions “Is tion. smokeless tobacco a good substitute for cigarettes?” and “What about using smokeless The statement that smokeless tobacco products tobacco to quit cigarettes?” Instead, the fact are “not safe,” which appears in many govern- sheet states that “because all tobacco use caus- ment publications, may be intended to be consis- es disease and addiction, NCI recommends tent with the smokeless tobacco warning labels that tobacco use be avoided and discontinued” required by the 1986 Comprehensive Smokeless and that “the accumulated scientific evidence Tobacco Education Act, one of which states, does not support changing this position.” “This product is not a safe alternative to cigarettes.” However, saying that smokeless tobacco • Until 2004, a document published by the is “not safe” is not enough. People need to be National Institute on Aging entitled “Smoking: fully informed about the relative risks of cigarette It’s Never Too Late to Stop”4 stated, “Some smoking and smokeless tobacco use in order to people think smokeless tobacco (chewing make sound decisions about the use of tobacco tobacco and snuff), pipes, and cigars are safer products. than cigarettes. They are not.” With respect to smokeless tobacco, this is simply false. So is Some government and health organizations and the heading under which these sentences health professionals may be reluctant to tell peo- appeared, which read: “Cigars, Chewing ple that smokeless tobacco use is less dangerous Tobacco, and Snuff Are Not Safer.” In than cigarette smoking out of concern that this response to an official request for correction information might prompt nonusers of tobacco to from the National Legal & Policy Center start using smokeless tobacco. However, the (NLPC),5 a nonprofit organization committed overall public health impact of any increase in to promoting open, accountable, and ethical smokeless tobacco use is extremely unlikely to practices in government, the wording of the outweigh the beneficial effect of cigarette smok- text was changed to “Some people think ers switching to smokeless tobacco, since it smokeless tobacco (chewing tobacco and would require 50 people to start using smokeless snuff), pipes, and cigars are safe. They are tobacco to equal the degree of health risk associ- not.” The heading was changed to “Cigars, ated with one person smoking. Concerns about Pipes, Chewing Tobacco, and Snuff Are Not the possibility that smokeless tobacco might act Safe.” The NLPC’s request that the document as a gateway to cigarette smoking also appear to mention that the use of smokeless tobacco is be unwarranted, based on the Swedish experi- significantly less hazardous than cigarette ence. smoking was ignored.

7 3. Congress should repeal the federally mandat- CONCLUSIONS AND ed warning on smokeless tobacco products RECOMMENDATIONS that states, “This product is not a safe alternative to cigarettes.” This warning may mis- The health consequences of cigarette smoking are lead smokeless tobacco users into thinking devastating, and current smoking cessation that they might as well smoke — a danger- strategies for combating this menace have had ous conclusion. Consideration should be very limited success. Adding tobacco harm given to placing the following message on reduction to the arsenal of weapons against cigarette (not smokeless tobacco) packages: smoking-related illness and death offers the “Warning: Smokeless tobacco use has risks, potential to save many lives, since there remain but there is a scientific consensus that ciga- approximately 45 million addicted smokers in the rette smoking is far more dangerous. United States. Tobacco harm reduction empowers Although quitting tobacco entirely is ideal, smokers to gain control over the consequences of switching from cigarettes to smokeless tobac- their nicotine addiction. The strategy is cost- co can reduce health risks to smokers and effective, accessible to almost all smokers, and those around them.” Placement of this warn- consistent with the moral principle that the public ing on packages of cigarettes ensures that it has a right to accurate and complete health infor- reaches the target audience of cigarette mation. However, its implementation will require smokers. rethinking of conventional tobacco control policies. 4. State legislatures should place higher taxes on more dangerous tobacco products than on ACSH believes that public health would benefit less dangerous tobacco products. The state of from the following actions and policy changes: Kentucky has already taken steps in this direction. 1. Government agencies and private health organizations should provide accurate and 5. Regulatory restrictions on the manufacture complete information about the health risks and sale of nicotine replacement medications of tobacco, including information about the should be revised to allow the use of higher differential risks of different types of tobacco doses and longer-term (even lifelong) use of use. the medication. This would enable these medications to be incorporated into harm 2. Manufacturers of tobacco products should reduction strategies. In addition, smokers acknowledge that smokeless tobacco use is should be informed (perhaps by messages on much less hazardous than cigarette smoking. cigarette packages) that permanent use of One company, British American Tobacco, nicotine replacement therapy is much safer has already done this and is incorporating than continuing to smoke. such information into its marketing of a snus- like smokeless tobacco product in some countries.

1. In the past, some snuff products were inhaled through the nose, but this practice is very uncommon today. 2. http://www.cdc.gov/nccdphp/publications/aag/osh.htm 3. http://www.nci.nih.gov/cancertopics/factsheet/Tobacco/smokeless 4. The current, modified version is available online at http://www.niapublications.org/agepages/smoking.asp 5. http://aspe.dhhs.gov/infoquality/requests.shtml Scroll down the page to where it says “NIH — Smokeless Tobacco” to find both the request and the agency’s response. 6. http://aspe.dhhs.gov/infoquality/requests.shtml Scroll down the page to where it says “SAMHSA – Smokeless Tobacco Risks” to find both the request and the agency’s response.

8 APPENDIX: EXAMPLES OF SMOKELESS TOBACCO PRODUCTS

Panel 1: Powdered dry snuff

Panel 2: Loose-leaf chewing tobacco

Panel 3: Moist snuff

Panel 4: Modern smokeless tobacco products

9 A CSH BOARD OF TRUSTEES

MFrederickcKenna Long Anderson, & Aldridge Esq. UJamesniversity E. ofEnstrom, California, Ph.D., Los Angeles M.P.H. PThomasamela B. Campbell Jackson and Jackson, Thomas M.P.H.C. Jackson Charitable CKennetholumbia UniversityM. Prager, Medical M.D. Center Fund Katherine L. Rhyne, Esq. ANigellbert EinsteinBark, M.D. College of Medicine UJackniversity Fisher, of California, M.D. San Diego King & Spalding LLP CElizabethommittee toMcCaughey, Reduce Infection Ph.D. Deaths Lee M. Silver, Ph.D. UElissaniversity P. Benedek,of Michigan M.D. Medical School NHon.ew York, Bruce NY S. Gelb Princeton University THenryhe Hoover I. Miller, Institution M.D. Thomas P. Stossel, M.D. TexasNorman A&M E. University Borlaug, Ph.D. UniversityDonald A. of Henderson,Pittsburgh Medical M.D., Center M.P.H. Harvard Medical School IRodneyndo-US Science W. Nichols & Technology Forum Elizabeth M. Whelan, Sc.D., M.P.H. YMichaelale University B. Bracken, School of Ph.D., Medicine M.P.H. American Council on Science and Health

ACSH FOUNDERS CIRCLE

UChristineniversity ofM. California, Bruhn, Ph.D.Davis IA.nstitute Alan forMoghissi, Regulatory Ph.D. Science MStephenemorial Sloan-KetteringS. Sternberg, CancerM.D. Center CRobertase Western J. White, Reserve M.D., University Ph.D.

ETaiwornst & K.Young Danmola, C.P.A. GJohnrove CityMoore, College, Ph.D., President M.B.A Emeritus KLorraineetchum Thelian

UThomasniversity R.of DeGregori,Houston Ph.D. LAlbertyons Lavey G. Nickel Nickel Swift, Inc. MKimberlyassachusetts M. Thompson,Institute of Technology Sc.D.

A CSH EXECUTIVE STAFF

Elizabeth M. Whelan, Sc.D., M.P.H., President

A CSH BOARD OF SCIENTIFIC AND POLICY ADVISORS

C.S.Ernest Mott L. Center Abel, Ph.D. ThomasRobert JeffersonL. Brent, UniversityM.D., Ph.D. / A. l. duPont Omaha,Michael NE D. Corbett, Ph.D. Philadelphia,George E. Ehrlich, PA M.D., M.B. Hospital for Children TGaryexas A&MR. Acuff, University Ph.D. JMortonohn Hopkins Corn, University Ph.D. WMichaelestern Health P. Elston, M.D., M.S. UniversityAllan Brett, of South M.D. Carolina UJulieniversity A. Albr of Nebraska,echt, Ph.D. Lincoln UNniversityancy Co oftugna, Delaware Dr.Ph., R.D., C.D.N. KWeyilliam West, N FL. Elwood, Ph.D. KKennethBinc G. Brown, Ph.D. GJameslendon E.College, Alcock, York Ph.D. University NH.ational Russell Beef Cross, Ph.D. BStepheneth Israel K. Deaconess Epstein, MedicalM.D., M.P.P.,Center FACEP Adel,Gale GAA. Buchanan, Ph.D. SanThomas Francisco, S. Allems, CA M.D., M.P.H. RollinsJames School W. Curran, of Public M.D., Health, M.P.H. Emory HarvardMyron E.School Essex, of PublicD.V.M., Health Ph.D. Bell,George Boyd M. & Burditt,Lloyd LLC J.D. University AmericanRichard G.Society Allison, for Nutritional Ph.D. Sciences PennsylvaniaTerry D. Etherton, State University Ph.D. Charles R. Curtis, Ph.D. TexasEdward A&M E. UniversityBurns, Ph.D. Ohio State University OhioJohn State B. Allred, University Ph.D. St.R. GregoryLouis University Evans, Center Ph.D., for M.P.H.the Study of Ilene R. Danse, M.D. UniversityFrancis F. of Busta, Minnesota Ph.D. Bolinas, CA Bioterrorism and Emerging Infections UniversityPhilip R. ofAlper, California, M.D. San Francisco Robert M. Devlin, Ph.D. William Evans, Ph.D. UniversityElwood F. of Caldwell, Minnesota Ph.D., M.B.A. University of Massachusetts University of Alabama UniversityKarl E. Anderson, of Texas Medical M.D. Branch, Galveston Seymour Diamond, M.D. Daniel F. Farkas, Ph.D., M.S., P.E. TexasZerle A&ML. Car Universitypenter, Ph.D. Diamond Headache Clinic Oregon State University HudsonDennis InstituteT. Avery Donald C. Dickson, M.S.E.E. Richard S. Fawcett, Ph.D. UniversityRobert G. of Cassens, Wisconsin, Ph.D. Madison Gilbert, AZ Huxley, IA Kaiser-PermanenteRonald P. Bachman, Medical M.D. Center Ralph Dittman, M.D., M.P.H. Owen R. Fennema, Ph.D. UniversityErcole L. ofCavalieri, Nebraska D.Sc.Medical Center Houston, TX University of Wisconsin, Madison InternationalRobert S. Baratz, Medical D.D.S.,Consultation Ph.D., Services M.D. John E. Dodes, D.D.S. Frederick L. Ferris, III, M.D. AlbanyRussell Medical N. A. Cecil,College M.D., Ph.D. National Council Against Health Fraud National Eye Institute Allentown,Stephen Barrett,PA M.D. Theron W. Downes, Ph.D. David N. Ferro, Ph.D. BartsRino andCerio, The M.D. London Hospital Institute of Pathology Michigan State University University of Massachusetts UniversityThomas G.of FloridaBaumgartner, Pharm.D., M.Ed. Madelon L. Finkel, Ph.D. HealthMorris Education E. Chafetz, Foundation M.D. UniversityMichael Pof. DoGeorgiayle, Ph.D. Weill Medical College of Cornell University LomaW. Lawrence Linda University Beeson, School Dr.P.H. of Public Kenneth D. Fisher, Ph.D. Health UniversityBruce M. ofChassy, Illinois, Ph.D.Urbana-Champaign UniversityAdam Drewnowski, of Washington Ph.D. Office of Disease Prevention and Health Sir Colin Berry, D.Sc., Ph.D., M.D. Leonard T. Flynn, Ph.D., M.B.A. Institute of Pathology, Royal London Hospital Milan,Martha MI A. Churchill, Esq. U.S.Michael Army A.Institute Dubick, of SurgicalPh.D. Research Morganville, NJ Barry L. Beyerstein, Ph.D. Simon Fraser University NewEmil York William Eye & Chynn, Ear Infirmary M.D., FACS., M.B.A. TorontoGreg Dubord, Center for M.D., Cognitive M.P.H. Therapy EmoryWilliam University H. Foege, M.D., M.P.H. Steven Black, M.D. Kaiser-Permanente Vaccine Study Center UniversityDean O. Cliver,of California, Ph.D. Davis Savannah,Edward R. GA Duffie, Jr., M.D. Doylestown,Ralph W. Fogleman, PA D.V.M. Blaine L. Blad, Ph.D. Kanosh, UT UniversityF. M. Clydesdale, of Massachusetts Ph.D. UniversityLeonard J.of Duhl,California, M.D. Berkeley UniversityChristopher of Maryland H. Foreman, Jr., Ph.D. Hinrich L. Bohn, Ph.D. University of Arizona VirginiaDonald Polytechnic G. Cochran, Institute Ph.D. and State DuncanDavid F.& Duncan,Associates Dr.P.H. UniversityF. J. Francis, of Massachusetts Ph.D. University Ben W. Bolch, Ph.D. Rhodes College AverillJames Park, R. Dunn, NY Ph.D. UniversityGlenn W. of Froning, Nebraska, Ph.D. Lincoln W. Ronnie Coffman, Ph.D. Joseph F. Borzelleca, Ph.D. Cornell University Medical College of Virginia InstituteRobert L.for DuP Behavioront, M.D.and Health Tucson,Vincent AZ A. Fulginiti, M.D. Bernard L. Cohen, D.Sc. Michael K. Botts, Esq. University of Pittsburgh Ankeny, IA UniversityHenry A. ofDymsza, Rhode Island Ph.D. ClaremontRobert S. GraduateGable, Ed.D.,University Ph.D., J.D. PublicJohn J.Health Cohrssen, Policy AdvisoryEsq. Board George A. Bray, M.D. Michael W. Easley, D.D.S., M.P.H. Shayne C. Gad, Ph.D., D.A.B.T., A.T.S. Pennington Biomedical Research Center International Health Management & Gad Consulting Services Gerald F. Combs, Jr., Ph.D. Research Associates Ronald W. Brecher, Ph.D., C.Chem., DABT USDA Grand Forks Human Nutrition Center GlobalTox International Consultants, Inc. ScottWilliam & White G. Gaines, Clinic Jr., M.D., M.P.H. ProfessionalCharles O. NuclearGallina, Associates Ph.D. McLeanGene M. Hospital/Harvard Heyman, Ph.D. Medical School TheJames Weinberg C. Lamb, Group IV, Ph.D., J.D., D.A.B.T. CantoxIan C. HealthMunro, Sciences F.A.T.S., International Ph.D., FRCPath

QRaymonduest Diagnostics Gambino, Incorporated M.D. SRichardavannah, M. GA Hoar, Ph.D. SLawrencean Antonio, E. TX Lamb, M.D. BHarriseth Israel M. MedicalNagler, Center/ M.D. Albert Einstein College of Medicine RRandyutgers R.University Gaugler, Ph.D. YTheodoreale University R. Holford,School of Ph.D.Medicine CWilliamollege Park, E. M. MD Lands, Ph.D. DurbanDaniel InstituteJ. Ncayiyana, of Technology M.D. J. Bernard L. Gee, M.D. Robert M. Hollingworth, Ph.D. Lillian Langseth, Dr.P.H. Yale University School of Medicine Michigan State University Lyda Associates, Inc. PPhilipurdue E.University Nelson, Ph.D. K. H. Ginzel, M.D. Edward S. Horton, M.D. University of Arkansas for Medical Science Joslin Diabetes Center/Harvard Medical School UniversityBrian A. Larkins,of Arizona Ph.D. DJoyceenver, A. CO Nettleton, D.Sc., R.D. William Paul Glezen, M.D. Joseph H. Hotchkiss, Ph.D. Baylor College of Medicine Cornell University NLarryational Laudan, Autonomous Ph.D. University of Mexico UJohnniversity S. Neuberger, of Kansas School Dr.P.H. of Medicine Jay A. Gold, M.D., J.D., M.P.H. Steve E. Hrudey, Ph.D. Medical College of Wisconsin University of Alberta LTomiberty B. Mutual Leamon, Insurance Ph.D. Company Cupertino,Gordon W. CA Newell, Ph.D., M.S., F.-A.T.S. Roger E. Gold, Ph.D. Susanne L. Huttner, Ph.D. Texas A&M University University of California, Berkeley EJaynvironmental H. Lehr, Ph.D.Education Enterprises, Inc. WesternThomas Kentucky J. Nicholson, University Ph.D., M.P.H. Reneé M. Goodrich, Ph.D. Lucien R. Jacobs, M.D. University of Florida University of California, Los Angeles UniversityBrian C. Lentle,of British M.D., Columbia FRCPC, DMRD YaleSteven University P. Novella, School M.D. of Medicine TheFrederick George K.Washington Goodwin, University M.D. Medical Center UniversityAlejandro of R. Toronto Jadad, M.D., D.Phil., F.R.C.P.C. Floy Lilley, J.D. Fernandina Beach, FL James L. Oblinger, Ph.D. North Carolina State University Timothy N. Gorski, M.D., F.A.C.O.G. Rudolph J. Jaeger, Ph.D. University of North Texas Environmental Medicine, Inc. UMDNJ-RobertPaul J. Lioy, Ph.D.Wood Johnson Medical School UniversityDeborah ofL. Toronto/O’Connor, The Ph.D.Hospital for Sick Children Ronald E. Gots, M.D., Ph.D. William T. Jarvis, Ph.D. International Center for Toxicology and Medicine Loma Linda University CWilliamharles R. M. Drew London, University Ed.D., of Medicine M.P.H. and Science TuftsJohn UniversityPatrick O’Grady, School of MedicineM.D. Henry G. Grabowski, Ph.D. Michael Kamrin, Ph.D. Duke University Michigan State University MFrankiami, FLC. Lu, M.D., BCFE OregonJames StateE. Oldfield, University Ph.D. James Ian Gray, Ph.D. John B. Kaneene, D.V.M., M.P.H., Ph.D. Michigan State University Michigan State University OregonWilliam State M. Lunch,University Ph.D. UniversityStanley T of. Oma Nevada,ye, RenoPh.D., F.-A.T.S., F.ACN, C.N.S. William W. Greaves, M.D., M.S.P.H. P. Andrew Karam, Ph.D., CHP Medical College of Wisconsin MJW Corporation UniversityDaryl Lund, of Wisconsin Ph.D. UMichaelniversity T.of Osterholm,Minnesota Ph.D., M.P.H. Kenneth Green, D.Env. Philip G. Keeney, Ph.D. American Interprise Institute Pennsylvania State University MedscapeGeorge D. General Lundberg, Medicine M.D. UniversityMichael W.of Wisconsin,Pariza, Ph.D. Madison Laura C. Green, Ph.D., D.A.B.T. John G. Keller, Ph.D. Cambridge Environmental, Inc. Olney, MD Alamo,Howar CAd D. Maccabee, Ph.D., M.D. PennsylvaniaStuart Patton, State Ph.D. University Kathryn E. Kelly, Dr.P.H. ZolSaul Consultants Green, Ph.D. Delta Toxicology Houston,Janet E. TXMacheledt, M.D., M.S., M.P.H. MassJames General Marc HospitalPerrin, forM.D. Children George R. Kerr, M.D. Hinsdale,Richard ILA. Greenberg, Ph.D. University of Texas, Houston PurdueRoger PUniversity. Maickel, Ph.D. TexasTimothy A&M Dukes University Phillips, Ph.D. George A. Keyworth II, Ph.D. UCLASander School Greenland, of Public DrHealth.P.H., M.S., M.A. Progress and Freedom Foundation GeorgeHenry MasonG. Manne, University J.S.D. Law School NationalMary Frances Institutes Picciano, of Health Ph.D. Michael Kirsch, M.D. DartmouthGordon W. College Gribble, Ph.D. Highland Heights, OH RutgersKarl Maramorosch, University, Cook Ph.D. College UniversityDavid R. ofPik Illinois,e, Ph.D. Urbana-Champaign John C. Kirschman, Ph.D. UniversityWilliam Grierson,of Florida Ph.D. Emmaus, PA UniversityJudith A. ofMarlett, Wisconsin, Ph.D., Madison R.D. CornellThomas University T. Poleman, Ph.D. Ronald E. Kleinman, M.D. HarvardLester Grinspoon,Medical School M.D. Massachusetts General Hospital/ Harvard Medical School RoswellJames R.Park Marshall, Cancer Institute Ph.D. Tampa,Gary P. FL Posner, M.D. Leslie M. Klevay, M.D., S.D. in Hyg. VanderbiltF. Peter Guengerich, University School Ph.D. of Medicine University of North Dakota School of Medicine and Health UniversityMary H. McGrof California,ath, M.D., San FranciscoM.P.H. Sciences UniversityJohn J. Powers, of Georgia Ph.D. Caryl J. Guth, M.D. Alan G. McHughen, D.Phil. Advance, NC David M. Klurfeld, Ph.D. University of California, Riverside U.S. Department of Agriculture UniversityWilliam D.of BritishPowrie, Columbia Ph.D. Philip S. Guzelian, M.D. James D. McKean, D.V.M., J.D. University of Colorado Kathryn M. Kolasa, Ph.D., R.D. Iowa State University East Carolina University TuskegeeC.S. Prakash, University Ph.D. Terryl J. Hartman, Ph.D., M.P.H., R.D. Patrick J. Michaels, Ph.D. The Pennsylvania State University James S. Koopman, M.D, M.P.H. University of Virginia University of Michigan School of Public Health CornellMarvin University P. Pritts, Ph.D. Clare M. Hasler, Ph.D. Thomas H. Milby, M.D., M.P.H. The Robert Mondavi Institute of Wine and Food Science, Alan R. Kristal, Dr.P.H. Walnut Creek, CA University of California, Davis Fred Hutchinson Cancer Research Center NationalDaniel J.Institute Raiten, of Ph.D.Health Joseph M. Miller, M.D., M.P.H. David Kritchevsky, Ph.D. Durham, NH Sacramento,Robert D. Havener, CA M.P.A. The Wistar Institute RameyDavid EquineW. Ramey, Group D.V.M. William J. Miller, Ph.D. Stephen B. Kritchevsky, Ph.D. University of Georgia UniversityVirgil W. ofHa Kentuckyys, Ph.D. Wake Forest University Baptist Medical Center PopulationR.T. Ravenholt, Health ImperativesM.D., M.P.H. Dade W. Moeller, Ph.D. Mitzi R. Krockover, M.D. Harvard University J.LCheryl Mailman G. Healton, School of Dr.PH.Public Health of Columbia SSB Solutions UniversityRussel J. ofReiter, Texas, Ph.D. San Antonio University Grace P. Monaco, J.D. Manfred Kroger, Ph.D. Medical Care Management Corp. Pennsylvania State University UniversityWilliam O.of WashingtonRobertson, School M.D. of Medicine AmericanClark W. CancerHeath, Society Jr., M.D. Brian E. Mondell, M.D. Laurence J. Kulp, Ph.D. Baltimore Headache Institute University of Washington GeorgetownJ. D. Robinson, University M.D. School of Medicine Dwight B. Heath, Ph.D. Brown University CaliforniaJohn W. CancerMorgan, Registry Dr.P.H. UniversitySandford of F .Miami Kuvin, School M.D. of Medicine/ Hebrew DartmouthBill D. Roebuc Medicalk, Ph.D.,School D.A.B.T. Robert Heimer, Ph.D. Yale School of Public Health University of Jerusalem NewStephen York J.University Moss, D.D.S.,College ofM.S. Dentistry/ Health Education Enterprises, Inc. TheDavid United B. Roll, States Ph.D. Pharmacopeia AmericanRobert B. Enterprise Helms, Ph.D.Institute NorthCarolyn Carolina J. Lackey, State University Ph.D., R.D. UniversityBrooke T. of Mossman, Vermont College Ph.D. of Medicine MichiganDale R. RStateomsos, University Ph.D. RutgersZane R. University, Helsel, Ph.D. Cook College UniversityJ. Claybur ofn California, LaForce, Los Ph.D. Angeles TheAllison Children’s A. Muller, Hospital Pharm.D of Philadelphia CookJoseph College, D. Rosen, Rutgers Ph.D. University DrexelJames University D. Herbert, Ph.D. UniversityPagona Lagiou,of Athens M.D., Medical Ph.D. School NorthwesternSteven T. Rosen, University M.D. Medical School SyracuseSarah Short, University Ph.D., Ed.D., R.D. PurdueJon A. UniversityStory, Ph.D. King’sSimon College Wessley, London M.D., and FRCP Institute of Psychiatry Kenneth J. Rothman, Dr.P.H. A. J. Siedler, Ph.D. Michael M. Sveda, Ph.D. Steven D. Wexner, M.D. Boston University School of Public Health University of Illinois, Urbana-Champaign Gaithersburg, MD Cleveland Clinic Florida Stanley Rothman, Ph.D. Marc K. Siegel, M.D. Joel Elliot White, M.D., F.A.C.R. Smith College New York University School of Medicine TGlennopeka, Swogger,KS Jr., M.D. Danville, CA Stephen H. Safe, D.Phil. Michael S. Simon, M.D., M.P.H. Texas A&M University Wayne State University USitaniversity R. Tatini, of Minnesota Ph.D. RCarolochester Whitlock, Institute Ph.D., of Technology R.D. Wallace I. Sampson, M.D. S. Fred Singer, Ph.D. Stanford University School of Medicine Science & Environmental Policy Project UniversitySteve L. Taylor,of Nebraska, Ph.D. Lincoln Wilmington,Christopher NC F. Wilkinson, Ph.D. Harold H. Sandstead, M.D. Robert B. Sklaroff, M.D. University of Texas Medical Branch Elkins Park, PA TuftsJames University W. Tillotson, Ph.D., M.B.A. NationalMark L. Institute Willenbring, on Alcohol M.D., Abuse Ph.D. and Alcoholism Charles R. Santerre, Ph.D. Anne M. Smith, Ph.D., R.D., L.D. Purdue University Ohio State University HDimitriosarvard School Trichopoulos, of Public Health M.D. UCarlniversity K. Winter, of California, Ph.D. Davis Sally L. Satel, M.D. Gary C. Smith, Ph.D. American Enterprise Institute Colorado State University WMurrayinchendon, M. Tuckerman,MA Ph.D. RJamesochester J. InstituteWorman, of TechnologyPh.D. Lowell D. Satterlee, Ph.D. John N. Sofos, Ph.D. Vergas, MN Colorado State University URobertniversity P. of Upchurch, Arizona Ph.D. URussellniversity S. of Worrall, California, O.D. Berkeley Jeffrey W. Savell Roy F. Spalding, Ph.D. Texas A&M University University of Nebraska, Lincoln UMarkniversity J. Utell,of Rochester M.D. Medical Center UStevenniversity H. of Zeisel, North Carolina M.D., Ph.D. Marvin J. Schissel, D.D.S. Leonard T. Sperry, M.D., Ph.D. Roslyn Heights, NY Barry University UniversityShashi B. of Verma, Nebraska, Ph.D. Lincoln NutritionMichael Institute,B. Zemel, University Ph.D. of Tennessee Edgar J. Schoen, M.D. Robert A. Squire, D.V.M., Ph.D. Kaiser Permanente Medical Center Johns Hopkins University UniversityWillard J. of Visek, Illinois M.D.,College Ph.D. of Medicine UniversityEkhard E. of Ziegler, Iowa M.D. David Schottenfeld, M.D., M.Sc. Ronald T. Stanko, M.D. University of Michigan University of Pittsburgh Medical Center ULynnniversity Waishwell, of Medicine Ph.D., and DentistryC.H.E.S. of New Jersey, School of Public Health AmericanJoel M. Schwartz, Enterprise InstituteM.S. UniversityJames H. of Steele, Texas, HoustonD.V.M., M.P.H. GeorgeDonald Washington M. Watkin, University M.D., M.P.H., F.A.C.P. BrooklynDavid E. College Seidemann, Ph.D. PennsylvaniaRobert D. Steele, State University Ph.D. Miles Weinberger, M.D. University of Iowa Hospitals and Clinics UniversityPatrick J. of Shea, Nebraska, Ph.D. Lincoln UniversityJudith S. ofS tern,California, Sc.D., Davis R.D. John Weisburger, M.D., Ph.D. Michael B. Shermer, Ph.D. Ronald D. Stewart, O.C., M.D., FRCPC Institute for Cancer Prevention/ New York Medical Skeptic Magazine Dalhousie University College Sidney Shindell, M.D., LL.B. Martha Barnes Stone, Ph.D. Medical College of Wisconsin Colorado State University TheJanet ToxDoc S. Weiss, M.D.

The opinions expressed in ACSH publications do not necessarily represent the views of all members of the ACSH Board of Trustees, Founders Circle and Board of Scientific and Policy Advisors, who all serve without compensation.

A CSH STAFF

ResearchJulianne Associate M. Chickering ExecutivePatricia A.Assistant Keenan to the President AssociateCheryl E. Director Martin DirectorTodd Seavey of Publications

AdministrativeJudith A. D’Agostino Assistant AccountantA. Marcial C. Lapeña ExecutiveGilbert L. and Ross, Medical M.D. Director AssociateJeff Stier, Director Esq. Jaclyn Eisenberg Jennifer Lee Tara McTeague Research Assistant Art Director Development Assistant

DirectorRuth Kava, of Nutrition Ph.D., R.D. ResearchMolly Lee Assistant PUBLICAT IONS ORDER FORM MEMBERSHIP / PA YMENT

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